Simplified therapeutic guidelines: the main tool of antimicrobial stewardship programs associated with optimal antibiotic therapy.

Hospitals regularly seek to upgrade their antimicrobial stewardship program (ASP). Our aim was to evaluate the impact of simplified therapeutic guidelines (STGs) compared to various established tools for ASP on the rate of optimal antibiotic therapy (OAT) and antibiotic consumption. Audits of antibiotic prescriptions were carried out over a 24-month period. Feedback information led to STGs (e.g., ≤ 15 drugs). The impact of STGs was based on the rate of OAT, defined as a diagnosis of the infectious disease in the patient's medical records associated with the corresponding therapy indicated in the STGs or in other guidelines. STGs were compared to five other means of ASP: internal or national guidelines, audit, information regarding antibiotic consumption and bacterial resistance, and restricted access to targeted antibiotics. Antibiotic consumption was measured in defined daily doses/1000 days of hospital stay, focusing on third-generation cephalosporins (TGC) and fluoroquinolones (FQ). Twenty-six hospitals were audited from April 2017 to June 2019. A total of 1,028 antibiotic prescriptions were analyzed, including 204 (20%) after STG implementation in seven hospitals. In multivariate analysis, OAT (n = 176, 17%) was associated with STGs, AOR 2.21 [1.51-3.22], and with three tools in place, 1.75 [1.24-2.48]. The relative variations of consumption of TGC and FQ for hospitals with or without STGs were - 13.1 vs. + 9.4% and - 18.5 vs. - 2.7%, respectively, from 2018 to 2019. STGs were more likely than other ASP tools to improve the rate of OAT and to reduce the consumption of antibiotics.

Urinary tract infection and antibiotic use around ureteral stent insertion for urolithiasis.

Urolithiasis is the main indication for a ureteral JJ stent. Our aim was to determine the incidence of urinary tract infections (UTIs) after a JJ stent for urolithiasis, with an emphasis on antibiotic use. Prospective, multicenter, cohort study over a 4-month period including all of the patients with urolithiasis requiring JJ stent insertion. The clinical and microbiological data and therapeutic information were recorded until removal of the JJ stent. Two hundred twenty-three patients at five French private hospitals were included. A urine culture was performed for 187 patients (84%) prior to insertion of a JJ stent, 36 (19%) of which were positive. One hundred thirty patients (58%) received an antibiotic therapy during surgery: 74 (33%) prophylaxis and 56 (25%) empirical antibiotic therapy, comprising 17 different regimens. The rate of prophylaxis varied according to the center, from 0 to 70%. A total of 208 patients were followed-up until removal of the first stent. The rate of UTIs was 6.3% (13/208); 8.1% of the patients who did not receive a prophylaxis had a UTI versus 1.4% of those who did receive a prophylaxis (p = 0.057). Seven empirical antibiotic regimens were used to treat these 13 patients. Another large panel of antibiotic prescriptions was observed at the time of JJ stent removal. The incidence of a UTI after JJ stent insertion for urolithiasis was 6.3%, in part due to a lack of prophylaxis. An unwarranted diversity of antibiotic use was observed at each step of care.

Impact of simplified therapeutic guidelines on antibiotic prescriptions: a prospective multicentre comparative study.

OBJECTIVES: We studied the impact of simplified therapeutic guidelines (STGs) associated with accompanied self-antibiotic reassessment (ASAR) on antibiotic use. METHODS: Prospective antibiotic audits and feedback took place at 15 hospitals for 12 months, allowing STGs with ≤15 drugs to be devised. STGs were explained to prescribers through sessions referred to as ASAR. Optimal therapy was defined by the conjunction of a diagnosis and the drug specified in the STGs. Analysis of consumption focused on critical drugs: amoxicillin/clavulanic acid, third-generation cephalosporins and fluoroquinolones. RESULTS: We compared prescriptions in five hospitals before (n = 179) and after (n = 168) the implementation of STGs + ASAR. These tools were associated with optimal therapies and amoxicillin/clavulanic acid prescriptions [adjusted odds ratio (AOR) 3.28, 95% CI 1.82-5.92 and 2.18, 95% CI 1.38-3.44, respectively] and fewer prescriptions for urine colonization [AOR 0.20 (95% CI 0.06-0.61)]. Comparison of prescriptions (n = 1221) from 10 departments of three clinics with STGs + ASAR for the first quarters of 2018 and 2019 revealed that the prescriptions by 23 ASAR participants more often complied with STGs than those by 28 other doctors (71% versus 60%, P = 0.003). STGs alone were adopted by 10 clinics; comparing the prescriptions (n = 311) with the 5 clinics with both tools, we observed fewer unnecessary therapies in the latter [AOR 0.52 (95% CI 0.34-0.80)]. The variation in critical antibiotic consumption between 2017 and 2018 was -16% for the 5 clinics with both tools and +20% for the other 10 (P = 0.020). CONCLUSIONS: STGs + ASAR promote optimal antibiotic therapy and reduce antibiotic use.

Risk Factors for Unnecessary Antibiotic Therapy: A Major Role for Clinical Management.

BACKGROUND: Assessment of antimicrobial use places an emphasis on therapeutic aspects of infected patients. Our aim was to determine the risk factors for unnecessary antibiotic therapy (UAT). METHODS: This was a prospective, multicenter study evaluating all curative antibiotic therapies prescribed over 2 consecutive days through the same electronic medical records. Each item that could participate in these prescriptions was collected from the computerized file (reason for hospitalization, comorbid conditions, suspected or definitive diagnosis of infection, microbial analyses). UAT was defined as the recognition of noninfectious sydromes (NIS), nonbacterial infections, use of redundant antimicrobials, and continuation of empirical broad-spectrum antimicrobials. RESULTS: Four hundred fifty-three antibiotic therapies were analyzed at 17 institutions. An infectious disease was the reason for hospitalization in 201 cases (44%). An unspecified diagnosis of infection was observed in 104 cases (23%). Microbial samples were taken in 296 cases (65%), allowing isolation of a pathogen in 156 cases (53%). Unspecified diagnosis was associated with the absence of a microbial sample compared to patients with a diagnosis: (56/104 [54%] vs 240/349 [69%]; P = .005). A total of 158 NIS were observed (35%). UAT was observed in 169 cases (37%), due to NIS in 106 cases. In multivariate analysis, the modifiable risk factors for UAT were unspecified diagnosis (adjusted odds ratio [AOR], 1.83; 95% confidence interval [CI], 1.04-3.20) and absence of a blood culture (AOR, 5.26; 95% CI, 2.56-10.00). CONCLUSIONS: UAT is associated with an unspecified diagnosis and the absence of microbial testing. Antimicrobial stewardship programs should focus on diagnostic difficulties and microbial testing, the latter facilitating antibiotic reassessment and therapeutic interruption.