Impact of a bloodstream infection stewardship program in hospitalized patients.

BACKGROUND: Bloodstream infections (BSIs) in hospitalized patients represent sentinel events requiring timely and responsive antimicrobial prescribing. These infections represent an attractive but seldom-evaluated stewardship opportunity. METHODS: Retrospective pre-post study design, with review of patient charts 18 months before and after initiation of a hospital Bloodstream Infection Stewardship Program (BSISP). Pre-intervention, the ward and attending physician were notified of all positive blood cultures. Post-intervention, an infectious disease (ID) pharmacist collaborating with an ID consultant was also notified. RESULTS: Two hundred twenty-six eligible BSIs were identified pre-intervention and 195 post-intervention. The urinary tract was the most common source of infection; most common bloodstream isolates were Escherichia coli, Staphylococcus aureus, beta-hemolytic streptococci, and Klebsiella pneumoniae; 71.7% of infections were community acquired. Empiric therapy was not given in 17.3% of cases and inadequate in 16.4% of patients. Therapy was altered on the basis of Gram stain results ('directed therapy') in 54.6% of episodes and was inadequate in 3.5%. Compared to pre-intervention, the post-intervention cohort received directed therapy on average 4.36 hours earlier (p = 0.003), was more likely to receive appropriate definitive therapy (99.0% post versus 79.1% pre, p <0.001), stepped down to oral therapy earlier (6.0 versus 8.0 days, p = 0.031), and received fewer directed prescriptions (214 per 100 cases post versus 260 per 100 cases pre; p = 0.001), including fewer prescriptions of quinolones and clindamycin. CONCLUSIONS: A BSISP could be an effective strategy for improving antimicrobial prescribing in hospitalized patients with a BSI.

HISTORIQUE: Chez les patients hospitalisés, les infections sanguines sont des événements sentinelles qui exigent des prescriptions antimicrobiennes opportunes et adaptées. Ces infections représentent une possibilité de gestion attrayante, mais rarement évaluée. MÉTHODOLOGIE: Les chercheurs ont utilisé une méthodologie d'étude avant-après comportant l'analyse des dossiers des patients 18 mois avant et après un programme de gestion des infections sanguines (PGIS) en milieu hospitalier. Avant l'intervention, le médecin du service a été avisé de toutes les cultures sanguines positives. Après l'intervention, un pharmacien infectiologue qui collaborait avec un consultant en infectiologie a également été avisé. RÉSULTATS: Au total, les chercheurs ont relevé 226 infections sanguines admissibles avant l'intervention et 195 après l'intervention. Les voies urinaires étaient la principale source d'infection et les principaux isolats sanguins, l'Escherichia coli, le Staphylococcus aureus, les streptocoques bêta-hémolytiques et le Klebsiella pneumoniae; 71,7 % des infections étaient d'origine communautaire. Dans 17,3 % des cas, les patients n'ont pas reçu de traitement empirique et chez 16,4 % des patients, le traitement n'était pas approprié. Il était modifié en fonction des résultats de la coloration de Gram de base (« thérapie dirigée ¼) dans 54,6 % des épisodes et n'était pas approprié dans 3,5 % des cas. Par rapport à celle d'avant l'intervention, la cohorte d'après l'intervention a reçu une thérapie dirigée en moyenne 4,36 heures plus tôt (p = 0,003) et était plus susceptible de recevoir un traitement définitif approprié (99,0 % après par rapport à 79,1 % avant, p <0,001), de passer à un traitement par voie orale plus rapidement (6,0 jours plutôt que 8,0, p = 0,031) et de recevoir moins d'ordonnances dirigées (214 sur 100 cas après, par rapport à 260 sur 100 cas avant; p = 0,001), y compris moins d'ordonnances de quinolones et de clindamycine. CONCLUSIONS: Un PGIS pourrait être une stratégie efficace pour améliorer les prescriptions d'antimicrobiens chez des patients hospitalisés atteints d'une infection sanguine.

The 2018 Global Point Prevalence Survey of antimicrobial consumption and resistance in 47 Canadian hospitals: a cross-sectional survey.

BACKGROUND: Patient-level surveillance of antimicrobial use (AMU) in Canadian hospitals empowers the reduction of inappropriate AMU and was piloted in 2017 among 14 hospitals in Canada. We aimed to describe AMU on the basis of patient-level data in Canadian hospitals in 2018 in terms of antimicrobial prescribing prevalence and proportions, antimicrobial indications, and agent selection in medical, surgical and intensive care wards. METHODS: Canadian adult, pediatric and neonatal hospitals were invited to participate in the standardized web-based cross-sectional Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) conducted in 2018. An identified site administrator assigned all wards admitting inpatients to specific surveyors. A physician, pharmacist or nurse with infectious disease training performed the survey. The primary outcomes were point prevalence rates for AMU over the study period regarding prescriptions, indications and agent selection in medical, surgical and intensive care wards. The secondary outcomes were AMU for resistant organisms and practice appropriateness evaluated on the basis of quality indicators. Antimicrobial consumption is presented in terms of prevalence and proportions. RESULTS: Forty-seven of 118 (39.8%) hospitals participated in the survey; 9 hospitals were primary care centres, 15 were secondary care centres and 23 were tertiary or specialized care centres. Of 13 272 patients included, 33.5% (n = 4447) received a total of 6525 antimicrobials. Overall, 74.1% (4832/6525) of antimicrobials were for therapeutic use, 12.6% (n = 825) were for medical prophylaxis, 8.9% (n = 578) were for surgical prophylaxis, 2.2% (n = 143) were for other use and 2.3% (n = 147) were for unidentified reasons. A diagnosis or indication was documented in the patient's file at the initiation for 87.3% (n = 5699) of antimicrobials; 62.9% (n = 4106) of antimicrobials had a stop or review date; and 72.0% (n = 4697) of prescriptions were guided by local guidelines. INTERPRETATION: Overall, three-quarters of AMU was for therapeutic use across participating hospitals. Canadian hospitals should be further incentivized to create and adapt local guidelines on the basis of recent antimicrobial resistance data.

The clinical impact of a urinary tract infection management bundle in a tertiary-care teaching hospital.

OBJECTIVE: The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs. DESIGN: Before-and-after intervention study.SettingsTertiary-care hospital.PatientsConsecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital. METHODS: The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists' prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle. RESULTS: Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment. CONCLUSIONS: A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.