Single-center survey of prescription trends and appropriate use plans for macrolide antimicrobials.

INTRODUCTION: Macrolides (MCs) are broad-spectrum antimicrobials with activity against many microorganisms. They are widely used, and the development of MC-resistant bacteria is a serious problem in Japan. It is therefore necessary to clarify the purpose and duration of administration, with the aim of promoting appropriate use. METHODS: Patients of all ages, for whom oral MCs were prescribed between 2016 and 2020 were included. They were divided into four groups based on the number of days per prescription. In the long-term treatment group, patients treated with MCs for ≥1000 days were specifically investigated for the purpose of treatment. RESULTS: Macrolide prescriptions increased from 2019 to 2020. Most patients received ≥28 days of treatment based on one prescription. During the study period, 1212 patients (28.6%) received a total of ≥50 days and 152 patients (3.6%) received a total of ≥1000 days of treatment. Approximately a third of long-term administrations were for nontuberculous mycobacterial infections (NTMs), and 18.3% of patients with NTMs were treated with MCs alone. In addition, many MCs were administered for their anti-inflammatory effects on neutrophils. CONCLUSIONS: Owing to their pleiotropic effects, MCs may also be administered for the treatment of noninfectious diseases. In general, the long-term administration of antimicrobials contradicts the strategy for the suppression of resistant bacteria. It is thus important to understand the actual clinical utility of MCs and the purpose and duration of administration. In addition, strategies for the appropriate use of MCs are required for each medical institution.

The effectiveness of prescription support and treatment reporting system on the appropriate usage of oral third-generation cephalosporins.

INTRODUCTION: Preauthorization and prospective audit and feedback system are reported to be effective for the achievement of appropriate use of intravenous antimicrobials, but few reports on oral antimicrobials are available, especially for adults. METHODS: The prescription of oral third-generation cephalosporins (oral 3rd Ceph) for inpatients and outpatients from 2013 to 2018 was investigated. The study period was divided into three phases. First, prescription support to suggest discontinuation of antimicrobials for unnecessary prescriptions, and alternative antimicrobials for inappropriate prescriptions were provided. Next, we continued prescription monitoring, and observed the trends of antimicrobial prescription without support. Finally, we have introduced prescription reporting system to promote the appropriate use of oral 3rd Ceph. In each phase, we evaluated days of therapy per 1000 patient-days and prescriptions per 1000 visits as an index of effectiveness of our interventions. RESULTS: The total annual amount of oral 3rd Ceph usage decreased significantly over time between phases, respectively. During the same period, the incidence rate of methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum ß-lactamase (ESBL)-producing bacteria, and AmpC ß-lactamase (AmpC)-producing bacteria was not changed significantly, indicating that oral 3rd Ceph usage was reduced without a concomitant increase of the drug-resistant bacteria. Simultaneously, the annual usage of other broad-spectrum antimicrobial agents such as oral fluoroquinolones and oral macrolides also decreased, which indicated these antimicrobials were not prescribed as an alternative for oral 3rd Ceph. CONCLUSIONS: The combination of prescription support activity and treatment reporting system for oral antimicrobial agents is an effective method for promoting appropriate oral antimicrobial use.

Establishment of an Antimicrobial Stewardship Program to Spare the Use of Oral Fluoroquinolones for Acute Uncomplicated Cystitis in Outpatients.

The increase in fluoroquinolone (FQ)-resistant Escherichia coli (EC) is a serious global problem. In addition, much of acute uncomplicated cystitis (AUC) cases are caused by EC. FQs have been selected for the treatment of cystitis in outpatients, and there is concern about treatment failure. It is therefore necessary to select appropriate antimicrobials to spare FQs. However, there are few reported effective antimicrobial stewardship programs (ASPs) for outpatients. We aimed to establish the effective ASP for outpatients diagnosed with AUC caused by EC, to spare the use of FQs, and to explore optimal oral antimicrobials for AUC. The study subjects were outpatients treated for AUC caused by extended-spectrum ß-lactamase-non-producing EC (non-ESBL-EC). Based on the antibiogram results, we recommended cefaclor (CCL) as the initial treatment for AUC, and educated clinical pharmacists who also worked together to advocate for CCL or cephalexin (CEX) prescriptions. FQ usages decreased, and cephalosporin (Ceph) prescriptions increased in all medical departments. The Ceph group (n = 114; CCL = 60, CEX = 54) in the non-FQ group had fewer treatment failures than the FQ group (n = 86) (12.3% vs. 31.4%). Cephs, including CCL and CEX, were effective treatments for AUC caused by non-ESBL-EC. Antimicrobial selection based on antibiogram results and the practice of an ASP in collaboration with clinical pharmacists were useful for optimizing antimicrobial therapy in outpatients.