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The Optimization of Antimicrobial Prescribing and Stewardship

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A special issue of Antibiotics (ISSN 2079-6382). This special issue belongs to the section "Antibiotics Use and Antimicrobial Stewardship".

Deadline for manuscript submissions: closed (31 December 2022) | Viewed by 26113

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Special Issue Editor

Dr. David Gillespie

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Guest Editor

1. Centre for Trials Research, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
2. Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
Interests: antibiotic stewardship; trials; adherence; behavior; Point-of-care tests

Special Issue Information

Dear Colleagues,

The discovery and subsequent development of antimicrobials was one of the most significant medical achievements of the 20^th century. Clinical infections now had effective treatments, and their preventative role led to significant improvements in complex surgical and cancer care. However, the rise of antimicrobial resistance, driven largely by antimicrobial use, has placed emphasis on research and practice where antimicrobial prescribing is optimized—typically through antimicrobial stewardship programs. These programs typically focus on reducing the inappropriate use of antimicrobials, which can expose patients to unnecessary side effects, waste their money, and undermine their self-care.

The goal of this Special Issue is to collate evidence across clinical medicine sectors (e.g., primary care, secondary care, dentistry, and pharmacy) and across different disease areas and patient populations where programs aiming to optimize the prescription of antimicrobials have been evaluated. By bringing together research across different areas, it is our hope that learning opportunities regarding the design, evaluation, and implementation of such programs will be highlighted.

We welcome full-scale evaluations (randomized or non-randomized), as well as feasibility and pilot studies, that involve testing study procedures prior to a full-scale evaluation. We are interested in antimicrobial stewardship interventions that fit within at least one of the following classifications (important intervention bundles that cut across classifications are also of interest):

Structural (e.g., the use of diagnostic tests to guide treatment)
Persuasive (e.g., audit and feedback)
Enabling (e.g., guidelines and education)
Restrictive (e.g., external approval for certain treatments)

Dr. David Gillespie
Guest Editor

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Keywords

antibiotics
prescribing
stewardship
primary care
secondary care
dentistry
pharmacy

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Published Papers (9 papers)

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Research

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11 pages, 1163 KiB

Open AccessArticle

Clinical Impact of a Pharmacist-Driven Prospective Audit with Intervention and Feedback on the Treatment of Patients with Bloodstream Infection

by Naoto Okada, Momoyo Azuma, Kaito Tsujinaka, Akane Abe, Mari Takahashi, Yumiko Yano, Masami Sato, Takahiro Shibata, Mitsuhiro Goda and Keisuke Ishizawa

Antibiotics 2022, 11(9), 1144; https://doi.org/10.3390/antibiotics11091144 - 24 Aug 2022

Cited by 3 | Viewed by 2216

Abstract

Evidence for the utility of pharmacist-driven antimicrobial stewardship programs remains limited. This study aimed to evaluate the usefulness of our institutional pharmacist-driven prospective audit with intervention and feedback (PAF) on the treatment of patients with bloodstream infections (BSIs). The effect of pharmacist-driven PAF was estimated using an interrupted time series analysis with a quasi-experimental design. The proportion of de-escalation during BSI treatment increased by 44% after the implementation of pharmacist-driven PAF (95% CI: 30–58, p < 0.01). The number of days of therapy decreased by 16 per 100 patient days for carbapenem (95% CI: −28 to −3.5, p = 0.012) and by 15 per 100 patient days for tazobactam/piperacillin (95% CI: −26 to −4.9, p < 0.01). Moreover, the proportion of inappropriate treatment in empirical and definitive therapy was significantly reduced after the implementation of pharmacist-driven PAF. Although 30-day mortality did not change, compliance with evidenced-based bundles in the BSI of Staphylococcus aureus significantly increased (p < 0.01). In conclusion, our pharmacist-driven PAF increased the proportion of de-escalation and decreased the use of broad-spectrum antibiotics, as well as the proportion of inappropriate treatment in patients with BSI. This indicates that pharmacist-driven PAF is useful in improving the quality of antimicrobial treatment and reducing broad-spectrum antimicrobial use in the management of patients with BSI. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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15 pages, 1097 KiB

Open AccessArticle

The Impact of Point-of-Care Blood C-Reactive Protein Testing on Prescribing Antibiotics in Out-of-Hours Primary Care: A Mixed Methods Evaluation

by Sharon Dixon, Thomas R. Fanshawe, Lazaro Mwandigha, George Edwards, Philip J. Turner, Margaret Glogowska, Marjorie M. Gillespie, Duncan Blair and Gail N. Hayward

Antibiotics 2022, 11(8), 1008; https://doi.org/10.3390/antibiotics11081008 - 26 Jul 2022

Cited by 5 | Viewed by 2201

Abstract

Improving prescribing antibiotics appropriately for respiratory infections in primary care is an antimicrobial stewardship priority. There is limited evidence to support interventions to reduce prescribing antibiotics in out-of-hours (OOH) primary care. Herein, we report a service innovation where point-of-care C-Reactive Protein (CRP) machines were introduced to three out-of-hours primary care clinical bases in England from August 2018–December 2019, which were compared with four control bases that did not have point-of-care CRP testing. We undertook a mixed-method evaluation, including a comparative interrupted time series analysis to compare monthly antibiotic prescription rates between bases with CRP machines and those without, an analysis of the number of and reasons for the tests performed, and qualitative interviews with clinicians. Antibiotic prescription rates declined during follow-up, but with no clear difference between the two groups of out-of-hours practices. A single base contributed 217 of the 248 CRP tests performed. Clinicians reported that the tests supported decision making and communication about not prescribing antibiotics, where having ‘objective’ numbers were helpful in navigating non-prescribing decisions and highlighted the challenges of training a fluctuant staff group and practical concerns about using the CRP machine. Service improvements to reduce prescribing antibiotics in out-of-hours primary care need to be developed with an understanding of the needs and context of this service. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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11 pages, 13471 KiB

Open AccessArticle

Short and Concise Peer-to-Peer Teaching—Example of a Successful Antibiotic Stewardship Intervention to Increase Iv to Po Conversion

by Johannes Wild, Bettina Siegrist, Lukas Hobohm, Thomas Münzel, Thomas Schwanz and Ingo Sagoschen

Antibiotics 2022, 11(3), 402; https://doi.org/10.3390/antibiotics11030402 - 17 Mar 2022

Viewed by 2454

Abstract

Antibiotic stewardship (ABS) programs aim to combine effective treatment with minimized antibiotic-related harms. Common ABS interventions are simple and effective, but their implementation in daily practice is often difficult. The aim of our study was to investigate if a single, short, peer-to-peer teaching intervention (junior doctor to junior doctor) during clinical routine can successfully improve antibiotic prescriptions. We performed a quasi-experimental before–after study on a regular care cardiology ward at a large academic medical center in Germany. We evaluated antibiotic use metrics retrospectively and calculated defined daily doses (DDD) with the anatomical therapeutic chemical/DDD classification system of the World Health Organization. We hypothesize that the over-representative use of intravenous administration is a potentially modifiable target, which can be proven by antibiotic use metrics analysis. After a single peer-to-peer teaching session with a focus on indications for iv to po conversion, the normalized percentage of intravenous compared to oral administration significantly decreased (from 86.5 ± 50.3% to 41.4 ± 70.3%). Moreover, after the intervention, antibiotics with high oral bioavailability were no longer administered intravenously at all during the following quarter. Our results indicate that even a single peer-to-peer training session is highly effective in improving the iv to po conversion rate in the short term. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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11 pages, 934 KiB

Open AccessArticle

Clinical and Microbiological Effects of an Antimicrobial Stewardship Program in Urology—A Single Center Before-After Study

by Oana Joean, Daniel Tahedl, Madita Flintrop, Thorben Winkler, Ruxandra Sabau, Tobias Welte, Markus A. Kuczyk, Ralf-Peter Vonberg and Jessica Rademacher

Antibiotics 2022, 11(3), 372; https://doi.org/10.3390/antibiotics11030372 - 10 Mar 2022

Cited by 6 | Viewed by 2712

Abstract

Antimicrobial resistance is a major public health issue caused by antibiotic overuse and misuse. Antimicrobial stewardship (AMS) has been increasingly endorsed worldwide, but its effect has been studied scarcely in urologic settings. A before-after study was performed from 2018 through 2020 to evaluate changes in antimicrobial prescription, resistance rates and clinical safety upon implementation of an AMS audit and feedback program in the Urology Department of a large German academic medical center. The primary endpoints were safety clinical outcomes: the rate of infection-related readmissions and of infectious complications after transrectal prostate biopsies. Resistance rates and antimicrobial consumption rates were the secondary endpoints. The AMS team reviewed 196 cases (12% of all admitted in the department). The overall antibiotic use dropped by 18.7%. Quinolone prescriptions sank by 78.8% (p = 0.02) and 69.8% (p > 0.05) for ciprofloxacin and levofloxacin, respectively. The resistance rate of E. coli isolates declined against ceftriaxone (−9%), ceftazidime (−12%) and quinolones (−25%) in the AMS period. No significant increase in infection-related readmissions or infectious complications after prostate biopsies was observed (p = 0.42). Due to the potential to reduce antibiotic use and resistance rates with no surge of infection-related complications, AMS programs should be widely implemented in urologic departments. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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10 pages, 1087 KiB

Open AccessArticle

Impact and Sustainability of Antibiotic Stewardship on Antibiotic Prescribing in Visceral Surgery

by Magdalena Monika Gruber, Alexandra Weber, Jette Jung, Jens Werner and Rika Draenert

Antibiotics 2021, 10(12), 1518; https://doi.org/10.3390/antibiotics10121518 - 11 Dec 2021

Cited by 7 | Viewed by 2472

Abstract

Background: Antibiotic stewardship (AS) ward rounds are a core element in clinical care for surgical patients. Therefore, we aimed to analyze the impact of surgical AS ward rounds on antibiotic prescribing, and the sustainability of the effect after the AS interventions are no longer provided. Methods: On four wards of the department of visceral surgery, we conducted two independent retrospective prescribing analyses (P1, P2) over three months each. During the study periods, the level of AS intervention differed for two of the four wards (ward rounds/no ward rounds). Results: AS ward rounds were associated with a decrease in overall antibiotic consumption (91.1 days of therapy (DOT)/100 patient days (PD) (P1), 70.4 DOT/100PD (P2)), and improved de-escalation rates of antibiotic therapy (W1/2: 25.7% (P1), 40.0% (P2), p = 0.030; W3: 15.4 (P1), 24.2 (P2), p = 0.081). On the ward where AS measures were no longer provided, overall antibiotic usage remained stable (71.3 DOT/100PD (P1), 74.4 DOT/100PD (P2)), showing the sustainability of AS measures. However, the application of last-resort compounds increased from 6.4 DOT/100PD to 12.1 DOT/100PD (oxazolidinones) and from 10.8 DOT/100PD to 13.2 DOT/100PD (carbapenems). Conclusions: Antibiotic consumption can be reduced without negatively affecting patient outcomes. However, achieving lasting positive changes in antibiotic prescribing habits remains a challenge. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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13 pages, 3401 KiB

Open AccessArticle

Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection

by Wendy Thompson, Jonathan Sandoe, Sue Pavitt, Tanya Walsh and Lucie Byrne-Davis

Antibiotics 2021, 10(11), 1345; https://doi.org/10.3390/antibiotics10111345 - 4 Nov 2021

Cited by 5 | Viewed by 4328

Abstract

Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists’ decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A ‘think aloud’ study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: ’information about (and salience of) health consequences’, ‘prompts and cues’, ‘restructuring the physical (and social) environment’ and ‘credible sources’. The think aloud study confirmed the tool’s acceptability to dentists and patients, and resulted in the title: ‘Step-by-step guide to fixing your toothache.’ Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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12 pages, 412 KiB

Open AccessArticle

Implementation of a Cellulitis Management Plan in Three Australian Regional Health Services to Address an Evidence–Practice Gap in Antibiotic Prescribing

by Jaclyn Bishop, Mark Jones, James Farquharson, Kathrine Summerhayes, Roxanne Tucker, Mary Smith, Raquel Cowan, N. Deborah Friedman, Thomas Schulz, David Kong and Kirsty Buising

Antibiotics 2021, 10(11), 1288; https://doi.org/10.3390/antibiotics10111288 - 22 Oct 2021

Cited by 1 | Viewed by 2684

Abstract

Despite the availability of evidence-based guidelines, antibiotics for cellulitis remain inappropriately prescribed. This evidence–practice gap is more evident in low-resource settings, such as rural hospitals. This implementation study developed and introduced a cellulitis management plan to improve antibiotic prescribing for cellulitis in three health services in regional Australia. Appropriateness of antibiotic prescribing for cellulitis at Day 1 was the primary outcome measure. Adults with ICD-10-AM codes for lower-limb cellulitis admitted as inpatients of the three health services between May and November 2019 (baseline, n = 165) and March and October 2020 (post-implementation, n = 127) were included in the assessment. The uptake of the cellulitis management plan was 29.1% (37/127). The appropriateness of antibiotic prescribing for cellulitis at Day 1 was similar at baseline (78.7%, 144/183) and in the intention-to-treat post-implementation group (81.8%, 126/154) [95% CI −5.6% to 11.3%, p = 0.50]. Commencement of the cellulitis management plan resulted in a non-statistically significant increase in antibiotic appropriateness at Day 1 compared to when a cellulitis management plan was not commenced (88.1% vs. 79.5%; 95% CI −5.6% to 19.8%; p = 0.20) Evaluation of more real-world strategies to address evidence–practice gaps, such as the appropriateness of antibiotic prescribing for cellulitis, is required. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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Review

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14 pages, 737 KiB

Open AccessReview

The Role of Biomarkers in Influenza and COVID-19 Community-Acquired Pneumonia in Adults

by Raquel Carbonell, Gerard Moreno, Ignacio Martín-Loeches, María Bodí and Alejandro Rodríguez

Antibiotics 2023, 12(1), 161; https://doi.org/10.3390/antibiotics12010161 - 12 Jan 2023

Cited by 8 | Viewed by 3347

Abstract

Pneumonia is a growing problem worldwide and remains an important cause of morbidity, hospitalizations, intensive care unit admission and mortality. Viruses are the causative agents in almost a fourth of cases of community-acquired pneumonia (CAP) in adults, with an important representation of influenza virus and SARS-CoV-2 pneumonia. Moreover, mixed viral and bacterial pneumonia is common and a risk factor for severity of disease. It is critical for clinicians the early identification of the pathogen causing infection to avoid inappropriate antibiotics, as well as to predict clinical outcomes. It has been extensively reported that biomarkers could be useful for these purposes. This review describe current evidence and provide recommendations about the use of biomarkers in influenza and SARS-CoV-2 pneumonia, focusing mainly on procalcitonin (PCT) and C-reactive protein (CRP). Evidence was based on a qualitative analysis of the available scientific literature (meta-analyses, randomized controlled trials, observational studies and clinical guidelines). Both PCT and CRP levels provide valuable information about the prognosis of influenza and SARS-CoV-2 pneumonia. Additionally, PCT levels, considered along with other clinical, radiological and laboratory data, are useful for early diagnosis of mixed viral and bacterial CAP, allowing the proper management of the disease and adequate antibiotics prescription. The authors propose a practical PCT algorithm for clinical decision-making to guide antibiotic initiation in cases of influenza and SARS-CoV-2 pneumonia. Further well-design studies are needed to validate PCT algorithm among these patients and to confirm whether other biomarkers are indeed useful as diagnostic or prognostic tools in viral pneumonia. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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18 pages, 1297 KiB

Open AccessReview

Variation in Antibiotic Treatment Failure Outcome Definitions in Randomised Trials and Observational Studies of Antibiotic Prescribing Strategies: A Systematic Review and Narrative Synthesis

by Rebecca Neill, David Gillespie and Haroon Ahmed

Antibiotics 2022, 11(5), 627; https://doi.org/10.3390/antibiotics11050627 - 6 May 2022

Cited by 2 | Viewed by 2166

Abstract

Antibiotic treatment failure is used as an outcome in randomised trials and observational studies of antibiotic treatment strategies and may comprise different events that indicate failure to achieve a desired clinical response. However, the lack of a universally recognised definition has led to considerable variation in the types of events included. We undertook a systematic review of published studies investigating antibiotic treatment strategies for common uncomplicated infections, aiming to describe variation in terminology and components of the antibiotic treatment failure outcomes. We searched Medline, Embase, and the Cochrane Central Register of Clinical trials for English language studies published between January 2010 and January 2021. The population of interest was ambulatory patients seen in primary care or outpatient settings with respiratory tract (RTI), urinary tract (UTI), or skin and soft tissue infection (SSTI), where different antibiotic prescribing strategies were compared, and the outcome was antibiotic treatment failure. We narratively summarised key features from eligible studies and used frequencies and proportions to describe terminology, components, and time periods used to ascertain antibiotic treatment failure outcomes. Database searches identified 2967 unique records, from which 36 studies met our inclusion criteria. This included 10 randomised controlled trials and 26 observational studies, with 20 studies of RTI, 12 of UTI, 4 of SSTI, and 2 of both RTI and SSTI. We identified three key components of treatment failure definitions: prescription changes, escalation of care, and change in clinical condition. Prescription changes were most popular in studies of UTI, while changes in clinical condition were most common in RTI and SSTI studies. We found substantial variation in the definition of antibiotic treatment failure in included studies, even amongst studies of the same infection subtype and study design. Considerable further work is needed to develop a standardised definition of antibiotic treatment failure in partnership with patients, clinicians, and relevant stakeholders. Full article

(This article belongs to the Special Issue The Optimization of Antimicrobial Prescribing and Stewardship)

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