SAVE ‘Stewardship antibiotica Verona’: Result of an enabling and multidimensional Antimicrobial Stewardship intervention promoting prescribing appropriateness across the entire surgical path of care

Background: As a part of the hospital-wide Antimicrobial Stewardship (AS) SAVE project, a Quality Improvement (QI) intervention was implemented in the surgical area of the Verona University Hospital. Rather than focusing on specific elements (i.e. Surgical Antibiotic Prophylaxis, SAP), the intervention was aimed at globally improving the antimicrobial prescribing practice across the entire surgical pathway. An enabling approach was adopted to foster surgeons to play a leading role in the optimizations of antimicrobial use in their wards. Methods: The QI intervention encompass a prolonged on the field training with an Infectious Disease (ID) specialist attending the clinical rounds daily for 4-8 weeks, followed by a 9-months auditing and feedback; an educational workshop, CME-accredited, was held between the two. The first phase was also capitalized for the development of ward-dedicated guidelines. The primary outcome was the variation in antibiotic consumption measured by Days of Therapy (DOTs) and Daily Defined Doses (DDDs) per 1000 patient-days (PDs). Variation in consumption, stratified according to the WHO AWaRe and the main classes of interest considering the epidemiological context (fluoroquinolones, carbapenems, and anti-MRSA agents), in-hospital mortality, length of hospital stay (LOS), incidence of Clostridium difficile infections (CDI), and carbapenem-resistant Enterobacteriaceae bloodstream infections (CRE-BSI) were the secondary outcomes. The interrupted-time-series analysis (ITSA) was used to evaluate the AS intervention effectiveness, comparing the 12-month pre- and post-intervention periods. Results: Eighty-six surgeons and 18 anesthesiologists were involved in 5 surgical and one surgical-dedicated Intensive Care Unit (ICU). Overall, 710 prescriptions were reviewed and the mean prevalence of patients receiving antibiotics ranged from 22% in the cardiac surgery to 74% in the ICU. Post-intervention global prescribing appropriateness exceeded 70% in all the wards, SAP appropriateness levels ranging 61-73 and not exceeding the 24-hours duration in more than 60%. The ITSA identified significant reduction in overall antimicrobial consumption in 3/5 wards, with downward slope in urology (-65 DOTs*1000PDs/month, P=0.038) and abruptly level change in traumatology and cardiac surgery (-111.6 DOTs*1000PDs P=0.032, -167 DOTs*1000PDs P=0.027). Although raw data showed lower WATCH usage in all the wards (from -27% to -43%), the ITSA confirmed significant desirable effects of the intervention only in the Cardiothoracic area (post-intervention: Cardiac surgery -10.9 DOT*1000PDs/month, P<0.001; ICU -83 DDDs*1000PDs/month, P< 0.001) where a significant reduction in the level of RESERVE (-142 DOTs*1000PDs, P<0.01; -251 DDDs*1000PDs, P=0.007), carbapenems, and anti-MRSA agents was also observed. Fluoroquinolones raw consumption decreased more than 60% everywhere; however, when assessed by ITSA, significant downward trends emerged only in Urology and General surgery (starting from higher baseline levels) as opposed to Traumatology and General Surgery, showing positive change in slope, presenting a sharp decrease in the pre-intervention year then stabilizing. The absence of significant variation in the in-hospital mortality and LOS confirmed the safety of the intervention. The incidence of C.difficile and CRE-BSI was low, with no significant trends emerging. Conclusion A QI intervention targeting the entire surgical pathways can enhance prescribing appropriateness and safely achieve valuable variation in antibiotic consumption. As great variability exists across different surgical specialities, a tailored approach in the intervention implementation and pre-definition of the desirable variation of targeted antimicrobial class consumption represent key elements for success. The study also provides useful insights prompting a reorganization of the ID consultation service to adequately address the peculiarity of the surgical area

High rate of pulmonary thromboembolism in patients with SARS-CoV-2 pneumonia

no abstract available; letter to the edito

White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in long-term care facilities-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks

Contains fulltext : 230158.pdf (Publisher’s version ) (Open Access

Emotional, cognitive and social factors of antimicrobial prescribing: can antimicrobial stewardship intervention be effective without addressing psycho-social factors?

There is increasing evidence that psycho-social factors can influence antimicrobial prescribing practice in hospitals and the community, and represent potential barriers to antimicrobial stewardship interventions. Clinicians are conditioned both by emotional and cognitive factors based on fear, uncertainty, a set of beliefs, risk perception and cognitive bias, and by interpersonal factors established through social norms and peer and doctor-patient communication. However, a gap is emerging between research and practice, and no stewardship recommendation addresses the most appropriate human resource allocation or modalities to account for psycho-social determinants of prescribing. There is a need for translation of the evidence available from human behaviour studies to the design and implementation of stewardship interventions and policies at hospital and community levels. The integration of behaviour experts into multidisciplinary stewardship teams seems essential to positively impact on prescribers' communication and decision-making competencies, and reduce inappropriate antibiotic prescribing

Enforcing surveillance of antimicrobial resistance and antibiotic use to drive stewardship: experience in a paediatric setting

Background: Antibiotic Stewardship (AS) interventions in paediatrics are still not standardized regarding methodology, metrics, and outcomes. We report the results of an AS intervention in the paediatric area based on education and guideline provision via an electronic App. Materials and methods: The AS intervention was conducted in 2021 through observation, education, audit and feedback and provision of an electronic App (Firstline.org) to support antibiotic prescription based on local susceptibility data. The primary outcome was the antibiotic consumption in the 12-months following the intervention (year 2022) compared to a historical 12-month control (year 2019) via an interrupted time series analysis. Secondary outcomes were appropriateness of therapy, length-of-stay, 30-day readmission, transfers to the paediatric intensive care unit, in-hospital mortality, and prevalence of antimicrobial resistance (AMR). Results: During the post-intervention phase, 29 cross-sectional audits and feedback were conducted including 467 patients. Prescriptions were appropriate according to the guidelines in 85.7% of cases, with a stable trend over time. A significant decrease of antibiotic consumption was measured in terms of Defined Daily Doses per 1000 Patient Days (-222.13; p<0.001) and Days of Therapy per 1000 Patient Days (-452.49; p <0.001) in the post-intervention period with a clear inversion of the Access to Watch ratio (from 0.7 to 1.7). Length of stay, in-hospital mortality, ICU transfers, and incidence of AMR infections remained stable, while 30-day readmission decreased from 4.9 per 100 admissions to 2.8 per 100 admissions (p <0.001). Conclusions: The intervention was associated with a significant reduction in antimicrobial consumption and an increase in the appropriateness of prescriptions. Electronic tools can be of value in promoting adherence to guidelines and ensuring the sustainability of results

The antimicrobial resistance travel tool, an interactive evidence-based educational tool to limit antimicrobial resistance spread

Background: International travel has been recognized as a risk factor contributing to the spread of antimicrobial resistance (AMR). However, tools focused on AMR in the context of international travel and designed to guide decision making are limited. We aimed at developing an evidence-based educational tool targeting both healthcare professionals (HCPs) and international travellers to help prevent the spread of AMR. Methods: A literature review on 12 antimicrobial-resistant bacteria (ARB) listed as critical and high tiers in the WHO Pathogen Priority List covering four key-areas was carried out: AMR surveillance data; epidemiological studies reporting ARB prevalence data on carriage in returning travellers; guidance documents reporting indications on screening for ARB in returning travellers; and recommendations for ARB prevention for the public. The evidence, catalogued at country-level, provided the content for a series of visualizations that allow assessment of the risk of AMR acquisition through travel. Results: Up to January 2021, the database includes data on: i) AMR surveillance for 2.018.241 isolates from 86 countries; ii) ARB prevalence of carriage from 11.679 international travellers; iii) 15 guidance documents published by major public health agencies. The evidence allowed the development of a consultation scheme for the evaluation of risk factors, prevalence of carriage, proportion, and recommendations for screening of AMR. For the public, pre-travel practical measures to minimize the risk of transmission were framed. Conclusions: This easy-to-use, annually updated, freely accessible AMR travel tool (https://epi-net.eu/travel-tool/overview/), is the first of its kind to be developed. For HCPs, it can provide a valuable resource for teaching and a repository that facilitates a stepwise assessment of the risk of AMR spread and strengthen implementation of optimized infection control measures. Similarly, for travellers the tool has the potential to raise awareness of AMR and outlines preventive measures that reduce the risk of AMR acquisition and spread

White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in long-term care facilities-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks

BACKGROUND: In long-term care facilities (LTCFs) residents often receive inappropriate antibiotic treatment and infection prevention and control practices are frequently inadequate, thus favouring acquisition of MDR organisms. There is increasing evidence in the literature describing antimicrobial stewardship (AMS) activities in LTCFs, but practical guidance on how surveillance data should be linked with AMS activities in this setting is lacking. To bridge this gap, the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks joined their efforts to provide practical guidance for linking surveillance data with AMS activities.MATERIALS AND METHODS: Considering the three main topics [AMS leadership and accountability, antimicrobial usage (AMU) and AMS, and antimicrobial resistance (AMR) and AMS], a literature review was performed and a list of target actions was developed. Consensus on target actions was reached through a RAND-modified Delphi process involving 40 experts from 18 countries and different professional backgrounds adopting a One Health approach.RESULTS: From the 25 documents identified, 25 target actions were retrieved and proposed for expert evaluation. The consensus process produced a practical checklist including 23 target actions, differentiating between essential and desirable targets according to clinical relevance and feasibility. Flexible proposals for AMS team composition and leadership were provided, with a strong emphasis on the need for well-defined and adequately supported roles and responsibilities. Specific antimicrobial classes, AMU metrics, pathogens and resistance patterns to be monitored are addressed. Effective reporting strategies are described.CONCLUSIONS: The proposed checklist represents a practical tool to support local AMS teams across a wide range of care delivery organization and availability of resources

Antimicrobial Stewardship in COVID-19 Patients: Those Who Sow Will Reap Even through Hard Times

Background: Since the SARS-CoV-2 pandemic emerged, antimicrobial stewardship (AS) activities need to be diverted into COVID-19 management. Methods: In order to assess the impact of COVID-19 on AS activities, we analyzed changes in antibiotic consumption in moderate-to-severe COVID-19 patients admitted to four units in a tertiary-care hospital across three COVID-19 waves. The AS program was introduced at the hospital in 2018. During the first wave, COVID-19 forced the complete withdrawal of hospital AS activities. In the second wave, antibiotic guidance calibration for COVID-19 patients was implemented in all units, with enhanced stewardship activities in Units 1, 2, and 3 (intervention units). In a controlled before and after study, antimicrobial usage during the three waves of the COVID-19 pandemic was compared to the 12-month prepandemic unit (Unit 4 acted as the control). Antibiotic consumption data were analyzed as the overall consumption, stratified by the World Health Organization AWaRe classification, and expressed as defined-daily-dose (DDD) and days-of-therapy (DOT) per 1000 patient-day (PD). Results: In the first wave, the overall normalized DOT in units 2–4 significantly exceeded the 2019 level (2019: 587 DOT/1000 PD ± 42.6; Unit 2: 836 ± 77.1; Unit 3: 684 ± 122.3; Unit 4: 872, ± 162.6; p p < 0.05). Antimicrobial stewardship activities resulted in a decreased amount of total antibiotic consumption over time and positively affected the watch class and piperacillin-tazobactam use in the involved units. Conclusions: During a pandemic, the implementation of calibrated AS activities represents a sound investment in avoiding inappropriate antibiotic therapy

White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the outpatient sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks.

The outpatient setting is a key scenario for the implementation of antimicrobial stewardship (AMS) activities, considering that overconsumption of antibiotics occurs mainly outside hospitals. This publication is the result of a joint initiative by the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks, which is aimed at formulating a set of target actions for linking surveillance data with AMS activities in the outpatient setting. A scoping review of the literature was carried out in three research areas: AMS leadership and accountability; antimicrobial usage and AMS; antimicrobial resistance and AMS. Consensus on the actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine or public health, from 18 low-, middle- and high-income countries. Evidence was retrieved from 38 documents, and an initial 25 target actions were proposed, differentiating between essential or desirable targets according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for all targets. Further to a second review, 6 statements were re-considered and 3 were deleted, leading to a final list of 22 target actions in the form of a practical checklist. This White Paper is a pragmatic and flexible tool to guide the development of calibrated surveillance-based AMS interventions specific to the outpatient setting, which is characterized by substantial inter- and intra-country variability in the organization of healthcare structures, maintaining a global perspective and taking into account the feasibility of the target actions in low-resource settings