Antimicrobial stewardship programs in a hospital setting : development of quality indicators and implementation of interventions

Health care is challenged by the emergence of antibiotic resistance and the slow pipeline of new antibiotics, especially against Gram negative multi-resistant bacteria. The most important cause of emergence and spread of antimicrobial resistance has been a massive overuse of antibiotics worldwide across all ecosystems over the past decades, including humans, animals, aquaculture, and agriculture. Antimicrobial resistance may lead to more difficult to treat infections and may hence be associated with increased patient mortality, longer hospital stays, and increased healthcare costs. Up to 30% of antimicrobial regimens in hospitals are considered inappropriate. An effective approach to improving antimicrobial use in hospitals is an organised antimicrobial stewardship program. In this thesis we tried to develop and validate quality indicators in order to monitor antimicrobial stewardship programs in a hospital setting. Furthermore we evaluated key components of an antimicrobial stewardship program to optimize antimicrobial prescribing. With a multidisciplinary panel from four European countries we developed 57 structure indicators from which ten indicators were identified as a minimal set of key indicators. A validation survey in eleven European hospitals showed a significant heterogeneity with regard to their scoring for structural components of effective antibiotic stewardship. We concluded that potential structure indicators examined in this study, with focus on the top-ten indicators, could be used for regular assessment of the extent and strength of hospital antimicrobial stewardship programs. The feasibility and clinical relevance of measuring a process indicator for appropriate iv use of highly bioavailable antimicrobial drugs, allowing early IV to oral switch, was evaluated revealing a substantial heterogeneity of the performance gap. Absence of an iv-to-po switch programme was associated with more inappropriate prescribing. The results of this study indicated that the iv-to-po quality indicator is widely applicable and could be a tool to evaluate compliance with iv-to-po switch guidelines. Optimizing antibiotic dosing regimens is a core activity within an antimicrobial stewardship program. Extended and continuous infusions with betalactam antibiotics have been suggested as a means of pharmacokinetic and pharmacodynamic optimisation of antimicrobial therapy. A survey was undertaken to investigate the recommendations on extended and continuous infusions of ceftazidime, cefepime, piperacillin–tazobactam, meropenem and vancomycin by the local antibiotic management teams (AMTs) in Belgian acute hospitals. This survey showed that extended and continuous infusions are widely implemented in Belgian hospitals but revealed significant variation in the recommended dosing regimens. Two interventional studies were performed to optimize antimicrobial prescribing. These focused on appropriate timing of the initiation of an antimicrobial treatment for presumed infections in the emergency ward and on parenteral to oral conversion of fluoroquinolone antibiotics. We showed that the implementation of merely persuasive interventions such as hospital-wide publication of guidelines in the local drug letter and educational interactive sessions towards nurses and physicians only resulted in limited improvement. However, a pro-active intervention by a clinical pharmacist to stimulate parenteral to oral conversion resulted in a significant reduction of the duration of the intravenous treatment, as well as in treatment cost. Finally we assessed the functioning of a multidisciplinary infectious diseases team (MIT), which is an example of educational outreach intervention. The MIT formulated a daily average of 5 interventions for non-critically ill adult patients in a teaching hospital. Following bedside assessment by junior staff, diagnostic and therapeutic recommendations were communicated by phone and by notes towards prescribers in the electronic patient file resulting in high acceptance rates, in particular for therapeutic recommendations. In general this thesis provides indicators to the AMT’s to evaluate their antimicrobial stewardship activities. Proactive interventions on an individual patient level are needed to optimize antimicrobial prescribing

Surgical antibiotic prophylaxis in a Belgian teaching hospital : a retrospective evaluation

C

Quality indicators for responsible antibiotic use in the inpatient setting: a systematic review followed by an international multidisciplinary consensus procedure

Background This study was conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project and aimed to develop generic quality indicators (QIs) for responsible antibiotic use in the inpatient setting. Methods A RAND-modified Delphi method was applied. First, QIs were identified by a systematic review. A complementary search was performed on web sites of relevant organizations. Duplicates were removed and disease and patient-specific QIs were combined into generic indicators. The relevance of these QIs was appraised by a multidisciplinary international stakeholder panel through two questionnaires and an in-between consensus meeting. Results The systematic review retrieved 70 potential generic QIs. The QIs were appraised by 25 international stakeholders with diverse backgrounds (medical community, public health, patients, antibiotic research and development, regulators, governments). Ultimately, 51 QIs were selected in consensus. QIs with the highest relevance score included: (i) an antibiotic plan should be documented in the medical record at the start of the antibiotic treatment; (ii) the results of bacteriological susceptibility testing should be documented in the medical record; (iii) the local guidelines should correspond to the national guidelines but should be adapted based on local resistance patterns; (iv) an antibiotic stewardship programme should be in place at the healthcare facility; and (v) allergy status should be taken into account when antibiotics are prescribed. Conclusions This systematic and stepwise method combining evidence from literature and stakeholder opinion led to multidisciplinary international consensus on generic inpatient QIs that can be used globally to assess the quality of antibiotic use

Evaluation of Belgian hospital drug formularies based on quality indicators

Study objectives: The Drug and Therapeutics Committee (DTC) has an essential role in managing the pharmacotherapeutic policy of a hospital. Because the formulary is a guide for appropriate drug selection and a tool for supporting the quality of drug use and cost control, it should be complete, concise and easy to use. The purpose of this study was to evaluate the format, organisation and content of formularies used in Belgian hospitals. Indicators, proposed on the basis of a literature review, were evaluated for validity, clarity and accessibility by two senior and five junior pharmacists. The selected indicators were classified in five groups: technical features, user-friendliness, information on drug procedures, product specific information and guidelines. Points were assigned to each indicator, according to their importance, to give a total of 1,000 points. The formularies were evaluated based on this model. Results: Seventy-three Belgian hospital formularies were evaluated. A current list of the medicines available in the formulary was presented by 69% of the hospitals. A minority of these (24%) were presented in a pocket format. Only a few formularies mentioned the objectives, tasks and constitution of the DTC. Four formularies (5%) contained guidelines for empirical treatment of infections. The quality of the majority of the formularies, according to the predefined indicators, was poor, with a mean of 145 points out a possible total of 1,000. Conclusion: The evaluation of 73 Belgian hospital formularies showed that their quality varies and should be enhanced in order to serve its target groups better

Antifungal drugs and rational use of antifungals in treating invasive aspergillosis: the role of the hospital pharmacist

Aim:This review discusses the most common used antifungal agents in the treatment of invasive fungal infections. In addition, guidelines for the treatment of invasive aspergillosis, as used in the Ghent University Hospital, are described. Moreover, the importance of determining the effectiveness of antifungal therapy as well as the potential role of the hospital pharmacist in the management of this infection is highlighted. Methods:A review of the English-language literature was conducted using the MEDLINE database and scientific websites. Search terms including antimycotics, antifungal therapy and invasive aspergillosis were used to refine the search, and preference was given to studies published after 1992. This was completed with recent treatment guidelines. Results:An overview of the most recent advances in antifungal therapy is described. In addition, a flowchart for treatment of invasive aspergillosis (proven, probable or possible) has been developed. Conclusion:Invasive fungal infections will remain a frequent and important complication of modern medicine. Considering the clinical and financial outcome of invasive fungal infections, the role of the hospital pharmacist can be a paramount to the treatment