Along with the emergence of antibiotic resistance, the steady decline in the discovery of new antibiotics creates one of the greatest current threats to human health. Antibiotic Stewardship Programs (ASPs) have been designed to monitor and improve the appropriateness of antibiotic use, which has been shown to be beneficially associated with patient outcomes, adverse events, resistance rates and costs. Current guidelines provide recommendations on three “building blocks” for successful stewardship stewardship prerequisites, stewardship objectives and improvement strategies. This thesis was divided into three main parts: First, we systematically developed a survey based on these three building blocks for ASPs and evaluated the current state of ASP in acute care hospitals in four European countries: the Netherlands, Slovenia, France and Italy. Second, we performed a cluster-randomized multicenter study to assess the difference in effect on length of hospital stay (LOS) and days of antibiotic therapy (DOT) between three recommended methods to measure and feedback information on hospital antibiotic use, when used as the first step of a stewardship intervention. Subsequently, we conducted a cost-benefit analysis alongside the cluster-randomized multicenter study. Third, we applied a modified-RAND Delphi procedure to systematically develop a set of four actionable quality indicators and one quantity metric for appropriate antibiotic use in adult ICUs, In addition, we developed an implementation toolbox, containing possible barriers that lead to poor performance on the selected indicators, and improvement strategies to overcome these specific barriers, with the aim to support stewardship actions aiming at increasing performance on antibiotic use. With this thesis we contributed to optimizing appropriate antibiotic use in hospitalized patients in order to reduce antibiotic resistance rates

Kallen, M.C.

Along with the emergence of antibiotic resistance, the steady decline in the discovery of new antibiotics creates one of the greatest current threats to human health. Antibiotic Stewardship Programs (ASPs) have been designed to monitor and improve the appropriateness of antibiotic use, which has been shown to be beneficially associated with patient outcomes, adverse events, resistance rates and costs. Current guidelines provide recommendations on three “building blocks” for successful stewardship stewardship prerequisites, stewardship objectives and improvement strategies.This thesis was divided into three main parts:First, we systematically developed a survey based on these three building blocks for ASPs and evaluated the current state of ASP in acute care hospitals in four European countries: the Netherlands, Slovenia, France and Italy.Second, we performed a cluster-randomized multicenter study to assess the difference in effect on length of hospital stay (LOS) and days of antibiotic therapy (DOT) between three recommended methods to measure and feedback information on hospital antibiotic use, when used as the first step of a stewardship intervention. Subsequently, we conducted a cost-benefit analysis alongside the cluster-randomized multicenter study.Third, we applied a modified-RAND Delphi procedure to systematically develop a set of four actionable quality indicators and one quantity metric for appropriate antibiotic use in adult ICUs, In addition, we developed an implementation toolbox, containing possible barriers that lead to poor performance on the selected indicators, and improvement strategies to overcome these specific barriers, with the aim to support stewardship actions aiming at increasing performance on antibiotic use.With this thesis we contributed to optimizing appropriate antibiotic use in hospitalized patients in order to reduce antibiotic resistance rates

International Migration, Integration and Social Cohesion online publications

UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Antibiotic stewardshipMeasuring and improving antibiotic use in hospitalsKallen, M.C.Publication date2019Document VersionOther versionLicenseOtherLink to publicationCitation for published version (APA):Kallen, M. C. (2019). Antibiotic stewardship: Measuring and improving antibiotic use inhospitals. [Thesis, fully internal, Universiteit van Amsterdam].General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:09 Mar 202311Summary in English285Summary in English11Since their discovery in the twentieth century, antibiotics have improved patient out-comes and provided health care opportunities. The eff ectiveness and easy availability of antibiotics, however, has led to overuse, causing bacteria to develop resistance against antibiotics. Along with the emergence of antibiotic resistance, the steady decline in the discovery of new antibiotics creates one of the greatest current threats to human health. Antibiotic Stewardship Programs (ASPs) have been designed to monitor and improve the appropriateness of antibiotic use, which has been shown to be benefi cially associ-ated with patient outcomes, adverse events, resistance rates and costs.In Chapter 1 we introduced the three building blocks for a successful ASP: stewardship prerequisites, stewardship objectives and improvement strategies. We emphasized the importance of proper monitoring of antibiotic use in hospitals and described diff erent methods available to measure and feedback on in-hospital antibiotic use, ranging from continuously monitoring quantitative antibiotic use at an institutional level, to perform-ing point-prevalence studies (PPS) on the appropriateness of antibiotic use in individual patients. In addition, we emphasized the importance of tailoring improvement activities based on local barriers, since performance might be hindered by a variety of barriers, and barriers in one setting may not be present in another. The chapter ends with an overview of research questions addressed in this thesis.In Chapter 2, we systematically developed a survey based on the three building blocks for ASPs. The systematic literature search resulted in 57 potentially relevant articles and two additional checklists, from which a total of 955 survey questions were selected and categorized. The fi nal survey consisted of 46 questions. Using this survey, we evaluated the current state of antibiotic stewardship in 80 Dutch acute care hospitals. The response rate was 80% (n=64), indicating a reliable refl ection of the current situation in Dutch acute care hospitals. Ninety-four percent of hospitals had established an antibiotic stew-ardship team (“A-team”). Nine percent received dedicated IT support. Fifty-one percent of the teams were fi nancially supported, with a median of 0.6 FTE per team (0.1 – 1.8). Each participating hospital carried out stewardship improvement strategies, but the level of activity diff ered. The majority of A-teams monitored the use of restricted agents (91%), therapeutic drug monitoring (TDM) (65%), bedside consultation (56%) and IV-to-oral switch (53%). Other stewardship objectives were monitored in only one third of the hospitals. Fifty-eight percent of the hospitals provided education to residents and 28% to specialists.Similarly, Chapter 3 describes the current state of ASP in acute care hospitals in four European countries: the Netherlands, Slovenia, France and Italy. Survey response rates were 80% (n= 64), 86% (n=25), 45% (n=97) and 66% (n=41), respectively. A formal ASP Chapter 11286program was present mainly in the Netherlands (91%) and France (84%). Presence of a stewardship team ranged from 42% in France up to 94% in the Netherlands. Lack of salary support for stewardship teams was an issue in all four countries: salary was pro-vided in 12% in Italy up to 68% in France, but often this was not suffi  cient to optimally develop and maintain ASPs. Furthermore, the countries varied substantially in the use of ‘prospective monitoring and advice’ as a strategy to improve stewardship objectives.Overall, there was variation between and within countries in the prerequisites met, and the objectives and improvement strategies chosen. Despite the many eff orts made in the last years to fi ght antibiotic resistance and implement antibiotic stewardship at the national and international level, our survey showed that there is room for improvement.A requirement for an eff ective stewardship program is the ability to measure the appro-priateness of antibiotic use in individual patients. An acknowledged method to measure the quality of antibiotic use is the use of quality indicators (QIs). QIs are measurable elements of practice performance which can be used to assess the quality of antibiotic care provided. In the past decade, many QIs have been designed to measure the quality of antibiotic care provided. In Chapter 4 we performed a systematic review to assess the currently available QIs for appropriate antibiotic use in hospitalized adult patients. Fourteen studies were included in the literature review, describing a total of 200 QIs: 17 structure and 183 process indicators. The most frequently mentioned QIs concerned empirical antibiotic therapy according to the guideline (71% of studies), switch from IV to oral therapy (64% of studies), drawing at least two sets of blood cultures and change to pathogen-directed therapy based on culture results (57% of studies). Moreover, we assessed the development methodology and validation procedures of these QIs. A (RAND)-modifi ed Delphi procedure was used in the majority of studies (57%). Six stud-ies took outcome measures into consideration during the procedure. Only fi ve out of fourteen studies (36%) tested the clinimetric properties of the QIs in practice; 41 of the 63 tested QIs (65%) were considered valid for use in the clinical setting. Overall, the set of QIs developed by the Drive AB group and the set of QIs developed by van den Bosch et al. were the most comprehensive, but only van den Bosch et al. had validated their QIs in a clinical setting. Therefore, we recommend in comparable settings to apply the set of QIs by van den Bosch et al. to measure and feedback on in-hospital antibiotic use.Another acknowledged method to measure antibiotic use in ASPs is the use of quan-titative data. In Chapter 5 we performed a retrospective observational study, measur-ing overall systemic antibiotic use at specialty-level over a 1-year period in fourteen university and non-university hospitals in the Netherlands. For this purpose the most frequently used metrics to measure and benchmark antibiotic use were applied: defi ned 287Summary in English11daily dose (DDD) and days of therapy (DOT). We observed a large variation in antibi-otic use between and within hospitals, and a low correlation between DDD and DOT as metrics of total antibiotic use in hospitalized adult patients. Likely, this was caused by diff erences in organisational factors, data sources, data registration and data extrac-tion. In our opinion, a clear understanding of these factors, together with a uniform and transparent approach in defi ning organizational units within hospitals, and uniform data sources, registration and extraction procedures are necessary for reliable measurement and valid comparison of antibiotic use using quantitative data. Therefore, we provided a list with recommendations on how to reliably measure quantitative antibiotic use on a specialty level in order to support an ASP.In Chapter 6 we performed a cluster-randomized multicenter study to assess the dif-ference in eff ect on length of hospital stay (LOS) and days of antibiotic therapy (DOT) between three recommended methods to measure and feedback information on hospital antibiotic use, when used as the fi rst step of a stewardship intervention. The methods were: 1) measurement and feedback on quantity of antibiotic use (DDD, DOT) from past year’s hospital pharmacy data versus feedback on performance scores from point prevalence studies using either 2) validated or 3) non-validated quality indicators (QIs). First, stewardship teams performed the measurements and received a feedback report for both clusters in their hospital. Second, teams were trained to apply a struc-tured approach, using an implementation tool, to systematically develop and perform setting-specifi c stewardship improvement strategies based on the feedback reports. The geometric mean of LOS of the entire patient group, corrected for national secular trends, decreased from 9·5 days (95% CI 8·9 – 10·1, 4245 patients) at baseline to 9·0 days (95% CI 8·5 – 9·6, 4195 patients) after the intervention (p<0·001), but no signifi cant dif-ferences were found between the three measurement and feedback methods. Similar results were found for total, IV and restricted DOT. Even though no diff erence in eff ect was found between the methods, the Overall use method was scored by the steward-ship teams as least eff ective for ASP purposes, compared to the PPS-ECDC and PPS-QI. Apparently, information on quantitative data made it more diffi  cult to select improve-ment targets. Importantly, more consistent use of the stewardship implementation tool resulted in a larger decrease in total DOT, IV DOT and restricted DOT, underlining the importance of a structured approach to stewardship.Subsequently, in Chapter 7,  we conducted a cost-benefi t analysis alongside the cluster-randomized multicenter study, from a hospital perspective, to estimate the costs associ-ated with the study intervention, specifi ed for each of the three recommended methods to measure and feedback information on hospital antibiotic use, in relation to economic benefi ts of the intervention, in terms of reductions in LOS and DOT. Based on a model Chapter 11288estimation the benefi t-to-cost ratios for one cluster during a 20 month intervention period were estimated at 17.8 for the overall use method, 14.7 for the PPS-QI method and 17.1 for the PPS-ECDC method. We showed that structured stewardship interven-tions are potentially cost-benefi cial, and that the type of measurement and feedback method had limited impact on the total costs, but rather the time investment in the development and performance of stewardship strategies.In Chapter 8 we applied a modifi ed-RAND Delphi procedure to systematically develop a set of four actionable quality indicators and one quantity metric for appropriate anti-biotic use in adult ICUs, including: 1) perform at least two sets of blood cultures before start of empirical systemic therapy; 2) perform therapeutic drug monitoring in patients treated with vancomycin or aminoglycosides; 3) perform surveillance cultures if selec-tive digestive or oropharyngeal decontamination is applied at the ICU; 4) biannual face-to-face meetings between ICU and microbiology staff  in which local resistance rates are discussed; and 5) quantitative antibiotic use at the ICU expressed in DOT. In addition, we developed an implementation toolbox, containing a list of 24 possible barriers that lead to poor performance on the selected indicators, and a list of 37 improvement strategies to overcome these specifi c barriers, with the aim to support stewardship actions aiming at increasing performance on antibiotic use. Clinimetric properties of the indicators and feasibility in daily practice of electronic data reuse from the EHR or PDMS will be tested during an evaluation study in the near future.In Chapter 9 we tested the appropriateness of antibiotic use with two sets of QIs at an ICU of a general teaching hospital in the Netherlands: 1) the set of QIs for appropriate antibiotic use at the ICU developed in Chapter 8, and 2) QIs on Selective Digestive tract Decontamination (SDD) based on recommendations by the Dutch Working Party on Antibiotic Policy (SWAB). We showed that, overall, patients received the recommended antibiotic care with regard to performing blood cultures, determining blood levels in time when indicated, obtaining surveillance and colonisation cultures, and stopping third generation cephalosporin therapy. However, there was considerable room for improvement in doubling the dose of SDD if required by protocol. The QIs can be used by hospital stewardship teams to determine where to set priorities to improve the appropriateness of antibiotic use and where to acknowledge successes in critically ill patients admitted at the ICU.In Chapter 10 we summarized our most relevant fi ndings and discussed them against the background of current literature. Furthermore, we provided a general conclusion and recommendations for future research and extension of antibiotic stewardship programs.

English

Antibiotic stewardship:Measuring and improving antibiotic use in hospitals

UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Antibiotic stewardshipMeasuring and improving antibiotic use in hospitalsKallen, M.C.Publication date2019Document VersionOther versionLicenseOtherLink to publicationCitation for published version (APA):Kallen, M. C. (2019). Antibiotic stewardship: Measuring and improving antibiotic use inhospitals.General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:26 Jul 202211Summary in English285Summary in English11Since their discovery in the twentieth century, antibiotics have improved patient out-comes and provided health care opportunities. The eff ectiveness and easy availability of antibiotics, however, has led to overuse, causing bacteria to develop resistance against antibiotics. Along with the emergence of antibiotic resistance, the steady decline in the discovery of new antibiotics creates one of the greatest current threats to human health. Antibiotic Stewardship Programs (ASPs) have been designed to monitor and improve the appropriateness of antibiotic use, which has been shown to be benefi cially associ-ated with patient outcomes, adverse events, resistance rates and costs.In Chapter 1 we introduced the three building blocks for a successful ASP: stewardship prerequisites, stewardship objectives and improvement strategies. We emphasized the importance of proper monitoring of antibiotic use in hospitals and described diff erent methods available to measure and feedback on in-hospital antibiotic use, ranging from continuously monitoring quantitative antibiotic use at an institutional level, to perform-ing point-prevalence studies (PPS) on the appropriateness of antibiotic use in individual patients. In addition, we emphasized the importance of tailoring improvement activities based on local barriers, since performance might be hindered by a variety of barriers, and barriers in one setting may not be present in another. The chapter ends with an overview of research questions addressed in this thesis.In Chapter 2, we systematically developed a survey based on the three building blocks for ASPs. The systematic literature search resulted in 57 potentially relevant articles and two additional checklists, from which a total of 955 survey questions were selected and categorized. The fi nal survey consisted of 46 questions. Using this survey, we evaluated the current state of antibiotic stewardship in 80 Dutch acute care hospitals. The response rate was 80% (n=64), indicating a reliable refl ection of the current situation in Dutch acute care hospitals. Ninety-four percent of hospitals had established an antibiotic stew-ardship team (“A-team”). Nine percent received dedicated IT support. Fifty-one percent of the teams were fi nancially supported, with a median of 0.6 FTE per team (0.1 – 1.8). Each participating hospital carried out stewardship improvement strategies, but the level of activity diff ered. The majority of A-teams monitored the use of restricted agents (91%), therapeutic drug monitoring (TDM) (65%), bedside consultation (56%) and IV-to-oral switch (53%). Other stewardship objectives were monitored in only one third of the hospitals. Fifty-eight percent of the hospitals provided education to residents and 28% to specialists.Similarly, Chapter 3 describes the current state of ASP in acute care hospitals in four European countries: the Netherlands, Slovenia, France and Italy. Survey response rates were 80% (n= 64), 86% (n=25), 45% (n=97) and 66% (n=41), respectively. A formal ASP Chapter 11286program was present mainly in the Netherlands (91%) and France (84%). Presence of a stewardship team ranged from 42% in France up to 94% in the Netherlands. Lack of salary support for stewardship teams was an issue in all four countries: salary was pro-vided in 12% in Italy up to 68% in France, but often this was not suffi  cient to optimally develop and maintain ASPs. Furthermore, the countries varied substantially in the use of ‘prospective monitoring and advice’ as a strategy to improve stewardship objectives.Overall, there was variation between and within countries in the prerequisites met, and the objectives and improvement strategies chosen. Despite the many eff orts made in the last years to fi ght antibiotic resistance and implement antibiotic stewardship at the national and international level, our survey showed that there is room for improvement.A requirement for an eff ective stewardship program is the ability to measure the appro-priateness of antibiotic use in individual patients. An acknowledged method to measure the quality of antibiotic use is the use of quality indicators (QIs). QIs are measurable elements of practice performance which can be used to assess the quality of antibiotic care provided. In the past decade, many QIs have been designed to measure the quality of antibiotic care provided. In Chapter 4 we performed a systematic review to assess the currently available QIs for appropriate antibiotic use in hospitalized adult patients. Fourteen studies were included in the literature review, describing a total of 200 QIs: 17 structure and 183 process indicators. The most frequently mentioned QIs concerned empirical antibiotic therapy according to the guideline (71% of studies), switch from IV to oral therapy (64% of studies), drawing at least two sets of blood cultures and change to pathogen-directed therapy based on culture results (57% of studies). Moreover, we assessed the development methodology and validation procedures of these QIs. A (RAND)-modifi ed Delphi procedure was used in the majority of studies (57%). Six stud-ies took outcome measures into consideration during the procedure. Only fi ve out of fourteen studies (36%) tested the clinimetric properties of the QIs in practice; 41 of the 63 tested QIs (65%) were considered valid for use in the clinical setting. Overall, the set of QIs developed by the Drive AB group and the set of QIs developed by van den Bosch et al. were the most comprehensive, but only van den Bosch et al. had validated their QIs in a clinical setting. Therefore, we recommend in comparable settings to apply the set of QIs by van den Bosch et al. to measure and feedback on in-hospital antibiotic use.Another acknowledged method to measure antibiotic use in ASPs is the use of quan-titative data. In Chapter 5 we performed a retrospective observational study, measur-ing overall systemic antibiotic use at specialty-level over a 1-year period in fourteen university and non-university hospitals in the Netherlands. For this purpose the most frequently used metrics to measure and benchmark antibiotic use were applied: defi ned 287Summary in English11daily dose (DDD) and days of therapy (DOT). We observed a large variation in antibi-otic use between and within hospitals, and a low correlation between DDD and DOT as metrics of total antibiotic use in hospitalized adult patients. Likely, this was caused by diff erences in organisational factors, data sources, data registration and data extrac-tion. In our opinion, a clear understanding of these factors, together with a uniform and transparent approach in defi ning organizational units within hospitals, and uniform data sources, registration and extraction procedures are necessary for reliable measurement and valid comparison of antibiotic use using quantitative data. Therefore, we provided a list with recommendations on how to reliably measure quantitative antibiotic use on a specialty level in order to support an ASP.In Chapter 6 we performed a cluster-randomized multicenter study to assess the dif-ference in eff ect on length of hospital stay (LOS) and days of antibiotic therapy (DOT) between three recommended methods to measure and feedback information on hospital antibiotic use, when used as the fi rst step of a stewardship intervention. The methods were: 1) measurement and feedback on quantity of antibiotic use (DDD, DOT) from past year’s hospital pharmacy data versus feedback on performance scores from point prevalence studies using either 2) validated or 3) non-validated quality indicators (QIs). First, stewardship teams performed the measurements and received a feedback report for both clusters in their hospital. Second, teams were trained to apply a struc-tured approach, using an implementation tool, to systematically develop and perform setting-specifi c stewardship improvement strategies based on the feedback reports. The geometric mean of LOS of the entire patient group, corrected for national secular trends, decreased from 9·5 days (95% CI 8·9 – 10·1, 4245 patients) at baseline to 9·0 days (95% CI 8·5 – 9·6, 4195 patients) after the intervention (p<0·001), but no signifi cant dif-ferences were found between the three measurement and feedback methods. Similar results were found for total, IV and restricted DOT. Even though no diff erence in eff ect was found between the methods, the Overall use method was scored by the steward-ship teams as least eff ective for ASP purposes, compared to the PPS-ECDC and PPS-QI. Apparently, information on quantitative data made it more diffi  cult to select improve-ment targets. Importantly, more consistent use of the stewardship implementation tool resulted in a larger decrease in total DOT, IV DOT and restricted DOT, underlining the importance of a structured approach to stewardship.Subsequently, in Chapter 7,  we conducted a cost-benefi t analysis alongside the cluster-randomized multicenter study, from a hospital perspective, to estimate the costs associ-ated with the study intervention, specifi ed for each of the three recommended methods to measure and feedback information on hospital antibiotic use, in relation to economic benefi ts of the intervention, in terms of reductions in LOS and DOT. Based on a model Chapter 11288estimation the benefi t-to-cost ratios for one cluster during a 20 month intervention period were estimated at 17.8 for the overall use method, 14.7 for the PPS-QI method and 17.1 for the PPS-ECDC method. We showed that structured stewardship interven-tions are potentially cost-benefi cial, and that the type of measurement and feedback method had limited impact on the total costs, but rather the time investment in the development and performance of stewardship strategies.In Chapter 8 we applied a modifi ed-RAND Delphi procedure to systematically develop a set of four actionable quality indicators and one quantity metric for appropriate anti-biotic use in adult ICUs, including: 1) perform at least two sets of blood cultures before start of empirical systemic therapy; 2) perform therapeutic drug monitoring in patients treated with vancomycin or aminoglycosides; 3) perform surveillance cultures if selec-tive digestive or oropharyngeal decontamination is applied at the ICU; 4) biannual face-to-face meetings between ICU and microbiology staff  in which local resistance rates are discussed; and 5) quantitative antibiotic use at the ICU expressed in DOT. In addition, we developed an implementation toolbox, containing a list of 24 possible barriers that lead to poor performance on the selected indicators, and a list of 37 improvement strategies to overcome these specifi c barriers, with the aim to support stewardship actions aiming at increasing performance on antibiotic use. Clinimetric properties of the indicators and feasibility in daily practice of electronic data reuse from the EHR or PDMS will be tested during an evaluation study in the near future.In Chapter 9 we tested the appropriateness of antibiotic use with two sets of QIs at an ICU of a general teaching hospital in the Netherlands: 1) the set of QIs for appropriate antibiotic use at the ICU developed in Chapter 8, and 2) QIs on Selective Digestive tract Decontamination (SDD) based on recommendations by the Dutch Working Party on Antibiotic Policy (SWAB). We showed that, overall, patients received the recommended antibiotic care with regard to performing blood cultures, determining blood levels in time when indicated, obtaining surveillance and colonisation cultures, and stopping third generation cephalosporin therapy. However, there was considerable room for improvement in doubling the dose of SDD if required by protocol. The QIs can be used by hospital stewardship teams to determine where to set priorities to improve the appropriateness of antibiotic use and where to acknowledge successes in critically ill patients admitted at the ICU.In Chapter 10 we summarized our most relevant fi ndings and discussed them against the background of current literature. Furthermore, we provided a general conclusion and recommendations for future research and extension of antibiotic stewardship programs.

NARCIS 

Antibiotic stewardship: Measuring and improving antibiotic use in hospitals

UvA-DARE

https://pure.uva.nl/ws/files/35537799/Chapter_11.pdf

Antibiotic stewardship: Measuring and improving antibiotic use in hospitals

Abstract

Similar works

Full text

Available Versions

International Migration, Integration and Social Cohesion online publications

International Migration, Integration and Social Cohesion online publications

NARCIS

UvA-DARE