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Improving Antimicrobial Use in Hospitalized Patients

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A special issue of Pharmacy (ISSN 2226-4787). This special issue belongs to the section "Pharmacy Practice and Practice-Based Research".

Deadline for manuscript submissions: closed (30 December 2021) | Viewed by 30396

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Special Issue Editors

Dr. Kayla R. Stover

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Guest Editor

Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
Interests: infectious diseases; antifungals; antimicrobial stewardship; pharmacy education and training
Special Issues, Collections and Topics in MDPI journals

Dr. Katie E. Barber

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Guest Editor

Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
Interests: optimizing pharmacokinetics/pharmacodynamics to overcome bacterial resistance; evaluating clinical outcomes in patients with altered pharmacokinetics/pharmacodynamics
Special Issues, Collections and Topics in MDPI journals

Dr. Jamie L. Wagner

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Guest Editor

Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
Interests: antimicrobial stewardship; gram-negative resistance; clinical outcomes
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

We are editing a Special Issue in the journal Pharmacy, focusing on “Improving Antimicrobial Use in Hospitalized Patients”. Overuse and misuse of antibiotics have resulted in rapidly increasing rates of resistance, making common infectious diseases more difficult to treat. The use of antimicrobial stewardship principles to slow the emergence and spread of resistant bacteria has been recognized globally as an important tool in optimizing antimicrobial usage. Through optimization of drug, dose, duration, and spectrum of activity, antimicrobial stewards can improve patient outcomes, reduce hospital-associated costs, and reduce the development of further bacterial resistance. In order to achieve these objectives, stewards and other practitioners are implementing innovative initiatives that provide practical guidance for antimicrobial use and solutions to potential barriers, as well as enhancing accountability of antibiotic prescribing to ultimately improve patient outcomes. Sharing these initiatives is invaluable, therefore, we invite you to submit your research and/or innovative methods that you’ve employed to improve antimicrobial use at your institution or health system.

We invite you to share your approaches and successes in improving antimicrobial use in hospitalized patients. We welcome submissions of all types, including original research, brief reports of original research, reviews, or short communications. In addition, we welcome submission of resident or trainee research projects that focused on improving antimicrobial use in hospitalized patients. We hope this Special Issue will inspire other stewards and practitioners to share their own practices, adopt new approaches, and innovate to advance stewardship principles.

Pharmacy (ISSN 2226-4787, https://0-www-mdpi-com.brum.beds.ac.uk/journal/pharmacy) is an international scientific peer-reviewed open access journal on pharmacy education and practice published quarterly online by MDPI. It is indexed by databases including EMBASE (Elsevier), HINARI (WHO), and PubMed (NLM).

Dr. Kayla R. Stover
Dr. Katie E. Barber
Dr. Jamie L. Wagner
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Pharmacy is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

antimicrobial use
stewardship
resistance
outcomes
process measures
metrics

Published Papers (9 papers)

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Research

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10 pages, 412 KiB

Open AccessArticle

Intravenous versus Oral Step-Down for the Treatment of Staphylococcus aureus Bacteremia in a Pediatric Population

by Sarah Grace Gunter, Mary Joyce B. Wingler, David A. Cretella, Jamie L. Wagner, Katie E. Barber and Kayla R. Stover

Pharmacy 2022, 10(1), 16; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy10010016 - 15 Jan 2022

Cited by 2 | Viewed by 2886

Abstract

Limited data are available regarding optimal antimicrobial therapy for Staphylococcus aureus bacteremia (SAB) in pediatric patients. The purpose of this study was to assess clinical characteristics and outcomes associated with intravenous (IV) versus oral step-down treatment of pediatric SAB. This study evaluated patients aged 3 months to 18 years that received at least 72 h of inpatient treatment for SAB. The primary endpoint was 30-day readmission. Secondary endpoints included hospital length of stay and inpatient mortality. One hundred and one patients were included in this study. The median age was 7.9 years. Patients who underwent oral step-down were less likely to be immunocompromised and more likely to have community-acquired SAB from osteomyelitis or skin and soft tissue infection (SSTI). More patients in the IV therapy group had a 30-day readmission (10 (25.6%) vs. 3 (5.3%), p = 0.006). Mortality was low (5 (5%)) and not statistically different between groups. Length of stay was greater in patients receiving IV therapy only (11 vs. 7 days, p = 0.001). In this study, over half of the patients received oral step-down therapy and 30-day readmission was low for this group. Oral therapy appears to be safe and effective for patients with SAB from osteomyelitis or SSTIs. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

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9 pages, 244 KiB

Open AccessArticle

Linezolid for the Treatment of Urinary Tract Infections Caused by Vancomycin-Resistant Enterococci

by Mary Joyce Wingler, Neel R. Patel, S. Travis King, Jamie L. Wagner, Katie E. Barber and Kayla R. Stover

Pharmacy 2021, 9(4), 175; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9040175 - 26 Oct 2021

Cited by 6 | Viewed by 5155

Abstract

Vancomycin-resistant enterococci (VRE) account for a large proportion of hospital-acquired infections. Determining optimal treatment of VRE urinary tract infections (UTIs) is challenging. The purpose of this study was to determine if a difference in efficacy or safety exists between linezolid and non-linezolid treatments for VRE UTIs. This retrospective cohort evaluated patients admitted between 1 June 2012–30 November 2017 who were treated for VRE UTI. Patients must have had at least one sign, symptom, or laboratory confirmation of UTI to be included. The primary endpoint of this study was difference in clinical cure between linezolid and non-linezolid treatment options. Secondary endpoints included 30-day recurrence, 30-day infection-related readmission, inpatient mortality, infection-related hospital length of stay (LOS), and time to appropriate therapy. A total of 45 patients (33 linezolid and 12 non-linezolid) were included. Clinical cure occurred in 71.4% linezolid and 58.3% non-linezolid (p = 0.476). No patients had a 30-day infection-related readmission or 30-day recurrence. Of the 45 patients, 6 (13.3%) patients died during admission, and 5 of those deaths were in the linezolid group (p = 1.000). No significant difference was found for clinical cure between linezolid and non-linezolid treatment options for VRE UTIs. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

8 pages, 544 KiB

Open AccessArticle

Influence of Probiotics on the Development of Clostridioides difficile Infection in Patients Receiving Fluoroquinolones

by Mary E. Sheffield, Bruce M. Jones, Blake Terrell, Jamie L. Wagner and Christopher M. Bland

Pharmacy 2021, 9(3), 141; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9030141 - 18 Aug 2021

Cited by 3 | Viewed by 3506

Abstract

Fluoroquinolones are associated with an increased risk of Clostridioides difficile infection (CDI). Probiotic supplementation has been shown to reduce the risk of antibiotic-associated diarrhea with variable effects on CDI. The objective of this study was to evaluate receipt of probiotics on development of primary CDI among hospitalized patients receiving fluoroquinolones. A retrospective cohort was evaluated that consisted of two groups of 100 patients each, admitted August 2018 through August 2020 that received ≥3 days of definitive monotherapy with levofloxacin or ciprofloxacin within 72 h of admission. Primary outcome was incidence of CDI. Secondary outcomes included rates of C. difficile diagnostic stool testing, additional infectious diagnostic testing, and non-CDI related gastrointestinal side effects. Patients on fluoroquinolones who received probiotics had a non-statistically significantly lower incidence in overall cases of CDI compared to those who did not receive probiotics (0% vs. 3%, p = 0.246). Patients who received probiotics had statistically significantly fewer C. difficile diagnostic stool tests performed (4% vs. 16%, p = 0.005) and fewer additional infectious diagnostic testing performed (4% vs. 10%, p = 0.096), respectively. Further research is warranted to optimize and standardize probiotic prescribing in high-risk patients. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

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7 pages, 506 KiB

Open AccessArticle

Treatment of Asymptomatic Bacteriuria after Implementation of an Inpatient Urine Culture Algorithm in the Electronic Medical Record

by Dianne Osiemo, Danny K. Schroeder, Donald G. Klepser, Trevor C. Van Schooneveld, Andrew B. Watkins and Scott J. Bergman

Pharmacy 2021, 9(3), 138; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9030138 - 11 Aug 2021

Cited by 3 | Viewed by 3523

Abstract

Ordering urine cultures in patients without pyuria is associated with the inappropriate treatment of asymptomatic bacteriuria (ASB). In 2015, our institution implemented recommendations based on practice guidelines for the management of ASB and revised the urine culture ordering process to limit cultures in immunocompetent patients without pyuria. The purpose of this study was to determine how the treatment of ASB has changed over time since altering the urine culture ordering process to reduce unnecessary cultures at an academic medical center. A quasi-experimental study was conducted for inpatients with urine cultures from January to March of 2014, 2015, 2016 and 2020. The primary outcome was the antibiotic treatment of asymptomatic bacteriuria for over 24 h. The secondary outcomes were the total days of antibiotic therapy, type of antibiotic prescribed and overall urine culture rates at the hospital. A total of 200 inpatients with ASB were included, 50 at random from each year. In both 2014 and 2015, 70% of the patients with ASB received antibiotic treatment. Antibiotics were prescribed to 68% and 54% of patients with ASB in 2016 and 2020, respectively. The average duration of therapy decreased from 5.12 days in 2014 to 3.46 days in 2020. Although the urine cultures were reduced, there was no immediate impact in the prescribing rates for patients with ASB after implementing this institutional guidance and an altered urine culture ordering process. Over time, there was an observed improvement in prescribing and the total days of antibiotic therapy. This could be attributed to increased familiarity with the guidelines, culture ordering practices or improved documentation. Based on these findings, additional provider education is needed to reinforce the guideline recommendations on the management of ASB. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

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7 pages, 1751 KiB

Open AccessArticle

Use of a Novel Clinical Decision Support Tool for Pharmacist-Led Antimicrobial Stewardship in Patients with Normal Procalcitonin

by Andrew B. Watkins, Trevor C. Van Schooneveld, Craig G. Reha, Jayme Anderson, Kelley McGinnis and Scott J. Bergman

Pharmacy 2021, 9(3), 136; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9030136 - 06 Aug 2021

Cited by 4 | Viewed by 2731

Abstract

In 2018, a clinical decision support (CDS) tool was implemented as part of a “daily checklist” for frontline pharmacists to review patients on antibiotics with procalcitonin (PCT) <0.25 mcg/L. This study used a retrospective cohort design to assess change in antibiotic use from pharmacist interventions after this PCT alert in patients on antibiotics for lower respiratory tract infections (LRTI). The secondary outcome was antibiotic days of therapy (DOT), with a subgroup analysis examining antibiotic use and the length of stay (LOS) in patients with a pharmacist intervention. From 1/2019 to 11/2019, there were 165 alerts in 116 unique patients on antibiotics for LRTI. Pharmacists attempted interventions after 34 (20.6%) of these alerts, with narrowing spectrum or converting to oral being the most common interventions. Pharmacist interventions prevented 125 DOT in the hospital. Vancomycin was the most commonly discontinued antibiotic with an 85.3% use reduction in patients with interventions compared to a 27.4% discontinuation in patients without documented intervention (p = 0.0156). The LOS was similar in both groups (median 6.4 days vs. 7 days, p = 0.81). In conclusion, interventions driven by a CDS tool for pharmacist-driven antimicrobial stewardship in patients with a normal PCT resulted in fewer DOT and significantly higher rates of vancomycin discontinuation. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

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9 pages, 223 KiB

Open AccessCommunication

Potential Excess Intravenous Antibiotic Therapy in the Setting of Gram-Negative Bacteremia

by Ashley R. Selby, Jaffar Raza, Duong Nguyen and Ronald G. Hall 2nd

Pharmacy 2021, 9(3), 133; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9030133 - 03 Aug 2021

Viewed by 2742

Abstract

(1) Background: Excessive intravenous therapy (EIV) is associated with negative consequences, but guidelines are unclear about when switching to oral therapy is appropriate. (2) Methods: This cohort included patients aged ≥18 years receiving ≥48 h of antimicrobial therapy for bacteremia due to Escherichia coli, Pseudomonas aeruginosa, Enterobacter, Klebsiella, Acinetobacter, or Stenotrophomonas maltophilia from 1/01/2008–8/31/2011. Patients with a polymicrobial infection or recurrent bacteremia were excluded. Potential EIV (PEIV) was defined as days of intravenous antibiotic therapy beyond having a normal WBC count for 24 h and being afebrile for 48 h until discharge or death. (3) Results: Sixty-nine percent of patients had PEIV. Patients who received PEIV were more likely to receive intravenous therapy until discharge (46 vs. 16%, p < 0.001). Receipt of PEIV was associated with a longer mean time to receiving oral antimicrobials (8.7 vs. 3 days, p < 0.001). The only factors that impacted EIV days in the multivariable linear regression model were the source of infection (urinary tract) (coefficient −1.54, 95%CI −2.82 to −0.26) and Pitt bacteremia score (coefficient 0.51, 95%CI 0.10 to 0.92). (4) Conclusions: PEIV is common in inpatients with Gram-negative bacteremia. Clinicians should look to avoid PEIV in the inpatient setting. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

8 pages, 745 KiB

Open AccessFeature PaperArticle

Effectiveness and Feasibility of Pharmacist-Driven Penicillin Allergy De-Labeling Pilot Program without Skin Testing or Oral Challenges

by You-Chan Song, Zachary J. Nelson, Michael A. Wankum and Krista D. Gens

Pharmacy 2021, 9(3), 127; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9030127 - 20 Jul 2021

Cited by 12 | Viewed by 3863

Abstract

Documented penicillin allergies have been associated with an increased risk of adverse outcomes. The goal of this project was to assess the effectiveness and feasibility of a pharmacist-led penicillin allergy “de-labeling” process that does not involve labor-intensive skin testing or direct oral challenges. Adult patients with penicillin allergies were identified and interviewed by an infectious diseases pharmacy resident during a 3-month pilot period. Using an evidence-based standardized checklist, the pharmacist determined if an allergy qualified for de-labeling. In total, 66 patients were interviewed during the pilot period. The average time spent was 5.2 min per patient interviewed. Twelve patients (18%) met the criteria for de-labeling and consented to the removal of the allergy. Four patients (6%) met the criteria but declined removal of the allergy. In brief, 58.3% of patients (7/12) who were de-labeled and 50% of patients (2/4) who declined de-labeling but had their allergy updated to reflect intolerance were subsequently prescribed beta-lactam antibiotics and all (9/9, 100%) were able to tolerate these agents. A pharmacist-led penicillin allergy de-labeling process utilizing a standardized checklist is an effective and feasible method for removing penicillin allergies in patients without a true allergy. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

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10 pages, 1379 KiB

Open AccessConcept Paper

Creation of a Pharmacy Student Longitudinal Rotation to Expand the Scope of an Antimicrobial Stewardship Program

by Tiffany Ward and Jaela Fredenrich

Pharmacy 2021, 9(3), 135; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9030135 - 05 Aug 2021

Cited by 1 | Viewed by 2480

Abstract

Allergy assessments and penicillin skin testing have emerged as a vital intervention for Antimicrobial Stewardship Programs (ASPs). Investment and involvement in such programs by ASPs, however, are often limited due to resources, time, and personnel constraints. Harnessing an underutilized resource, 4th-year advanced pharmacy practice experience (APPE) students, allows for expanded ASP involvement and scope of practice. We aim to outline and provide insight on how 4th-year APPE students serve as an asset to an ASP. Through our novel longitudinal rotation experience, APPE students complete penicillin allergy assessments, patient education, and work alongside a clinical pharmacist to refer patients for penicillin skin testing if appropriate. Students also achieve many of the education standards required by the Accreditation Counsel for Pharmacy Education (ACPE) for graduation within the Doctor of Pharmacy degree while developing a strong foundation in antimicrobial stewardship and gaining invaluable knowledge for their future. The addition of APPE pharmacy students to our ASP has also enabled our program to achieve its goals and expand involvement and reach within our facility. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

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8 pages, 1350 KiB

Open AccessPerspective

Application of Standardized Antimicrobial Administration Ratio as a Motivational Tool within a Multi-Hospital Healthcare System

by Stephanie Shealy, Joseph Kohn, Emily Yongue, Casey Troficanto, P. Brandon Bookstaver, Julie Ann Justo, Hana R. Winders, Sangita Dash and Majdi N. Al-Hasan

Pharmacy 2021, 9(1), 32; https://0-doi-org.brum.beds.ac.uk/10.3390/pharmacy9010032 - 07 Feb 2021

Cited by 5 | Viewed by 2525

Abstract

The standardized antimicrobial administration ratio (SAAR) is a novel antimicrobial stewardship metric that compares actual to expected antimicrobial use (AU). This prospective cohort study examines the utility of SAAR reporting and inter-facility comparisons as a motivational tool to improve overall and broad-spectrum AU within a three-hospital healthcare system. Transparent inter-facility comparisons were deployed during system-wide antimicrobial stewardship meetings beginning in October 2017. Stakeholders were advised to interpret the results to foster competition and incorporate SAAR data into focused antimicrobial stewardship interventions. Student’s t-test was used to compare mean SAARs in the pre- (July 2017 through October 2017) and post-intervention periods (November 2017 through June 2019). The mean pre-intervention SAARs for hospitals A, B, and C were 0.69, 1.09, and 0.60, respectively. Hospital B experienced significant reductions in SAAR for overall AU (from 1.09 to 0.83; p < 0.001), broad-spectrum antimicrobials used for hospital-onset infections (from 1.36 to 0.81; p < 0.001), and agents used for resistant gram-positive infections in the intensive care units (from 1.27 to 0.72; p < 0.001) after the interventions. The alignment of the SAAR across the health-system and sustained reduction in overall and broad-spectrum AU through implementation of inter-facility comparisons demonstrate the utility in the motivational application of this antimicrobial use metric. Full article

(This article belongs to the Special Issue Improving Antimicrobial Use in Hospitalized Patients)

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