Antimicrobial Stewardship Programs in Inpatient Settings

摘要: s Triaged: 6,334 Abstracts Excluded: 5,775s 5,775 Full Text Review: 559 Articles 539 Not an included study design: 260 No intervention: 108 Outpatient setting: 71 stewardship: 57 Other: 43 Hand Search: 15 Included: 35 Studies Evidence-based Synthesis Program (ESP) Results • Existing Cochrane Review (Davey 2013) Included 89 studies published through 2009 Focused on prescribing outcomes Categorized interventions as: Persuasive (education, reminders, audit and feedback) Restrictive (order forms, formulary restriction) Structural (EMR, decision support systems) Patient-Centered Outcomes Mortality Interventions to increase guideline compliance for patients with community acquired pneumonia reduced mortality: (4 studies, RR 0.89 [0.82, 0.97]) effective (3 studies) decrease excessive (11 were not significantly associated mortality Other : effect length of stay (6 mean difference, -0.04 days [-0.34, 0.25]) Associated increased hospital readmissions (5 1.26 [1.02, 1.57]) Reduction in C. difficile infection: 15% 65% at one month post-intervention 4 interrupted time series Prescribing Calculated median size all outcomes; positive sign = change intended direction Persuasive, restrictive, structural interventions: improved Median ranged from 4% 46% across intervention types design VA-ESP Evidence o 9 RCTs, CCTs, 2 CBAs, 20 ITS by type: 14 feedback 5 restriction preauthorization implementation no computerized protocol or policy ASP Intervention (# Length Stay Readmission CDI Prospective Audit Feedback (14) + 1 ≈ p=NR, Formulary Restriction Preauthorization (5) 3 NR Guidelines (4) without 1study Computerized Decision Support Protocols KQ1 – Effectiveness: Clinical Use Selection Timing Duration Decreased: 8 Appropriate: study, Compliant/appropriate: Compliant/ appropriate: Effectiveness Microbial (9 6 reported improvement  decreased infection resistance differences Cost costs difference KQ2 Key Implementation Components All author opinion Consistent persistent effort qualified personnel Effective communication skills electronic medical records systems KQ3 Different Settings Suspected Conditions Davey 2013 review VA Medical Centers Similar results (unchanged [1], [2], mixed [3], [3]) recent eligible Most University-affiliated hospitals ICU programs overall “any suspected infection” Respiratory (7 KQ4 Harms Programs possible harms (other than patient, prescribing, microbial KQ1) Anecdotal evidence inappropriate switch narrow-spectrum antimicrobial Termination program speculated be due provider dissatisfaction restrictions KQ5 Barriers Implementation, Sustainability, Scalability studies; interview/survey data) Lack familiarity, experience, awareness Disagreement guidelines/conflicting guidelines between professionals Organizational constraints Sustainability (1 study) over years when was terminated (No Discussion Antimicrobial stewardship strategies can limit costs, substantial Greatest body is Systematic earlier provided comparable effects persuasive restrictive base substantial; much less KQ2-5 designed adequately assess impact other clinical Suggestions improving adherence ASPs: Involvement stakeholders leaders development Addition quality cycles Understanding the culture Collaboration physicians pharmacists (mostly rather evidence-based) Limitations: Quality evidence: Low Few randomized controlled trials Limited ability control secular trends confounding variables Possibility regression rates Findings specific have been replicated Limitations (continued): improvements often sustained long-term follow-up done academic centers; generalizability settings difficult. Within centers, variation settings, structures, patient bases, Strength: has diverse Weakness: Hard sure that each works interventions; most identify harms, would powered recognize them Future Research Needs Given complexity conducting well-designed difficult Large healthcare organizations should consider organizing activities (that are likely on-going within organization) provide useful information comparative effectiveness different Overall Conclusions Despite these many shortcomings, suggests outcomes, mostly usage, short periods (1-3 years) The literature supports system sensible, practical improve Recommendations Data use unit, type patients, groups, individual providers gathered determine where might ideal need prevention programs, microbiology laboratories, pharmacy services, infectious disease physicians, record systems, continuous staff trainee education certification utilized contribute Leadership also informed involved planning; leadership essential Formative evaluation used modification