Guidelines regarding antimicrobial stewardship programs recommend an infectious diseases-trained physician and an infectious diseases-trained pharmacist as core members. Inclusion of clinical microbiologists, infection-control practitioners, information systems experts and hospital epidemiologists is considered optimal. Recommended stewardship interventions include prospective audit and intervention, formulary restriction, education, guideline development, clinical pathway development, antimicrobial order forms and the de-escalation of therapy. The primary outcome associated with these interventions has been the associated cost savings; however, few published investigations have taken into account the overall cost of the intervention. Over the past 5 years, there has been an increased focus upon interventions intended to decrease bacterial resistance or reduce superinfection, including infections associated with Clostridium difficile colitis. Few programs have been associated with a reduction in antimicrobial drug adverse events. Antimicrobial stewardship programs are becoming increasingly associated with clear benefits and will be integral in the in-patient healthcare setting.
Cascade reporting (CR) involves reporting the susceptibilities of broad-spectrum agents only when the organism is resistant to more narrow-spectrum agents. The purpose of this study is to evaluate the impact of CR on antibiotic de-escalation practices and to characterize the impact of CR on clinical outcomes. CR rules were implemented in the microbiology laboratory at Atlantic Health System (AHS) in June 2013. A retrospective chart review was conducted at two community teaching hospitals in adult patients who had a blood culture positive for a Gram-negative organism susceptible to cefazolin and who were empirically treated with broad-spectrum beta-lactam (BSBL) antibiotics. De-escalation practices were compared in the pre-CR (July 2012-December 2012) and post-CR (July 2013-December 2013) periods. The primary endpoint was the percentage of patients whose BSBL agent was de-escalated to agents listed on the post-CR antibiotic susceptibility report within 48 h of the final report. Secondary endpoints include the difference in pre-CR and post-CR periods in terms of hospital length of stay, in-hospital mortality, 30-day readmission, Clostridium difficile infections, and re-initiation of a BSBL agent within 7 days. A total of 73 patients were included; 31 in the pre-CR and 42 in the post-CR period. Patients had similar baseline characteristics. Therapy was de-escalated in 48 % of pre-CR vs 71 % of post-CR patients (p = 0.043). No significant differences were observed in secondary endpoints between patients in the pre-CR and post-CR periods. CR resulted in significant improvements in de-escalation practices without affecting safety outcomes.
Drug resistant tuberculosis has been recognized since chemotherapy first became available. However, drug resistance has increased in many countries, and recently strains resistant to both rifampicin and isoniazid (multidrug resistant tuberculosis) have emerged. This review discusses the epidemiology of multidrug resistant tuberculosis (MDRTB), and the control of MDRTB in healthcare facilities. Relevant papers for this review were identified by a systematic literature search on Medline. MDRTB is already established world-wide, and although the overall problem of resistance remains low in the UK, it is of significant clinical importance due to its high case-fatality, higher transmission risk, and complex treatment. The key elements of MDRTB control are prompt recognition, confirmation and treatment of cases, and the institution of strict infection control procedures to reduce the airborne spread of infection from infectious patients to others. This review emphasizes the importance of a multidisciplinary approach to management, with liaison between tuberculosis physicians, the microbiology department, infection control team, consultant in communicable disease, and occupational health.
The first of these articles reviews the epidemiology of MRSA and its clinical importance in a healthcare setting. The methods of controlling the spread of hospital acquired MRSA are discussed with an emphasis on the role of screening staff for MRSA. Relevant papers for the review were identified by a systematic literature search on Medline. The prevalence of MRSA is increasing in the United Kingdom, as is the prevalence of 'epidemic' MRSA strains. Several countries have recently reported cases of Staphylococcus aureus with intermediate-level resistance to vancomycin. The key measures to minimizing hospital-acquired MRSA are stringent infection control programmes and strict antibiotic policies. Staff screening should only be undertaken after a detailed risk assessment of the local situation has been made by the occupational health and infection control teams. Priority should be given to high-risk areas of a hospital where MRSA is endemic.
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