Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

Wagner, Brittin; Filice, Gregory; Drekonja, Dimitri; Greer, Nancy; MacDonald, Roderick; Rutks, Indulis; Butler, Mary; Wilt, Timothy J

doi:10.1086/678057

Cited by 114 publications

(75 citation statements)

References 57 publications

(168 reference statements)

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“…A recently performed systematic review found that the quality of evidence supporting specific antimicrobial stewardship interventions was low, but did recommend audit and feedback, guideline implementation, and decision support [55]. Additional strategies for ASPs have been tested in studies with poorly defined outcomes, resulting in low-quality evidence for their efficacy.…”

Section: Antibiotic Stewardshipmentioning

confidence: 99%

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

et al. 2017

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Purpose: To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. Methods: Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. Results: The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. Conclusions: These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.

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Section: Antibiotic Stewardshipmentioning

confidence: 99%

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

et al. 2017

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“…ASPs have been shown to have beneficial effects in terms of the consumption and cost of antimicrobials and the prevalence of resistant bacteria (Del Arco et al, 2015;Horikoshi et al, 2016;Horikoshi et al, 2017;Wagner et al, 2014).…”

Section: Introductionmentioning

confidence: 99%

The impact of earlier intervention by an antimicrobial stewardship team for specific antimicrobials in a single weekly intervention

Hagiwara

Sato

Miyazaki

et al. 2018

International Journal of Infectious Diseases

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Objective: The objective of this study was to evaluate the effects of earlier intervention by an antimicrobial stewardship team (AST) on antimicrobial use, antimicrobial resistance rates, and the clinical outcomes, without changing the weekly intervention schedule. Methods: A retrospective study was conducted at Fukuoka University Hospital between April 2013 and March 2016. The effects were compared among three study periods (SP): SP1 (patients receiving antimethicillin-resistant Staphylococcus aureus agents and carbapenems for 14 days), SP2 (patients receiving specific antimicrobials for 14 days), and SP3 (patients receiving specific antimicrobials regardless of the duration of treatment). Results: The timing of AST intervention was shortened from an average of 15.5 days after administration in SP1 to 4.2 days in SP3. The antimicrobial use density (AUD) of carbapenems and piperacillin-tazobactam decreased significantly (SP2 vs. SP3, p < 0.05), and the costs of specific antimicrobials decreased (SP1, US$ 1 080 000; SP2, US$ 944 000; SP3, US$ 763 000). The rates of carbapenem resistance among Pseudomonas aeruginosa isolates showed a significant reduction from 16.2% in SP2 to 8.7% in SP3 (p < 0.05). The mortality rate and length of stay did not change during the study period. Conclusions: Earlier intervention by an AST could contribute to the proper use of antimicrobials without adversely affecting patient outcomes.

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“…This resulted in a call to action for acute care hospitals to implement antimicrobial stewardship programs (ASPs) (4,5), a term that is used to describe the integrated strategy of improving antimicrobial use in order to enhance patient outcomes, reduce antimicrobial cost, and minimize the side effects associated with antimicrobial use, including drug resistance and nosocomial infections (4,6,7). Although there are studies that have already presented data on the efficacy of ASPs in the inpatient setting (8)(9)(10), limitations compromise their generalization (i.e., the studies were only conducted in the United States [8], age and study design limitations [9], a lack of clinical outcomes [10], etc.). The purpose of our systematic review and meta-analysis was to measure the efficacy of the implementation of an ASP expressed in daily defined doses (DDD) per 1,000 patient days in the hospital setting independently of the age and study design and to assess the subsequent clinical and economic outcomes.…”

mentioning

confidence: 99%

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs

Karanika

Paudel

Grigoras

et al. 2016

Antimicrob Agents Chemother

300

192

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bThe implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre-and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was ؊19.1% (95% confidence interval [CI] ‫؍‬ ؊30.1 to ؊7.5), and the use of restricted antimicrobial agents decreased by ؊26.6% (95% CI ‫؍‬ ؊52.3 to ؊0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was ؊39.5% (95% CI ‫؍‬ ؊72.5 to ؊6.4). ). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.A bout one-third of the hospitalized patients and more than two-thirds of critically ill patients are on antimicrobial therapy at any time (1, 2), and up to half of antibiotic prescriptions are inappropriate or not necessary (3). In 2013, the Centers for Disease Control and Prevention (CDC) reported that about 2 million patients are infected yearly with antimicrobialresistant organisms in the United States, and about 23,000 deaths are directly attributed to these infections (3). This resulted in a call to action for acute care hospitals to implement antimicrobial stewardship programs (ASPs) (4, 5), a term that is used to describe the integrated strategy of improving antimicrobial use in order to enhance patient outcomes, reduce antimicrobial cost, and minimize the side effects associated with antimicrobial use, including drug resistance and nosocomial infections (4, 6, 7). Although there are studies that have already presented data on the efficacy of ASPs in the inpatient setting (8-10), limitations compromise their generalization (i.e., the studies were only conducted in the United States [8], age and study design limitations [9], a lack of clinical outcomes [10], etc.). The purpose of our systematic review and meta-analysis was to measure the efficacy of the implementation of an ASP expressed in daily defined doses (DDD) per 1,000 patient days in the hospital setting independently of the age and study design and to assess the subsequent clinical and economic outcomes. MATERIALS AND METHODSThis systematic review and meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol (11).Search strategy. A systematic electronic search of PubMed, EMBASE, and Google Scholar databases was performed for pertinent studies up t...

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Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

Abstract: Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

Cited by 114 publications

References 57 publications

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

The impact of earlier intervention by an antimicrobial stewardship team for specific antimicrobials in a single weekly intervention

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs

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