Effects of infectious disease consultation and antimicrobial stewardship program at a Japanese cancer center: An interrupted time-series analysis

Abstract

In cancer patients, appropriate diagnosis and management of infection are frequently challenging owing to subtle or atypical presentation. We investigated the effectiveness of infectious disease (ID) consultations and the Antimicrobial Stewardship Program (ASP) in a Japanese cancer center. This 36-month-period, single-institution, interrupted time series analysis was retrospectively conducted during April 1, 2018–March 31, 2021, to evaluate a two-phase intervention: Phase 1 (notification of antimicrobials by the infection control team) and Phase 2 (establishing an ID consultation service and implementing ASP). Among 32,202 patients hospitalized, 22,096 and 10,106 hospitalizations occurred at baseline and during intervention period, respectively. The Antimicrobial Stewardship Team (AST) provided feedback on specific broad-spectrum antimicrobials in 913 instances (347 appropriate [38%]; 566 inappropriate [62%]), and 440 ID consultations were completed, with a 75% overall acceptance rate for AST suggestions. In Phase 2, monthly carbapenem days of therapy (CAR-DOT) decreased significantly, and narrow-spectrum antibiotic usage increased significantly in both trend and level; monthly DOT of antipseudomonal agents decreased significantly in trend. The results of these analyses of antimicrobial use are consistent with the DOT-based data based on antimicrobial use density (AUD). The total number of inpatient specimens increased significantly; the trend of multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus infections decreased, without changes in the incidence of other resistant organisms, all-cause in-hospital mortality, and length of stay. Actual and adjusted CAR purchase costs per patient-day decreased without significant changes in the actual and adjusted purchase cost per patient-day for all intravenous antimicrobials. Combining ID consultation and ASP reduced carbapenem use without negative patient outcomes. Their implementation could facilitate establishment of safe cancer treatment facilities in Japan and improve prognosis in cancer patients.

Impact of the antimicrobial stewardship program on hospital-acquired candidemia

“…This was attributed to the education-based antimicrobial stewardship program which was effective in decreasing the incidence and mortality rate of hospital-acquired candidemia and multidrug-resistant infections 9 . However, several ASP studies did not show a statistically significant reduction in the incidence of hospital-acquired candidemia with a reduction in broad-spectrum antimicrobial use 10 – 12 . In this study, the relatively long study period and the decrease in the use of antimicrobials (especially CAR-DOT) may have contributed to the decrease in the incidence of hospital-acquired Candidemia .…”

Reduction strategies for inpatient oral third-generation cephalosporins at a cancer center: An interrupted time-series analysis

“…It is difficult to provide comprehensive interventions in cancer centers owing to the complexity of patient conditions caused by underlying cancers, hematological malignancies, neutropenia, various departments involved in multidisciplinary patient management, departmental structures, and internal guidelines [ 28 ]. In addition, the use of antimicrobials is higher among patients with cancer than among the general population [ 3 , 4 ]. However, even in a population of patients with cancer and high antimicrobial use, each of our interventions contributed to a reduction in the use of oral 3GCs without worsening patient outcomes or increasing the use of alternative broad-spectrum antimicrobial agents and decreased the overall cost of oral antimicrobial agents.…”

“…It is challenging to change the antimicrobial-prescribing behavior of physicians for several reasons: physicians tend to disregard the seriousness of preventing the development of resistant bacteria, and knowledge outside the physician’s field of expertise does not appear to be updated [ 24 ]. Prospective audit and feedback of antimicrobials are effective but time-consuming [ 3 ], and intervention is often difficult because oral antimicrobials are already prescribed as a discharge prescription. The number of ID physicians in Japan is inadequate compared to that in the United States [ 3 ].…”

Exploration of Trends in Antimicrobial Use and Their Determinants Based on Dispensing Information Collected from Pharmacies throughout Japan: A First Report

“…Sulfamethoxazole and trimethoprim have been approved for use in general hospitals. Sulfamethoxazole-trimethoprim is recommended for the prevention of Pneumocystis pneumonia [38]. Because general hospitals include a variety of departments, antimicrobial agents may have been prescribed for a wide range of infections.…”