The effect of a whole-system approach in an antimicrobial stewardship programme at the Singapore General Hospital

Abstract

Inappropriate antibiotic use contributes to antimicrobial resistance. Multi-faceted antimicrobial stewardship programmes (ASPs) are recommended for sustainable changes in prescribing practices. A multi-disciplinary ASP was established in October 2008 and piloted in the Departments of General Surgery, Renal Medicine and Endocrinology sequentially. To improve the quality of patient care via optimising the (1) choice, (2) dose, (3) route and (4) duration of antibiotics, a "whole-system" approach incorporating prospective review with immediate concurrent feedback (ICF), prescriber education (public or individualised), de-escalation of therapy, dose optimisation and parenteral-to-oral conversion, while recognising the autonomy of primary prescribers, was adopted. The audited department received a quarterly outcomes report and any common unaccepted practices would be addressed. Outcomes were analysed for 12 months post-ASP implementation. A total of 1,535 antibiotic prescriptions were reviewed. Antimicrobial use in 376 (24.5%) prescriptions was inappropriate. Of 596 interventions made, 70.2% were accepted. A reduction in audited antibiotics consumption resulted in acquisition cost savings of S$198,575 for the hospital. Patients' cost-savings attributable to ASP-initiated interventions were $91,194. The overall all-cause mortality rate and median monthly inpatient-days pre- and post-intervention remained stable. A "whole-system" ASP was effective in optimising antibiotic use in our hospital, without compromising clinical outcomes.

Compliance with published recommendations for postoperative antibiotic management of children with appendicitis: A chart audit

“…Specific strategies for success are required in different settings [5,30]. Adherence to antibiotic recommendations can decrease the number of doses of intravenous medication and length of stay, both of which reduce the cost of the hospitalization without adverse effects to the patients [13,[31][32][33][34].…”

Antimicrobial Stewardship Programs: A Review of Recent Evaluation Methods and Metrics

“…Although measurement of non-targeted or total antimicrobials is more labor intensive than measuring targeted agents alone, this information is essential to allow for the detection of compensatory increases in the use of other agents, which can lead to the "squeezing the balloon" phenomenon [79]. However, some studies only reported consumption of targeted antimicrobials [8,20,30,44,54,75].…”

“…Moreover, many programs appear to be treating these clinical outcomes as balancing measures, in that they want to confirm that reductions in antimicrobial use have not compromised important patient outcomes. For example, some authors have listed these outcomes under the heading of 'Programme safety' or 'Negative consequences' [24,54].…”

“…Where specific antimicrobials were targeted [4, 6, 8, 18, 40, 43, 44, 46, 47•, 61, 63], the majority of studies reported cost of all antibiotics or antimicrobials [7, 9, 11, 20, 42, 56•, 81] while three reported solely on targeted antimicrobials [29,30,54]. Eleven studies estimated actual or potential cost savings in antimicrobial acquisition due to the stewardship intervention [7, 9, 10, 12, 22, 29, 41, 54, 55•, 80, 81].…”

Resultados de um Programa Multidisciplinar de Otimização do Uso de Antimicrobianos

“…2 Diversas estratégias têm sido propostas para combater a resistência microbiana no mundo, dentre elas destacam-se os Programas de Otimização de Uso de Antimicrobianos, que começaram a ser incorporados nos Serviços de Controle de Infecção Hospitalar. 3 A implementação do Programa de Otimização do Uso de Antimicrobianos requer um esforço multiprofissional e envolve uma série de intervenções específicas a fim de monitorar o uso de antimicrobianos e proporcionar um padrão de terapia baseada em evidência. Dentre os objetivos dos chamados programas de vigilância do uso de antimicrobianos "Antimicrobial stewardship" estão: melhorar o resultado para o paciente, garantir sua segurança, reduzir a velocidade de emergência da resistência microbiana e reduzir custos, promover a educação continuada e o feedback constante ao prescritor.…”