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Author(s)

Sebastian Philip, Andreas Lundgaard

Why was it done?

The screening aimed to ensure the rational use of antibiotics, contributing to the fight against antibiotic resistance and potentially shortening hospital stays by optimizing treatment.

What was done?

A systematic screening of antibiotic treatments for patients was conducted as part of the daily tasks performed by clinical pharmacists at The Medical Acute Care Unit, Bispebjerg Hospital.

How was it done?

For each patient receiving antibiotic treatment in the emergency department, the chosen therapy was systematically reviewed against regional antibiotic guidelines, considering factors such as allergies, resistance profiles, renal function, clinical indication and overall condition of the patient. Recommendations of adjustment of treatment were discussed with the attending physician for potential changes in therapy, including changes to dosage, frequency, route of administration, alternative antibiotic drug, or discontinuation of treatment. All interventions were documented, including the details of the therapy, the recommendation, and whether the attending physician approved the suggested changes.

What has been achieved?

A large dataset has been collected, detailing the number of patients receiving antibiotic treatment, the number of interventions conducted, the specific antibiotic treatment each patient received, the type of intervention performed and its indication, and whether the intervention was approved or rejected by the responsible physician.
The project has laid the groundwork for understanding the clinical pharmacist’s role in enhancing rational antibiotic pharmacotherapy.

What next?

It is planned to analyze the collected data to determine the types of changes in therapy most commonly recommended by clinical pharmacists and to which degree the interventions were approved or denied by the attending physician.
This will provide insights into the pharmaceutical contributions to more rational antibiotic use, highlighting commonly observed ‘areas for improvement’ that could potentially be addressed through education.

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Author(s)

A. ALENTADO MATEU 1 , L. ALVAREZ ARROYO 1 , R. MARTINEZ GOZALBEZ 2 , O. PEREZ OLASO 3 , R. LIMÓN RAMIREZ 4, B. MONTAÑÉS PAULS 1 .
1 HOSPITAL UNIVERSITARIO LA PLANA, FARMACIA, VILA-REAL, ESPAÑA.
2 HOSPITAL UNIVERSITARIO LA PLANA, INFORMÁTICA, VILA-REAL, ESPAÑA.
3 HOSPITAL UNIVERSITARIO LA PLANA, MICROBIOLOGIA, VILA-REAL, ESPAÑA.
4 HOSPITAL UNIVERSITARIO LA PLANA, MEDICINA PREVENTIVA, VILA-REAL, ESPAÑA.

Why was it done?

For years, Antimicrobial Stewardship Programs (ASP) teams have been working to improve the quality of antimicrobial prescription by optimizing treatments, controlling bacteremia and managing infections caused by resistant or difficult to treat microorganisms.
It is essential to have a software tool that allows real-time monitoring of both treatments and certain cultures.

What was done?

The ASP team, in collaboration with the information technology unit designed, developed and implemented a computer application at our center to support the ASP team. This application screens inpatients, searching for any of the predefined parameter alerts based on the type of antibiotic prescribed, the microorganism causing the infection, positive blood cultures or patients who are difficult to manage.

How was it done?

This alert system is based on the integration of the various hospital clinical information systems. Admitted patients are selected after a medical prescription of certain predefined antibiotics (carbapenems, daptomycin, linezolid, piperacillin/tazobactam, ceftazidime/avibactam, etc); these data are obtained from the electronic prescription programme (Athos-Prisma®). Microbiological criteria (Gestlab@ programme) include multi-resistant microorganisms (Escherichia coli, Methicillin-resistant Staphylococcus aureus), positive blood cultures, Pseudomonas, etc. Based on clinical criteria, patients who are difficult to manage can be manually included in the computer programme, mainly by the internal medicine and intensive care unit departments. The antimicrobial and microbiological criteria are dynamic and can be modified as needed.

What has been achieved?

From June 1 st 2023 to February 1 st 2024, 300 different patients have underwent interventions. In the patient’s electronic medical record from the ASP application, 355 ASP recommendations were made for 236 patients. ASP interventions included recommended isolation measures (242), modifying or suspending antibiotic treatment (68), maintaining adequate antibiotic treatment (22), initiating antibiotic treatment (11) and requesting complementary tests (12), such as imaging, cultures or serology.

What next?

This application is a fundamental communication tool for ASP teams allowings different recommendations for optimizing antimicrobial treatment to be made in the application. It automatically generates a note in the patient’s clinical history, making it accessible to all healthcare professionals and allowings for easy extrapolation to other hospitals, enabling its implementation in daily clinical practice.

Author(s)

Ignacio Javier Tamboleo Sánchez, Julia Fernández Vela, Fernando Lago Ballester, Mª CARMEN MIRA SIRVENT, Elena Conesa Nicolas

Why was it done?

The initiative started in October 2022, it was a response to the challenges associated with prolonged intravenous antibiotic use. The overarching goals were to enhance patient care, mitigate unnecessary intravenous antibiotic prescriptions, and foster a culture of responsible antimicrobial stewardship. Recognizing the need for a systematic and collaborative approach, the Antimicrobial Stewardship Program (ASP) pharmacist played a central role in implementing interventions across various medical specialties, with a clear focus on improving patient outcomes.

What was done?

The initiative promoted the adoption of sequential antibiotic therapy among hospitalised patients undergoing intravenous treatment for more than three days. Leveraging the Wise Antimicrobial Stewardship Support System® (WASPSS®) and detailed analysis of medical records, the programme identified eligible patients based on criteria such as clinical stability, oral bioavailability, infection specifics, and antibiotic suitability.

How was it done?

The ASP pharmacist’s central role proved instrumental, with 74% of alerts resulting in actionable recommendations. WASPSS® detects every patient with intravenous antibiotic more than 3 days and the ASP pharmacist decides which patients will benefit from sequential therapy. Choosing the recommendation criteria is essential to have a good response from medical specialties ensuring a more efficient and tailored approach to intervention implementation. The main obstacles to the introduction of this initiative were the establishment of refined communication routes and the targeted training to the different specialties which are not yet fully implemented.

What has been achieved?

Results revealed that 74% of alerts met the criteria for transitioning from intravenous to oral administration. Among the 573 alerts reviewed, 45.1% witnessed a successful switch to oral antibiotics, 21.2% showed no change, and 16.7% of patients were discharged. Notably, higher acceptance rates were observed in specific specialties, such as pneumology (61.3%) and general medicine (54.4%). Nevertheless, oncology (35,3%) general and digestive surgery (25,8%) had the lowest acceptance rate. In conclusion, the global acceptance rate was lowest than expected (43,8%) but there are many improvements measures that are being carried out.

What next?

This initiative serves as a beacon for responsible antibiotic management, making noteworthy contributions to patient safety, cost-effectiveness, and the overall quality of healthcare delivery. Recommending ongoing collaboration, continuous training, and regular analysis of recommendation criteria will enhance its impact.

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Author(s)

Ana Concepción Sánchez Cerviño, Jorge Coca Crespo, Maria Rivera Ruiz, Juan Ignacio Alcaraz López, Adrián López Fernández, Elena Pérez García, Bárbara Ubeda Ruiz, Amelia Sánchez Guerrero

Why was it done?

Sequential therapy, or switch therapy, consists of an early conversion from intravenous to oral (PO) treatment, without compromising the therapeutic effectiveness. In advantage, PO in selected cases, avoids intravenous associated risks, it is more comfortable to patients and represents an important economic saving.

The aim of the GPI was to implement a daily program that allows the pharmacist to identify the patients that would benefit from the AST.

What was done?

Implementation of a program of antibiotic sequential therapy (AST) and evaluate the outcome of the pharmaceutical recommendations carried out in a third-level hospital.

How was it done?

A database was created to select the active antibiotic prescriptions with more than 72 hours duration, susceptible to AST: metronidazole, clindamycin, levofloxacin, ciprofloxacin and linezolid.

Patients clinical criteria for initiating AST were established as:
• Temperature ≤ 37 ºC
• Systolic blood pressure ≥ 90 mmHg
• Heart rate < 100 bpm • Respiratory rate < 24 rpm • Oxygen saturation ≥ 90% • Capacity for oral intake Once the patients were identified, the pharmacist communicated the recommendation to the doctor in charge, and worked together to make a final decision. Due to the high burden of care, the follow-up of patients who could not be substituted to PO in the first 72 hours was lost.

What has been achieved?

From October 2022 to March 2023, 453 patients on intravenous antibiotic treatment were reviewed. The mean age was 65.7 ± 20.9, and 57.4% of the patients were men.
47 patients were selected as they met the established criteria.

All the antibiotics presented a similar percentage of recommendation with a mean of 19.2% ± 6.3. Of this percentage, 59.6% of the patients were switched to oral antibiotics. Stands out linezolid, with a 83.3% of acceptance.

Lower respiratory tract infections were the most prevalent, representing 51.6% of the total. However, only 11 patients (5.1%) were suggested for AST due to the frequent use of nasal spectacles or oxygen therapy, a criterion that excludes AST

What next?

The high number of accepted recommendations shows the importance of implementing an AST programme in order to optimize antimicrobial treatment, and this initiative could be easily implemented to all Pharmacy Services.

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Author(s)

Carlos José Cortés Sánchez, Josefina Giménez Castellanos, Mónica Abdilla Bonías, Arantxa Valdivia Piqueres, José María Gómez Portolés, Irene Toledo Guasp, Eva García Cortés

Why was it done?

Proper use of antimicrobials is essential to ensure their efficacy and minimize the emergence of resistance. The evaluation of antibiotic prescription in a district hospital can provide information about clinical practice, adherence to local protocols, and the possibility of addressing antimicrobial resistance issues.

What was done?

Review the appropriateness of antibiotic prescription according to local guidelines and protocols.

How was it done?

This is 4-month prospective observational study(May to August 2023) in a district hospital. A daily list of admitted patients on antibiotic treatment was obtained through OrionClinic® electronic prescription. Each patient was reviewed and discussed for appropriateness with antimicrobial stewardship team in a Microsoft-TEAMS© chat. The following data were recorded: registration date, patient identification, hospitalization unit, microbiological culture, treatment modality (prophylaxis, empirical, or targeted) and appropriateness using a Microsoft FORMS©.
Descriptive analysis expressed as number and percentage and relationships derived from registration: percentage of patients by hospitalization unit, treatment modality, and appropriateness. Percentage of patients on empirical treatment with microbiological culture. And appropriateness according to treatment modality.

What has been achieved?

A total of 172 patients were analysed, of which 83(48.25%) were surgical patients (orthopaedic surgery, general surgery, urology, gynaecology, otolaryngology), 64(37.2%) are from internal medicine,MIN, 17(9.9%) from intensive care unit,ICU, and 8(4.7%) from paediatrics,PED. Of the total of patients, 95(55.2%) had requested a microbiological culture. About 52(30.2%) patients were on prophylactic treatment, 103(59.9%) empirically, and 17(9.9%) on targeted treatment. In conclusion, 119(69.2%) antibiotic treatments were appropriate (prophylactic 26/50%, empiric 80/77.67% and targeted treatment 13/76.5%).
Breaking-down data by hospitalization unit and treatment, of the 83 surgical (49 prophylactic, 28 empirical, and 6 targeted) 47(56.6%) were appropriate. Among the 64 MIN patients(1 prophylactic, 56 empirical, and 7 targeted), 54(84.4%) were appropriate. In ICU of 17 patients(2 prophylactic, 12 empirical, and 3 targeted), 11(64.7%) were appropriate. In PED of 8 patients(7 empirical and 1 targeted), 7(87.5%) were appropriate. Of the total of patients on empirical treatment(103), in 28(27.2%) there isn’t microbiological sample.

What next?

This is a preliminary analysis of our hospital’s situation in order to assess where interventions are needed for those patients who are not appropriate. It also helps us identify the hospitalisation units in which it is more necessary to implement strategic non-imposing measures to improve antibiotic prescription.

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Author(s)

Sergio Portillo-Haro, Aída Rueda-Naharro, María Martínez-Pérez, Manuela Martínez-Camacho, David García-Marco

Why was it done?

Currently, multi-resistant microorganisms are a huge global problem of Public Health. In addition, this problem will be bigger in the next decades. The main strategy to face this threat is improve the use of antibiotics. DADA was born with this purpose. The app lets the Pharmacy Department manage a sizable number of inpatients using the time to analyse the results obtained by DADA. In other words, we have improved the efficiency in our use of time.
How was it done?
The app was developed in July 2022, and since then it has been updated multiple times to adapt it to our needs and expectations and the changes in clinical guidelines. Every Monday and Thursday, the app is started up. The results are analysed carefully by a pharmacist and afterwards the conclusions are transmitted to an Infectious Diseases Medician, who decides if modify the treatment.

What was done?

In July 2022, Pharmacy Department designed an app easy to use and comfortable in order to detect active antibiotic treatments that might be de-escalated. This app, DADA (Automated Antibiotic De-escalation) is fed with data of antibiotic treatments and microbiological cultures. DADA reads and understands every gap of information, and finally search results between the active treatments comparing it with theorical de-escalation sequencies, designed by Infectious Diseases Commission in our hospital and based in local epidemiological guidelines. In this way, DADA works with automatic decision algorithms. In addition, DADA also provides alerts of active treatments for resistant microorganisms to that antibiotic.

How was it done?

The app was developed in July 2022, and since then it has been updated multiple times to adapt it to our needs and expectations and the changes in clinical guidelines. Every Monday and Thursday, the app is started up. The results are analyzed carefully by a pharmacist and afterwards the conclusions are transmited to an Infectious Diseases Medician, who decides if modify the treatment.

What has been achieved?

Since August 2022 to March 2023, using DADA, the Pharmacy Department has made 25 proposals of antibiotic de-escalation, and 11 proposals were accepted (44.0%) by Medicians. In addition, the Department made two proposals of change for resistance to that antibiotic, both accepted by Medicians. This app has improved efficiency of time in the clinical team.

What next?

The main outcome is to improve the confidence of Medicians in this tool, in order to increase the percentage of acceptance in the proposals. Furthermore, the app can be more complete and interprets data, such as analytics parameters. In the future, other hospitals might use this tool to analyse their patients or in outpatients treatments.

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Author(s)

Nóra Gyimesi, Andrea Bor, Eszter Erika Nagy, András Süle

Why was it done?

Evidence suggests that the rate of bacterial co-infection among COVID-19-infected patients is low. However, routine use of antibiotics was common in the early stages of the treatment.

What was done?

Clinical pharmacist participated in the therapeutic decision making of COVID-19 patients treated in our institution in order to ensure the optimal choice of medicines with special regard to the use of antibiotics.

How was it done?

A daily therapeutic discussion was started in the quarantine department from 2021, with the participation of clinical pharmacists, during which all therapy initiation were consulted. The pharmacist was involved in the walk-arounds and reviewed the medication therapies of each patient daily. The clinical pharmacist advised on the starting, or, if it was considered unnecessary, the stopping of the antibiotic therapies, as well as the monitoring required. The choice and dosage of antibiotics were also consulted.

What has been achieved?

Of the 314 patients treated in the Quarantine Department of our institution between September 2020 and May 2021 104 (33%) received antibiotic therapy during treatment, with 73% of cases initiated within 72 hours of admission. In 68 cases, bacterial superinfection was the indication for antibiotic therapy, of which only 9 cases had radiologist-confirmed bacterial co-infection. The rate of antibiotic usage has decreased after the intervention was started. During the second wave of the coronavirus epidemic (until February 2021), 41% of patients received antibiotics, while during the third wave (from March 2021), 28% of patients.

What next?

The pharmacist involvment, along with increasing experience and evidence for the clinical management of COVID-19, have moderated antibiotic use, however antibiotic overuse is still significant. Our Department of Pharmacy developed a local COVID-19 treatment guideline with emphasis on antibiotic use requirements. The education and promotion of this guideline will be undertaken by clinical pharmacists. Multidisciplinary therapeutic decision-making and strengthening of antibiotic stewardship programs are necessary for proper antibiotic use practices in the treatment of coronavirus patients.

Author(s)

CLARA NOTARIO DONGIL, ALEJANDRO MARCOS DE LA TORRE, MARÍA CARMEN CONDE GARCÍA, MARÍA MAR ALAÑÓN PARDO, BEATRIZ PROY VEGA, NATALIA ANDRÉS NAVARRO

Why was it done?

Most of the cultures performed in outpatients were not reviewed or were reviewed too late. An early detection for an adequate control of multidrug-resistant bacteria and the setting of a targeted antibiotic treatment, in case of being necessary, was the aim of this project. Hence basis for the implementation of an ASP is laid down, giving also advice to medical staff regarding appropriate antibiotic treatments.

What was done?

Multiresistant bacteria containment is a public health priority. Antibiotic Stewardship Programs (ASPs) can help to enhance patient outcomes by improving antibiotic prescribing. ASPs are common in hospitals, but are not usually available in primary care.

How was it done?

1- A circuit between microbiology laboratory staff, preventive medicine and pharmacy service was done. The first two collaborated by presenting data from lab results.
2- Cultures of multidrug-resistant species of outpatients were included. Results were interpreted by a hospital pharmacist on a daily basis.
3- A circuit of telephone calls between pharmacy and primary care was settled in order to communicate high epidemiological impact species detected. Pharmacist collaborates by giving advice regarding the right drug, right dose and right time, only when antibiotic treatment was necessary. Reports were registered on the medical history.
4- Variables collected in database were: age, sex, institutionalized, antibiotics received, kidney disease, culture type, specie.

What has been achieved?

During five months, 52 patients were included (52% male, 48% female). Mean age: 68 years. 11% institutionalized patients. 31% presented kidney disease.
Urine culture (58%),skin culture (13%), bronchial/sputum culture (12%), stool culture (12%), , and other cultures (5%) were analysed. Multidrug-resistant species (spp) were: Klebsiella spp (34%); Pseudomonas spp (8%); Mycobacterium spp (6%); other spp (52%).
17 pharmacist interventions were carried out, all of them related to appropriated treatment. 2 patients were hospitalized in order to receive parenteral antibiotic.

What next?

Optimizing antibiotics use is important to effectively treat infections. Identifying species that generate therapeutic difficulties is essential. Pharmacist advice could reduce treatment failures applying efforts to improve antibiotic use, being link of union between hospital and primary care. Other activities such as providing training to medical staff or spread results regarding to the use of antibiotics will be critical for ASP development.

Author(s)

Marta García-Queiruga, Begoña Feal-Cortizas, José María Gutiérrez-Urbón, Andrea Luaces-Rodríguez, Alejandro Martínez-Pradeda, Sandra Rotea-Salvo, Carla Fernandez-Oliveira, Víctor Giménez-Arufe, Luis Margusino-Framiñán, Isabel Martín-Herranz

Why was it done?

Daptomycin is an intravenous antibiotic usually prepared in Hospital Pharmacy services. Normally it is dosed based on body weight, which requires each intravenous mixture to be prepared in an individual manner for each patient. This might lead to an increased assistance workload in elaboration areas, a higher number of errors in the preparation and high costs due to waste materials generated during preparation.

What was done?

The aim of this study is to describe the preparation of intravenous daptomycin by dose banding, a system in which daptomycin doses are rounded up or down in order to standardize and protocolize the preparation of intravenous mixtures as much as possible.

How was it done?

In order to improve this situation, dose banding strategy was implemented in February 2019: the obtained final dose was rounded in such a way that only mixtures of 500, 700 and 850 mg were prepared (in agreement with Hospital Pharmacy and Infectious and Microbiology medical teams) , following this scheme:
PRESCRIBED DOSE PREPARED DOSE
< 400 mg Prescribed dose (individualized) 400–599 mg 500 mg ≥600–799 mg 700 mg ≥800 mg 850 mg

What has been achieved?

Previous year before starting dose banding strategy (2018), 5493 individualized doses of daptomycin were prepared for 437 patients in our Pharmacy service. Between June 2020 and June 2021, 2680, 2555 and 997 units of daptomycin 500, 700 and 850 mg, respectively, were prepared for 360 patients. Batches of standardized doses were prepared in advance and kept refrigerated (stability of 10 days in 100 ml of physiological saline) until dispensation. In addition, during the same period, 15 patients (4 from pediatrics) received 209 individualized doses (3.2% of the total doses) due to their low body weight.

What next?

This strategy might decrease the number of errors in preparation and reduce processing times, which is essential since early appropriate antibiotic treatment in severe infection has been associated with better outcomes. Dose banding model could be extrapolated to other drugs with good physical, medical and microbiological stability in dilution, which are frequently prescribed and when few dose bands can cover most of the prescriptions.

Author(s)

Sonja Guntschnig

Why was it done?

The aim of this good practice initiative (GPI) was to identify local resistance patterns, improve prescribing quality, reduce hospital costs, calculate antibiotic use data, track problem organisms, infection clusters and enable transfer chains tracing.

What was done?

With the introduction of a new antimicrobial stewardship (AMS) group into Tauernklinikum, Zell am See, a new informatics tool called HyBase® by epiNet AG was implemented to establish an interface linking microbiological results, consumption of antimicrobials, the hospital infections surveillance system “Krankenhaus-Infektions-Surveillance-System”(KISS) and the hospitals antimicrobial resistance data. AMS teams need suitable AMS surveillance systems to track intervention changes and measure results.

How was it done?

After purchasing release by the hospital management, HyBase needed an interface with several IT system providers, namely the internal microbiology laboratory (KISS software), System Application and Product in processing (SAP), and two external microbiology laboratories.

What has been achieved?

Antibiotic consumption figures were obtained retrospectively by calculating defined daily doses (DDD). This also gave insight into problematic use of certain antibiotics and indicated potential for antibiotic restriction.
Antimicrobial resistance patterns were displayed, which led to the introduction of infection control and AMS measures. Alert organism surveillance data was obtained and evaluated for different wards.

What next?

Learning from this implementation will enable changes in antimicrobial prescribing which will lead to improvements, both in healthcare quality and patient safety as well as a potential reduction in prescribing costs. Alert organism clusters will be detectable as will be transfer chains in the healthcare setting. It will also allow for the introduction of infection control agent stewardship for example by testing hand disinfection compliance or recording the spread of surface adherent organisms.
This GPI addresses the WHO antimicrobial resistance global action plan and local antimicrobial medicines concerns. It may prove useful for other healthcare settings and can be easily implemented to obtain data necessary for robust effective antimicrobial stewardship.