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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.

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Author(s)

SILVIA CONDE, ÁNGEL MARCOS, JOSEP TORRENT, CLARA SALOM, LAURA CANADELL

Why was it done?

Prior to the start of the project, inpatient treatments were not validated. The objective of this pharmaceutical care project was to improve the pharmacotherapy of the patients admitted to the hospital in terms of efficacy and safety.

What was done?

We implemented a pharmaceutical care project in a 153-bed regional hospital.

How was it done?

The pharmaceutical care project was based on 2 main strategies. The first of them was the validation of the treatment prescribed to inpatients according to their clinical situation. We planned to validate inpatient’s treatment from Monday to Friday during working hours.
The second one was the incorporation of the clinical pharmacist to hospital’s antimicrobial stewardship program. We established 2 meetings per week with the antimicrobial stewardship group. Revisions were focused on prescriptions of broad-spectrum antibiotics for more than 48 hours, antibiotic treatments longer than 7 days and prescriptions of aminoglycosides, vancomycin, and linezolid, among others.

What has been achieved?

During the 6 first months (January-June 2021), a total of 222 pharmaceutical interventions were performed, being the most frequent:
– “Discontinue medication” (22.97%), mainly because of “Undue duration” (31.37%) and “Therapeutic duplication” (29.41%)
– “Modify dose” (31.62%)
– “Change medication” (17.12%), mainly due to “Adjustment to antibiogram” (26.32%), “Medication exchange” (18.42%) and “Inadequate medication for the clinical situation of the patient” (15.79%).
The pharmaceutical intervention acceptance rate was 81.10%.

Related to the antimicrobial stewardship program, a total of 171 revisions were performed, making any treatment advice in 51 of them (29.82%). The most frequent recommendation was to “Discontinue treatment because of undue duration” (25.49%), followed by “Adjustment to antibiogram” (15.69%), “De-escalate treatment” (11.76%) and “Increment of antibiotic dose” (11.76%). Acceptance rate was 94%.

What next?

The pharmaceutical care program allows both the early identification of possible medication errors and upgrades in inpatients’ treatment.

Author(s)

Andreas von Ameln-Mayerhofer, Martin Breuling, Ina Geist

Why was it done?

In the context of antibiotic stewardship, rapid oralisation of a parenteral antibiotic is recommended in many antibiotic stewardship guidelines. Such a sequence therapy is easy to implement if both application pathways lead to comparable efficacy levels at the site of infection. However, this does not apply to all anti-infectives, in particular some beta-lactam antibiotics represent a challenge in therapy. Additionally, the information about this topic is very sparse in the literature.

What was done?

In order to achieve an improvement in antimicrobial prescriptions, we have addressed possible problems regarding oralisation of antibiotics. For this purpose, we graphically compared the simulated efficacy levels of parenteral and oral forms of beta-lactams.

How was it done?

We programmed a computer based procedure that allows a simulation of plasma levels of antibiotics upon intravenous versus oral administration. Based on the obtained data and EUCAST-based MIC-distributions for a set of bacteria, we assessed the respective putative clinical actions.

What has been achieved?

Our simulations show that some oral beta-lactams do not reach the PK/PD condition of a sufficient therapy (fT>MHK) in the approved dosage. The simulations have been used for education seminars with physicians and partly led to an improvement in oralisation procedures. Additionally, an oralisation standard has been established.

What next?

Our next step is to develop a special prescription form for oral antibiotics which will enable us to control prescription behaviour even more effectively. We plan to monitor the prescription habits for anti-infectives more closely before and after establishing the prescription form.

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Author(s)

Marinos Petrongonas, Maria Fragiadaki, Eleni Rinaki, Leonidas Tzimis

Why was it done?

Implementation of antimicrobial stewardship programmes in hospitals is part of the national strategy to promote prudent use of antimicrobials. As HPs chair stewardship teams, they are responsible for assessing prescription and monitoring antimicrobial use. Designing and developing automated informative tools facilitates HPs in their role.

What was done?

Hospital pharmacists (HPs) designed and developed software tools to support the antibiotic stewardship team’s work. Particular developments were: a) Α PC application (GrAD_calc), in Microsoft Excel, to calculate antimicrobial consumption, instead of ABC_calc tool. GrAD_calc takes advantage of the unique codes for each branded product and transforms aggregated data, provided by the Hospital Information System (HIS), into antibiotic consumption in DDDs/100 occupied bed-days. Results are presented in charts and figures, in a format that enables ease of comparative monitoring over time. b) Necessary indexes of the above calculator and documentation needed as justification for restricted antimicrobials dispensing have been integrated into the HIS; in result, data for national surveillance programme for antimicrobial consumption are automatically exported. Useful information for pre- and post-prescription review, like demographics, indication(s), co-morbidities, current and previous treatments, microbiology tests’ results, susceptibility reports, is available and easily accessible to prescribers, HPs, and infection disease specialists.

How was it done?

HPs created GrAD_calc on their own resources, while changes in HIS were made by ICT service provider, following technical specifications described by HPs. A number of technical problems have been resolved with the contribution of HPs.

What has been achieved?

• Monitoring of antimicrobial use by pharmacy is quicker and effortless. • Handwritten documentation included in restricted antimicrobials’ prescriptions has been replaced by an electronic decision support system, as tool to improve antimicrobial prescribing and stewardship. • Useful information from patient’s medical record is directly available to HPs and physicians, and facilitates hospital’s policy for assessing antimicrobial prescriptions. • Data, like indication, medicine, dosage scheme, microbiology results and susceptibility reports, are recorded electronically and update patients’ pharmaceutical records, permitting further use for pharmaco-epidemiology studies. 

What next?

Next challenge is wide use of tools developed, to optimise pharmaceutical services provided and dispense restricted antibiotics only when accordingly justified. GrAD_calc is applicable in hospital setting and HIS’s tool is incorporated and can be used by all regional hospitals.

Author(s)

Pilar Aznarte-Padial, Lourdes Gutierrez-Zuñiga, Carmen Valencia-Soto, Sara Guijarro-Herrera, Carmen Hidalgo-Tenorio, Juan Pasquau-Liaño

Why was it done?

Re-evaluation of empirical antimicrobial treatment, after knowledge of the microbiological results, is a practice that contributes to the proper use of antimicrobials, but the consultation of these findings by the medical prescribers may be delayed. The hospital pharmacist is an essential member of Antibiotic Stewardship programs, who can maintain an individualised monitoring of prescription and maintaining direct communication with the medical prescribers. The monitoring of the antimicrobial prescriptions and the revision of microbiological results, allows us to carry out an individualised advice to optimise the antimicrobial therapy

What was done?

Pharmaceutical advices were sent from the Pharmacy Service to the prescribing doctor, through the Electronic Prescription Program (EPP) to optimize antimicrobial therapy after the microbiological results are known

How was it done?

From January 2015, together with daily monitoring of prescriptions of antibiotics, the results of microbiological cultures requested were consulted. We started to send warning messages from the Pharmacy Department to doctors, through EPP. Our goal was to advise in relation with microorganisms resistant to the prescribed antibiotic, microorganisms not covered and proposals of the de-escalation.

What has been achieved?

During 2015, we made 166 communications; 20 the same day of the discharge. Of the remaining 146, 46 were of de-escalation, 44 of resistant antimicrobials and 56 of non-covered microorganisms. Global acceptance was 80.1% (117/146): 80.1% of the de-escalation, 81.8% of antibiotic resistant microorganisms and 78.6% of non-covered microorganisms. The Services which received more advices were: Internal Medicine (57/146), General Surgery (38/146) and Pneumology (9/146), with an acceptance of 82.5%, 76.3% and 100.0%, respectively. The carbapenems were the most involved antibiotic group (58.9%). Ertapenem was involved in advices of non-covered microorganisms in 21.4%. The most commonly used antibiotics after the de-escalation were: fluoroquinolones (18.9%), beta-lactams with a beta-lactamase inhibitor (10.8%), fosfomycin (10.8%) and ampicillin (10.8%).

What next?

The acceptance degree obtained permits to consider this initiative as a valid strategy to optimize antibiotic prescriptions. This procedure reduces the use of restricted antibiotics, by lowering the cost of treatments and the resistance emergence.

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Author(s)

Stephen Hughes, Katie Heard

Why was it done?

The context, strategies, and delivery of AMS vary markedly between hospitals, largely falling within two headings, that of restriction or enablement. Restricted access to broad-spectrum antimicrobials through pharmacy and microbiology control of supply is the most common approach as requires minimal resource and implementation. This controls antimicrobial misuse but the long term benefits are less clear. The negative professional culture this restriction develops may erode inter-professional trust and delay time to first-dose, negatively impacting upon sepsis management whilst approval is sought. CDSS was used to transform the working role of the AMS team.

What was done?

A real-time clinical decision support system (CDSS) has been tested and implemented for the first time in an acute NHS hospital. CDSS has enabled the service evolve from an effective restricted antimicrobial stewardship (AMS) service to a more desirable enablement service, where the team aspires to support all prescribers to take responsibility for good AMS practice

How was it done?

In April 2016 a commercial CDSS was introduced at a single site London teaching hospital with an established, multi-professional AMS team. A service evaluation was conducted to understand the impact of CDSS on practice. Data was collected for three months pre and post implementation, including time spent compiling data for AMS daily ward round, the number and types of ABX-related interventions made and total antimicrobial use (defined daily dose [DDD] per 100 occupied bed days [OBDs]).

What has been achieved?

Implementation of CDSS saw a transformation of the AMS service from tele-consult service from the microbiology labs to a patient-facing ward based service, through use of mobile technology. The relocation of AMS team staff resource allowed for increase ward presence and daily ward rounds on surgical, medical and admission wards. AMS interventions increased (138/quarter to 298/quarter) post-intervention. Clinician acceptance of AMS team interventions increased from 81% to 98%. High-impact interventions, such as escalation of septic patients, early discharge and ID reviews, increased on the ward based reviews. Total ABX (DDD/100OBD) reduced by 18% over study period.

What next?

The CDSS is being used to evolve the service to further support AMS practice. Patient orientated outcome data is being collected and used to drive further service improvements

Author(s)

Emma Ramos Santana, Enrique Tevar Alfonso, Maria Jose Castillos Mendez, Maria Luz Padilla Salazar, Lucy Abella Vazquez, Jesus Ode Febles, Marcelino Hayek Peraza, Javier Merino Alonso

Why was it done?

The implementation of an antimicrobial stewardship program (AMS) is very important, but it has to be accompanied by personal resources. It is therefore necessary to effectively use the time spent in the AMS.

What was done?

We have worked with the Information Technology Service to develop an “Intelligent Antimicrobial Screening Program” (IASP).

How was it done?

Using the information available in Electronic Health Record (EHR) and in pharmacy and microbiology applications we have developed a computer tool that analyze hundreds of situations through pre-established conditions

What has been achieved?

Currently the system analyzes more than 40 conditions related to the correct use of antimicrobials based on antibiotic characteristics, patient situation and microbiological data.
Some of the most relevant conditions are:
●Antibiotic prescribed more than 6 days.
●Patient with parenteral antibiotic for more than 3 days and with other oral medicines.
●Antibiotic that must be adjusted in patients with renal impairment prescribed in patients with glomerular filtration rate (GFR)65 years old, GFR5 days prescribed or other nephrotoxic prescribed.
●Patients with linezolid and thrombocytopenia or anemia or without an hemogram in the last week.
●Patients with daptomicyn and high creatininkinase (CK) or without a recent determination.

What next?

This software allows to collect information contained in different systems and displays it in an organized view to the user. This makes it an easily system that can be exported to other hospitals.
Our next objective is to consult the microbiological information. Therefore the system will be able to recommend about the optimal antimicrobial treatment, detecting situations in which the treatment can be de-escalated or alerting in case of resistance.