Reasons include inappropriate prescribing for antimicrobial prophylaxis, This booklet does not contain speciſc guidelines for treatment of human immunodeſ- .gov/vaccines/recs/schedules/downloads/adult//bloccocverbnerbe.cf Stanford Health Care Antimicrobial Dosing Reference Guide. This document bloccocverbnerbe.cf ؞ ABX Subcommittee Approved: March Soc Am. ;54(12) doi/cid/cis Stanford Hospital & Clinics Antimicrobial Dosing Reference Guide This document and bloccocverbnerbe.cf ABX Subcommittee Approved: January 30, Formulas .. Antimicrob Agents Chemother ;. 54(1) .
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B. Guidelines for the Treatment of Various Infections in Adults . H. Antimicrobial Dosing for Adult Patients Based on Renal Streptococcal Pharyngitis: Update by the Infectious Diseases Society America. .. URL: bloccocverbnerbe.cf .gov/std/treatment//STD-TreatmentRRpdf. 2. vise this antimicrobial guide after five years. T he threat that one guide for local doctors caring for the critically ill septic patient. Ho w e .. ; 12(10): 4. 5. bloccocverbnerbe.cf Accessed. bloccocverbnerbe.cf bloccocverbnerbe.cf AND. Kalil AC .. guidelines for management of severe sepsis and septic shock:
This approach sometimes results in the use of relatively broader-spectrum antimicrobials than are necessary, but antimicrobial stewardship dictates that therapy be tailored to the causative pathogen when possible; this was the impetus for limiting the drug formulary.
Escalation or de-escalation of therapy is a collaborative responsibility among the attending physician, the laboratory department, and the pharmacist. Every antimicrobial order is reviewed for opportunities to optimize therapy, and susceptibility results are available through the daily report of culture results generated by the laboratory and printed by the pharmacist.
Education about the criteria for IV-to-PO conversion and adherence with best practice and current clinical guidelines was provided to physicians and nurses during implementation of the ASP and is now reinforced quarterly. Nurses are instructed to notify pharmacy staff when any IV antimicrobial has exceeded the recommended duration of therapy, based on clinical guidelines and patient-specific eligibility for IV-to-PO step-down. Physician education focuses on building awareness of IV-to-PO step-down recommendations.
The pharmacy department monitors records of all IV orders so that the pharmacist can assess the need for IV administration and contact the physician to suggest a PO antimicrobial alternative, if appropriate. In noncritical instances determined by how close a patient is to being eligible for IV-to-PO step-down , a label suggesting PO step-down choices and criteria to justify the conversion is provided and affixed to the progress notes.
Three days after making a step-down recommendation, the pharmacist initiates a case review and, if necessary, contacts the physician to determine why the conversion has not been carried out. This process ensures that the route change has been considered and provides an educational opportunity for both parties.
Initially, there was a general lack of understanding among staff about ASPs. Staff members who were interested in ASPs did not know how to develop one and were unsure who should be leading such a program, because the hospital lacked an infectious disease specialist. Overcoming this first development barrier involved selecting an individual to take ownership of and spearhead the ASP.
The second barrier was the lack of funding and time, and members of the team had to be willing to work overtime without compensation. Other barriers to program implementation included lack of consistent education to all staff on ASP practices, lack of adequate download-in and uptake by physicians, and lack of role clarity about the responsibility for antimicrobial prescribing among disciplines.
Regular and positive communication among staff members, particularly between physicians and the ASP pharmacist, and empowerment of nurses have been essential to the success of the ASP. The effectiveness of the ASP has been measured primarily through changes in susceptibility to targeted antimicrobials among various gram-negative and gram-positive organisms Table 1.
Over time, the susceptibility rates for commonly used antibiotics have shown either a positive trend or have remained stable. The ASP has also been evaluated in terms of the number of pharmacist recommendations made and the number accepted. Antimicrobial recommendations made and tracked by the ASP pharmacist increased from an average of 2.
Over the same period, pharmacy requests for infectious disease consults increased from 1 per month to 3 per week. Consumption of targeted IV antibiotics, defined daily doses, and antimicrobial acquisition costs were also measured. Among the targeted IV antibiotics, piperacillin—tazobactam and vancomycin usage was reduced the most, with the defined daily dose per patient-days decreasing from There were overall trends for reductions in consumption, defined daily dose, and cost, but the relationship between these trends and the ASP could not be substantiated because of multiple demographic and organizational changes during the implementation phase, including increases in the numbers of patients requiring antibiotics and hospital admissions, a reduction in the length of hospital stay, and a lack of alternative level of care patients.
It is difficult to ascertain which ASP strategies resulted in the changes discussed above. We believe that substituting a narrow-spectrum antibiotic for piperacillin-tazobactam, targeting the overall utilization of vancomycin, and increased awareness of risk factors for MRSA played significant roles in the reduction of these antibiotics.
Because all of the interventions were implemented simultaneously, it is not possible to delineate specifically which strategies were and were not effective. We suggest that, to allow determination of which interventions are most effective, future programs should start small, implementing just 1 or 2 strategies before adding others, and should define outcome measures at the outset of program development, to allow measurement of the impact of an intervention after its implementation.
Adult Treatment Recommendations
This approach would allow for more comprehensive data collection, improved program evaluation, and potential reduction in resistance from staff members who prefer small, incremental changes in daily practice.
The Winchester District Memorial Hospital is a leader in antimicrobial stewardship and an exemplary case of how a small bed hospital was able, with minimal resources, to mobilize and implement a successful ASP by overcoming barriers unique to the rural setting. Evidence-based practice guidelines clearly highlight the need for and benefit of antimicrobial stewardship within health care institutions; however, the mere publication of recommendations has not led to the widespread implementation of guidelines in hospitals.
The Winchester District Memorial Hospital represents the forefront of change by moving research into practice, employing locally adapted, evidence-based practice standards in an efficient manner to promote a cultural shift in prescribing behaviour. This program will ultimately improve outcomes for patients through the avoidance of antimicrobial resistance and adverse effects and the preservation of the current antimicrobial armamentarium. This article serves as evidence supporting comprehensive ASPs and their facilitation through minimal resources in a small, rural hospital.
Competing interests: None declared. None received. National Center for Biotechnology Information , U. Can J Hosp Pharm. She is also a part-time professor with the University of Ottawa, Ottawa, Ontario.
Author information Copyright and License information Disclaimer. Address correspondence to: Copyright Canadian Society of Hospital Pharmacists. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP. Core Strategies Conduct a Prospective Audit with Intervention and Feedback Before implementation of the ASP, the pharmacist performed a general review of antimicrobial orders to detect discrepancies with respect to clinical guidelines with individual antimicrobial agents, including indication, dose, frequency in relation to renal function , and duration of therapy.
Enforce Formulary Restriction and Need for Authorization for Nonformulary Antibiotics Formulary restriction and preauthorization are considered to form the most effective approaches to controlling the use of antimicrobial agents 9 ; at the Winchester District Memorial Hospital, formulary-related decisions are made by the Pharmacy and Therapeutics Committee.
Guideline recommendations and antimicrobial resistance: the need for a change
Causes of non-adherence to therapeutic guidelines in severe community-acquired pneumonia. A clinical questionnaire was submitted to 36 physicians from Latin America; they were asked to indicate the empirical treatment in two fictitious cases of severe respiratory infection: In the case of communityacquired pneumonia, 11 prescriptions of 36 The causes for non-compliant treatment were monotherapy The reasons for lack of compliance were monotherapy In the case of nosocomial pneumonia, the compliance rate with the guidelines was 2.
Key words: Acute respiratory infection is associated with high morbidity and social costs, 1 , 2 which significantly increase in complicated cases with septic shock.
Various studies conducted in Europe, 11 , 12 the United States 13 and Australia 14 have analyzed adherence to therapeutic guidelines in empirical antibiotic prescription. However, no similar studies have been performed in Latin America. A survey was administered to 36 Latin American physicians with extensive experience in the intensive care unit ICU. The same questionnaire was utilized to conduct an Australian study published by Dulhunty et al.
In the present study, only cases of respiratory infection were analyzed: Both settings are described in the electronic supplementary materials. In addition, for each clinical case, they were requested to indicate how many and which antibiotics they would prescribe, their dose and duration. For these cases, the presence of empyema or any other complication that required surgical intervention or an invasive procedure was discarded.
The weight of the patient was indicated as being 80kg, and their renal and liver function was listed as normal.
They were asked to choose between one and three antibiotics without including antivirals, antifungals or tuberculostatic drugs. The dose of medication was calculated and expressed in g per day. The two settings were bilateral community-acquired pneumonia with secondary septic shock case 1, available in the electronic supplementary materials ; and nosocomial pneumonia in the postoperative period following cholecystectomy case 2, available in the electronic supplementary materials.
The number of antibiotics indicated, along with their dose and duration, was recorded. The indicated regimen and the dose of antibiotic were then consulted according to the indications from the respective therapeutic guides. Because this was a spontaneous survey conducted using fictitious clinical cases, informed consent was not solicited to perform this study.
The survey participants were informed about the purpose of the survey and notified that their compliance was not a condition for obtaining the certificate of course participation. The results are expressed as the medians and interquartile ranges for continuous variables or as an absolute frequency and percentage frequency for categorical variables.
Thirty-six physicians responded to the survey: Results are expressed as the absolute values and percentages: ICU - intensive care unit. In the two clinical cases, a total of antibiotics were detailed Tables 2 and 3: In case 1, the most employed group of antibiotics was beta-lactams 29 of 68 prescriptions; Macrolides clarithromycin and azithromycin were indicated in 19 of 68 prescriptions The most prescribed antibiotic patterns were as follows Figure 1: In 32 of 36 cases Active anti- Pseudomonas treatment was prescribed in 15 of 36 patients The causes of non-compliance were monotherapy 4 of 25; The most employed antibiotics were clarithromycin 10 prescriptions , clindamycin 1 prescription and amoxicillin clavulanic 1 prescription.
In case 2, the most indicated antibiotics were meropenem 20 prescriptions of 67; The most highly employed regimens are shown in figure 2: Monotherapy was indicated in 5 of 36 patients In all cases, active treatment was indicated for P.
Active treatment for MRSA was indicated in 30 of 36 patients The causes of non-compliance were monotherapy in 5 prescriptions of 35 If the administration of only one active antibiotic for P. In line with the results obtained from studies conducted on other continents, 11 - 14 this conclusion carries strong implications because a low adherence to therapeutic recommendations is associated with greater morbidity and mortality as well as with an increase in health costs.
The proposed causes of non-adherence were differences between the patient being treated and the condition described in the guidelines, the presence of kidney or liver failure, the unavailability or excessive costs of specific antibiotics, and differences between local flora and international recommendations. Although the therapeutic guidelines recommend initiation of broad-spectrum treatment in high-suspect cases of multi-resistant pathogens, this was not considered a correct option because in the setting presented, the patient did not have risk factors for nosocomial pathogens.
There were various causes of non-adherence. Another cause for the lack of adherence was the extensive coverage for P. It has been previously shown that the prevalence of multi-resistant organisms and MRSA is higher in Latin America than in other countries.
We collected data on microbiology and resistance patterns and identified discrete pattern categories. We assessed the extent to which recommendations considered resistance, in addition to efficacy and safety, when recommending antibiotics. Results We identified guidelines, which reported a total of recommendations. In only 16 6. In a further 69 Across syndromes, 12 patterns of resistance with implications on recommendations were observed.
Conclusion There is consistent evidence that guidelines on empirical antibiotic use did not routinely consider resistance in their recommendations. Decision-makers should analyse and report the extent of local resistance patterns to allow better decision-making.
Research was limited only to an electronic screening so printed versions of clinical practice guidelines may have been missed. Recommendations were arbitrarily hierarchised according to the influence of resistance data collected. Further research on the quality and relevance of specific recommendations based on resistance is needed identifying further obstacles to progress antimicrobial resistance and bringing them to light.
Background The appropriate use of antibiotics has become a worldwide priority. Time trend analyses have reported an increase in antimicrobial resistance AMR including extended spectrum beta-lactamase, Gram-negative bacteria resistant to carbapenems or plasmid-mediated colistin resistance.
We hypothesised that scientific societies and professional associations invested time and energies finalising guidelines to provide information on empirical antibiotic use. We assumed that these guidelines have at the core resistance threats and report information on country-specific resistance patterns, as these are essential information to guide the empirical choice of antibiotics. Therefore, we mapped guidelines targeting five common infectious conditions where empirical therapy prevails and evaluated what proportion of recommendations consider resistance patterns as a driver of the clinical decision-making, how resistance influences recommendations and whether resistance can be better incorporated.
Methods This study is part of a large comprehensive review of antibiotics that aims to revise the selection of antibiotics included in the WHO Model List of Essential Medicines, and is part of the Global Action Plan on Antimicrobial Resistance, 10 a series of international actions to monitor and control antibiotics resistances.
They represent the most prevalent infectious diseases worldwide, a balanced case mix of benign and severe diseases and cover the spectrum of empirical antibiotic treatment choices. To our knowledge, there is no single repository of CPGs on antibiotics.Garnacho-Montero et al. Footnotes Competing interests: Antibiotics Basel ; 5 1: Amoxicillin and penicillin V remain first-line therapy due to their reliable antibiotic activity against GAS.
The most highly employed regimens are shown in figure 2: