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Original article

Vol. 149 No. 4142 (2019)

Appropriateness of antimicrobial prescribing in a Swiss tertiary care hospital: a repeated point prevalence survey

  • Nicolas Gürtler
  • Andrea Erba
  • Céline Giehl
  • Sarah Tschudin-Sutter
  • Stefano Bassetti
  • Michael Osthoff
DOI
https://doi.org/10.4414/smw.2019.20135
Cite this as:
Swiss Med Wkly. 2019;149:w20135
Published
10.10.2019

Summary

AIMS OF THE STUDY

Inappropriate use of antimicrobials is associated with the emergence of antimicrobial resistance and adverse events. Antimicrobial stewardship programmes may both optimise treatment of infections and reduce antimicrobial resistance but are implemented in only a minority of Swiss hospitals. In addition, data on prescribing patterns and quality are scarce. We conducted a repeated point prevalence survey to evaluate the quality of antimicrobial prescribing in a single tertiary care centre.

METHODS

Antimicrobial use was audited twice (summer 2017 and winter 2018) among all patients admitted to the University Hospital Basel, Switzerland. Data were collected from the electronic health record. Appropriateness of antimicrobial use was evaluated according to previously published rules and local national guidelines.

RESULTS

We evaluated 1112 patients of whom 378 (34%) received 548 prescriptions in total (30% for prophylaxis). Penicillins with β-lactamase inhibitors were most commonly used (30%), followed by cotrimoxazole (12%) and ceftriaxone (7%). Intravenous administration was chosen in 56% of patients. Prior to antimicrobial therapy, blood cultures were collected in 69% of patients. Overall, 182 (33%) prescriptions were not appropriate; reasons included lack of indication (11%), incorrect dosing (7%), delay in intravenous to oral switch (9%) or non-adherence to local guidelines (15%). A minority of patients received antimicrobials despite documented allergies (2%). Almost 38% of empirical prescriptions were inappropriate, compared with only 19% of prophylactic and 20% of targeted prescriptions. Penicillins with β-lactamase inhibitors and cephalosporins were most commonly involved in inappropriate prescribing (>50%) followed by carbapenems (30%), narrow-spectrum penicillins (17%) and cotrimoxazole (6%), with oral administration being involved less frequently than intravenous administration (15 vs 37%). Infectious diseases consultation and presence of immunosuppression were associated with reduced odds (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.21–0.70 and OR 0.31, 95% CI 0.17–0.54, respectively) of inappropriate prescription in the per-patient multivariable analysis, whereas being admitted to a surgical or intensive care unit was associated with increased odds (OR 1.83 and 5.67) compared with a medical unit.

CONCLUSION

Almost one third of prescriptions were inappropriate in our tertiary care centre despite local guidelines and an on-demand infectious diseases consultation service. Our results underscore the need for expanding current antimicrobial stewardship efforts, including national initiatives such as stewardship and prescribing guidelines, repeated surveys and identification of areas for improvement including timely intravenous to oral switches in order to reduce the consequences of inappropriate prescribing and of multidrug resistant organisms.

References

  1. Cantón R, Morosini MI. Emergence and spread of antibiotic resistance following exposure to antibiotics. FEMS Microbiol Rev. 2011;35(5):977–91. doi:.https://doi.org/10.1111/j.1574-6976.2011.00295.x
  2. Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis. 2006;42(Suppl 2):S82–9. doi:.https://doi.org/10.1086/499406
  3. Choosing wisely. [Cited 17 Dec. 2018] Available at: http://www.choosingwisely.org/societies/society-for-healthcare-epidemiology-of-america/.
  4. Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176–87. doi:.https://doi.org/10.1016/S0140-6736(15)00473-0
  5. Antimicrobial resistance, Factsheet. September 2016. http://www.who.int/mediacentre/factsheets/fs194/en/. Accessed on 11 Jan. 2018
  6. Bundesamt für Gesundheit BAG. Strategie Antibiotikaresistenzen Bereich Mensch. Available at: https://www.bag.admin.ch/bag/de/home/strategie-und-politik/nationale-gesundheitsstrategien/strategie-antibiotikaresistenzen-schweiz.html
  7. Gasser M, Schrenzel J, Kronenberg A. Aktuelle Entwicklung der Antibiotikaresistenzen in der Schweiz. Swiss Med Forum. 2018;18(46):943–9. doi:.https://doi.org/10.4414/smf.2018.03404
  8. BAG-Bulletin. (2018, July 2nd). How is antibiotic resistance evolving? Retrieved from https://www.bag.admin.ch/bag/en/home/themen/mensch-gesundheit/uebertragbare-krankheiten/antibiotikaresistenzen/wie-entwickelt-sich-die-antibiotikaresistenzlage---.html [assessed on 13 July 2018]
  9. Glinz D, Leon Reyes S, Saccilotto R, Widmer AF, Zeller A, Bucher HC, et al. Quality of antibiotic prescribing of Swiss primary care physicians with high prescription rates: a nationwide survey. J Antimicrob Chemother. 2017;72(11):3205–12. doi:.https://doi.org/10.1093/jac/dkx278
  10. Cusini A, Rampini SK, Bansal V, Ledergerber B, Kuster SP, Ruef C, et al. Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey. PLoS One. 2010;5(11):e14011. doi:.https://doi.org/10.1371/journal.pone.0014011
  11. Mettler J, Simcock M, Sendi P, Widmer AF, Bingisser R, Battegay M, et al. Empirical use of antibiotics and adjustment of empirical antibiotic therapies in a university hospital: a prospective observational study. BMC Infect Dis. 2007;7(1):21. doi:.https://doi.org/10.1186/1471-2334-7-21
  12. Di Giammarino L, Bihl F, Bissig M, Bernasconi B, Cerny A, Bernasconi E. Evaluation of prescription practices of antibiotics in a medium-sized Swiss hospital. Swiss Med Wkly. 2005;135(47-48):710–4. doi:.https://doi.org/10.4414/smw.2005.11174
  13. Osthoff M, Bielicki J, Widmer AF, For Swissnoso. Evaluation of existing and desired antimicrobial stewardship activities and strategies in Swiss hospitals. Swiss Med Wkly. 2017;147:w14512.
  14. Widmer AF, Lakatos B, Frei R. Strict infection control leads to low incidence of methicillin-resistant Staphylococcus aureus bloodstream infection over 20 years. Infect Control Hosp Epidemiol. 2015;36(6):702–9. doi:.https://doi.org/10.1017/ice.2015.28
  15. Battegay M, Bättig V, Bloch-Infanger C, Erb S, Fasel D, Khanna N, et al. Infektiologie und Spitalhygiene Weissbuch 2016. Basel, Switzerland: Universitätsspital Basel; 2016.
  16. Seaton RA, Nathwani D, Burton P, McLaughlin C, MacKenzie AR, Dundas S, et al. Point prevalence survey of antibiotic use in Scottish hospitals utilising the Glasgow Antimicrobial Audit Tool (GAAT). Int J Antimicrob Agents. 2007;29(6):693–9. doi:.https://doi.org/10.1016/j.ijantimicag.2006.10.020
  17. Hawkyard CV, Koerner RJ. The use of erythromycin as a gastrointestinal prokinetic agent in adult critical care: benefits versus risks. J Antimicrob Chemother. 2007;59(3):347–58. doi:.https://doi.org/10.1093/jac/dkl537
  18. Guidelines of the Swiss Society for Infectious Diseases. [Cited 11 Sep. 2019] Available at: https://www.sginf.ch/guidelines/guidelines-overview.html
  19. Spivak ES, Cosgrove SE, Srinivasan A. Measuring Appropriate Antimicrobial Use: Attempts at Opening the Black Box. Clin Infect Dis. 2016;63(12):1639–44. doi:.https://doi.org/10.1093/cid/ciw658
  20. Cressman AM, MacFadden DR, Verma AA, Razak F, Daneman N. Empiric Antibiotic Treatment Thresholds for Serious Bacterial Infections: A Scenario-Based Survey Study. Clin Infect Dis. 2018. doi:.https://doi.org/10.1093/cid/ciy1031
  21. Mertz D, Koller M, Haller P, Lampert ML, Plagge H, Hug B, et al. Outcomes of early switching from intravenous to oral antibiotics on medical wards. J Antimicrob Chemother. 2009;64(1):188–99. doi:.https://doi.org/10.1093/jac/dkp131
  22. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. doi:.https://doi.org/10.1016/0021-9681(87)90171-8
  23. Pulcini C, Botelho-Nevers E, Dyar OJ, Harbarth S. The impact of infectious disease specialists on antibiotic prescribing in hospitals. Clin Microbiol Infect. 2014;20(10):963–72. doi:.https://doi.org/10.1111/1469-0691.12751
  24. Habib AM, Wong AD, Schreiner GC, Satti KF, Riblet NB, Johnson HA, et al. Postoperative prophylactic antibiotics for facial fractures: A systematic review and meta-analysis. Laryngoscope. 2019;129(1):82–95. doi:.https://doi.org/10.1002/lary.27210
  25. Domingo F, Dale E, Gao C, Groves C, Stanley D, Maxwell RA, et al. A single-center retrospective review of postoperative infectious complications in the surgical management of mandibular fractures: Postoperative antibiotics add no benefit. J Trauma Acute Care Surg. 2016;81(6):1109–14. doi:.https://doi.org/10.1097/TA.0000000000001232
  26. Zhang CD, Zeng YJ, Li Z, Chen J, Li HW, Zhang JK, et al. Extended antimicrobial prophylaxis after gastric cancer surgery: a systematic review and meta-analysis. World J Gastroenterol. 2013;19(13):2104–9. doi:.https://doi.org/10.3748/wjg.v19.i13.2104
  27. Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605–27. doi:.https://doi.org/10.1086/676022
  28. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al.; American Society of Health-System Pharmacists (ASHP); Infectious Diseases Society of America (IDSA); Surgical Infection Society (SIS); Society for Healthcare Epidemiology of America (SHEA). Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013;14(1):73–156. doi:.https://doi.org/10.1089/sur.2013.9999
  29. Society for Healthcare Epidemiology of America. Don’t continue surgical prophylactic antibiotics after the patient has left the operating room. [Cited 11 Sep. 2019] Available at: http://www.choosingwisely.org/clinician-lists/shea-prophylactic-antibiotics/
  30. Akhloufi H, Hulscher M, van der Hoeven CP, Prins JM, van der Sijs H, Melles DC, et al. A clinical decision support system algorithm for intravenous to oral antibiotic switch therapy: validity, clinical relevance and usefulness in a three-step evaluation study. J Antimicrob Chemother. 2018;73(8):2201–6. doi:.https://doi.org/10.1093/jac/dky141
  31. Ingram PR, Seet JM, Budgeon CA, Murray R. Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital. Intern Med J. 2012;42(6):719–21. doi:.https://doi.org/10.1111/j.1445-5994.2012.02809.x
  32. Akhloufi H, Streefkerk RH, Melles DC, de Steenwinkel JE, Schurink CA, Verkooijen RP, et al. Point prevalence of appropriate antimicrobial therapy in a Dutch university hospital. Eur J Clin Microbiol Infect Dis. 2015;34(8):1631–7. doi:.https://doi.org/10.1007/s10096-015-2398-6
  33. James R, Upjohn L, Cotta M, Luu S, Marshall C, Buising K, et al. Measuring antimicrobial prescribing quality in Australian hospitals: development and evaluation of a national antimicrobial prescribing survey tool. J Antimicrob Chemother. 2015;70(6):1912–8. doi:.https://doi.org/10.1093/jac/dkv047
  34. Aghdassi SJS, Gastmeier P, Piening BC, Behnke M, Peña Diaz LA, Gropmann A, et al. Antimicrobial usage in German acute care hospitals: results of the third national point prevalence survey and comparison with previous national point prevalence surveys. J Antimicrob Chemother. 2018;73(4):1077–83. doi:.https://doi.org/10.1093/jac/dkx494
  35. Holmes NE, Howden BP. The rise of antimicrobial resistance: a clear and present danger. Expert Rev Anti Infect Ther. 2011;9(6):645–8. doi:.https://doi.org/10.1586/eri.11.49
  36. Chaves NJ, Cheng AC, Runnegar N, Kirschner J, Lee T, Buising K. Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals. Intern Med J. 2014;44(6):568–74. doi:.https://doi.org/10.1111/imj.12373
  37. Baur D, Gladstone BP, Burkert F, Carrara E, Foschi F, Döbele S, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis. 2017;17(9):990–1001. doi:.https://doi.org/10.1016/S1473-3099(17)30325-0
  38. Septimus EJ, Owens RC, Jr. Need and potential of antimicrobial stewardship in community hospitals. Clin Infect Dis. 2011;53(Suppl 1):S8–14. doi:.https://doi.org/10.1093/cid/cir363
  39. Goff DA. Antimicrobial stewardship: bridging the gap between quality care and cost. Curr Opin Infect Dis. 2011;24(Suppl 1):S11–20. doi:.https://doi.org/10.1097/01.qco.0000393484.17894.05
  40. Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA Surg. 2019;154(7):590–8. doi:.https://doi.org/10.1001/jamasurg.2019.0569
  41. Leedahl DD, Personett HA, Nagpal A, Barreto EF. Prevention of Clostridium difficile Infection in Critically Ill Adults. Pharmacotherapy. 2019;39(3):399–407. doi:.https://doi.org/10.1002/phar.2200
  42. Brown KA, Daneman N, Schwartz KL, Langford B, McGeer A, Quirk J, et al. The Urine Culturing Cascade: Variation in Nursing Home Urine Culturing and Association with Antibiotic Use and Clostridiodes difficile infection. Clin Infect Dis. 2019;ciz482. doi:.https://doi.org/10.1093/cid/ciz482
  43. Tamma PD, Miller MA, Cosgrove SE. Rethinking How Antibiotics Are Prescribed: Incorporating the 4 Moments of Antibiotic Decision Making Into Clinical Practice. JAMA. 2019;321(2):139–40. doi:.https://doi.org/10.1001/jama.2018.19509
  44. Turnidge JD, Thursky K, Chen CS, McNeil VR, Wilkinson IJ. Antimicrobial use in Australian hospitals: how much and how appropriate? Med J Aust. 2016;205(10):S16–20. doi:.https://doi.org/10.5694/mja15.00899
  45. Mota I, Gaspar Â, Chambel M, Piedade S, Morais-Almeida M. Hypersensitivity to beta-lactam antibiotics: a three-year study. Eur Ann Allergy Clin Immunol. 2016;48(6):212–9.
  46. Sikkens JJ, van Agtmael MA, Peters EJ, Vandenbroucke-Grauls CM, Kramer MH, de Vet HC. Assessment of appropriate antimicrobial prescribing: do experts agree? J Antimicrob Chemother. 2016;71(10):2980–7. doi:.https://doi.org/10.1093/jac/dkw207

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