THE IMPACT OF ANTIMICROBIAL STEWARDSHIP ON THE PATTERNS OF ANTIBIOTICS’ PRESCRIPTION AND CLINICAL OUTCOMES IN THE MEDICAL WARD OF A MALAYSIAN TERTIARY CARE HOSPITAL

  • OVAIS ULLAH SHIRAZI Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia (IIUM), 25200 Kuantan, Pahang, Malaysia
  • NORNY SYAFINAZ AB RAHMAN Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia (IIUM), 25200 Kuantan, Pahang, Malaysia, Big Data Research in Drug Utilization Research Group, Kulliyyah of Pharmacy, International Islamic University Malaysia (IIUM), 25200 Kuantan, Pahang, Malaysia
  • CHE SURAYA ZIN Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia (IIUM), 25200 Kuantan, Pahang, Malaysia, Big Data Research in Drug Utilization Research Group, Kulliyyah of Pharmacy, International Islamic University Malaysia (IIUM), 25200 Kuantan, Pahang, Malaysia
  • HANNAH MD MAHIR Pharmacy Department, Hospital Sungai Buloh, Ministry of Health Malaysia, Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia
  • SYAMHANIN ADNAN Pharmacy Department, Hospital Sungai Buloh, Ministry of Health Malaysia, Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia

Abstract

Objective: To evaluate the impact of antimicrobial stewardship (AMS) on antibiotic prescribing patterns and certain clinical outcomes, the length of stay (LOS) and the re-admission rate (RR) of the patients treated within the medical ward of a tertiary care hospital in Malaysia.


Methods: This quasi-experimental study was conducted retrospectively. The prescriptions of the AMS included alert antibiotics (AA) such as cefepime, ceftazidime, colistin (polymyxin E), imipenem-cilastatin, meropenem, piperacillin-tazobactam and vancomycin were reviewed for the period of 24 mo before (May, 2012–April, 2014) and after (May, 2014–April, 2016) the AMS implementation for the patients who were treated within the medical ward of a Malaysian tertiary care hospital. Patterns of antibiotics prescribed were determined descriptively. The impact of the AMS on the length of stay (LOS) and readmission rate (RR) was determined by the interrupted time series (ITS) comparative analysis of the pre-and post-AMS segments segregated by the point of onset (May, 2014) of the AMS program. Data analysis was performed through autoregressive integrated moving average (ARIMA) Winter Additive model and the Games-Howell non-parametric post hoc test by using IBM Statistical Package for Social Sciences version 25.0 for Windows (SPSS Inc., Chicago, IL, USA).


Results: A total of 1716 prescriptions of the AA included for the AMS program showed that cefepime (623, 36.3%) and piperacillin-tazobactam (424, 24.7%) were the most prescribed antibiotics from May 2012 to April 2016. A 23.6% drop in the number of the AA prescriptions was observed during the 24-month post-AMS period. The LOS of the patients using any of the AA showed a post-AMS decline by 3.5 d. The patients’ LOS showed an average reduction of 0.12 (95% CI, 0.05–0.19, P=0.001) with the level and slope change of 0.18 (95% CI, 0.04–0.32, P=0.02) and 0.074 (95% CI, 0.02–0.12, P=0.002), respectively. Similarly, the percent RR reduced from 20.0 to 9.85 during the 24-month post-AMS period. The observed post-AMS mean monthly reduction of the RR for the patients using any AA was 0.38 (95% CI, 0.23–0.53, P<0.001) with the level and slope change of 0.33 (95% CI, 0.14–0.51, P=0.02) and 0.37 (95% CI, 0.16–0.58, P=0.001), respectively.


Conclusion: The AMS program of a Malaysian tertiary care hospital was a coordinated set of interventions implemented by the AMS team of the hospital that comprised of the infectious diseases (ID) physician, clinical pharmacists and microbiologist. The successful implementation of the AMS program from May, 2014 to April, 2016 within the medical ward resulted in the drop of the number of AA prescriptions that sequentially resulted in the significant (P<0.05) post-AMS reduction of the LOS and the RR.

Keywords: Antimicrobial stewardship (AMS) program, Interrupted time series (ITS) analysis, Alert antibiotics (AA), Prescription patterns, Length of stay (LOS) and readmission rate (RR)

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References

Lobanovska M, Pilla G. Penicillin’s discovery and antibiotic resistance: lessons for the future? Yale J Biol Med 2017;90:135–45.
2. Arruda MC, de Aguiar RS, Jardim WM, Melo LH, Mendonça T, Cavalcanti AB. Cohorting to prevent acquisition of multidrug-resistant bacteria: an interrupted time series study. Am J Infect Control 2019;47:180–5.
3. Al-Zakwani I, Al-Thuhli M, Al-Hashim A, Al Balushi KA. Drug utilization pattern in an intensive care unit at a tertiary care teaching hospital in Oman. Asian J Pharm Clin Res 2017;10:194-7.
4. Day SR, Smith D, Harris K, Cox HL, Mathers AJ. An Infectious diseases physician-led antimicrobial stewardship program at a small community hospital associated with improved susceptibility patterns and cost-savings after the first year. Open Forum Infect Dis 2015;2:ofv064.
5. Murray CK. Field wound care: prophylactic antibiotics. Wilderness and Environmental Medicine; 2017. p. 90–102.
6. Shahin M, Moghim S, Havaei SR, Ghanbari F, Havaei SA. Determination of antimicrobial resistance pattern and molecular characteristics of methicillin-resistant Staphylococcus aureus strains isolated from patients in a teaching hospital of Isfahan, Iran. Gene Reports 2018;12:289–93.
7. Anil C, Shahid RM. Antimicrobial susceptibility patterns of pseudomonas aeruginosa clinical isolates at a tertiary care hospital in Kathmandu, Nepal. Asian J Pharm Clin Res 2013;6:235-8.
8. Astuti D, Andrajati R, Supardi S. Influence of pharmacist–doctor communication on pediatric antibiotic prescriptions. Asian J Pharm Clin Res 2017;10:46-9.
9. Buckel WR, Veillette JJ, Vento TJ, Stenehjem E. Antimicrobial stewardship in community hospitals. Med Clin North Am 2018;102:913-28.
10. Erturk Sengel B, Bilgin H, Oren Bilgin B, Gidener T, Saydam S, Pekmezci A. The need for antibiotic stewardship program in a hospital using a computerized preauthorization system. Int J Infect Dis 2019;82:40-3.
11. Ma C, Smith HW, Chu C, Juarez DT. Big data in pharmacy practice: current use, challenges, and the future. Integr Pharm Res Pract 2015;4:91–9.
12. DiDiodato G, McAthur L. Transition from a dedicated to a non-dedicated, ward-based pharmacist antimicrobial stewardship programme model in a non-academic hospital and its impact on length of stay of patients admitted with pneumonia: a prospective observational study. BMJ Open Qual 2017;6. http://orcid.org/0000-0003-2836-8037
13. Chen C, Dong W, Shen JJ, Cochran C, Wang Y, Hao M. Is the prescribing behavior of Chinese physicians driven by financial incentives? Soc Sci Med 2014;120:40–8.
14. Libertin CR, Watson SH, Tillett WL, Peterson JH. Dramatic effects of a new antimicrobial stewardship program in a rural community hospital. Am J Infect Control 2017;45:979–82.
15. Fishman N. Policy statement on antimicrobial stewardship by the society for healthcare epidemiology of America (SHEA), the infectious diseases society of America (IDSA), and the pediatric infectious diseases society (PIDS). Infect Control Hosp Epidemiol 2012;33:322–7.
16. Brown CL, Reygate K, Slee A, Coleman JJ, Pontefract SK, Bates DW, et al. A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important? Int J Pharm Pract 2017;25:195–202.
17. Mitchell BG, Ferguson JK, Anderson M, Sear J, Barnett A. Length of stay and mortality associated with healthcare-associated urinary tract infections: a multi-state model. J Hosp Infect 2016;93:92–9.
18. El Morr C, Ginsburg L, Nam S, Woollard S. Assessing the performance of a modified LACE index (LACE-rt) to predict unplanned readmission after discharge in a community teaching hospital. Interact J Med Res 2017;6:2.
19. Nistal Nuno B. Segmented regression analysis of interrupted time series data to assess outcomes of a South American road traffic alcohol policy change. Public Health 2017;150:51–9.
20. Wagner AK, Soumerai SB, Zhang F, Ross Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002;27:299–309.
21. Adhikari S, Piza M, Taylor P, Deshpande K, Lam D, Konecny P. Sustained multimodal antimicrobial stewardship in an Australian tertiary intensive care unit from 2008–2015: an interrupted time-series analysis. Int J Antimicrob Agents 2018;51:620–8.
22. Alawi M, Darwesh B. A stepwise introduction of a successful antimicrobial stewardship program. Experience from a tertiary care university hospital in Western, Saudi Arabia. Saudi Med J 2016;37:1350–8.
23. Ansari F, Gray K, Nathwani D, Phillips G, Ogston S, Ramsay C, et al. Outcomes of an intervention to improve hospital antibiotic prescribing: interrupted time series with segmented regression analysis. J Antimicrob Chemother 2003;52:842–8.
24. Balinskaite V, Johnson AP, Holmes A, Aylin P. The impact of a national antimicrobial stewardship program on antibiotic prescribing in primary care: an interrupted time series analysis. Clin Infect Dis 2019;69:227–32.
25. Slekovec C, Leroy J, Vernaz Hegi N, Faller JP, Sekri D, Hoen B, et al. Impact of a region wide antimicrobial stewardship guideline on urinary tract infection prescription patterns. Int J Clin Pharm 2012;34:325–9
26. Pasquale TR, Trienski TL, Olexia DE, Myers JP, Tan MJ, Leung AK. Impact of an antimicrobial stewardship program on patients with acute bacterial skin and skin structure infections. Am J Heal Pharm 2014;71:1136–9.
27. Perez KK, Olsen RJ, Musick WL, Cernoch PL, Davis JR, Peterson LE, et al. Integrating rapid diagnostics and antimicrobial stewardship improves outcomes in patients with antibiotic-resistant Gram-negative bacteremia. J Infect 2014;69:216–25.
28. Ng CK, Wu TC, Chan WMJ, Leung YSW, Li CKP, Tsang DNC, et al. Clinical and economic impact of an antibiotics stewardship programme in a regional hospital in hong kong. Qual Saf Heal Care 2008;17:387–92.
29. Rimawi RH, Mazer MA, Siraj DS, Gooch M, Cook PP. Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med 2013;41:2099–107.
30. Lepanluoma M, Takala R, Kotkansalo A, Rahi M, Ikonen TS. Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg 2014;103:66–72.
31. Sandhu P, Singh S, Soualhi A, Tanwar H. Improving antimicrobial stewardship in an Acute Medical Unit (AMU) during patient discharge following introduction of an antimicrobial information card. Am J Infect Control 2020. DOI:10.1016/j.ajic.2020.08.014
32. Dustin Waters C. Pharmacist-driven antimicrobial stewardship program in an institution without infectious diseases physician support. Am J Heal Pharm 2015;72:466–8.
33. Basch E, Deal AM, Kris MG, Scher HI, Hudis CA, Sabbatini P, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J Clin Oncol 2016;34:557–65.
34. Wright A, Hawkins CH, Anggard EE, Harper DR. A controlled clinical trial of a therapeutic bacteriophage preparation in chronic otitis due to antibiotic-resistant Pseudomonas aeruginosa?; a preliminary report of efficacy. Clin Otolaryngol 2009;34:349–57.
35. Grigoryan L, Naik AD, Horwitz D, Cadena J, Patterson JE, Zoorob R. Survey finds improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention. Am J Infect Control 2016;44:1544–8.
36. Schweizer ML, Braun BI, Milstone AM. Research methods in healthcare epidemiology and antimicrobial stewardship-quasi-experimental designs. Infect Control Hosp Epidemiol 2016;37:1135–40.
37. MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005;18:638–56.
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SHIRAZI, O. U., N. S. A. RAHMAN, C. S. ZIN, H. M. MAHIR, and S. ADNAN. “THE IMPACT OF ANTIMICROBIAL STEWARDSHIP ON THE PATTERNS OF ANTIBIOTICS’ PRESCRIPTION AND CLINICAL OUTCOMES IN THE MEDICAL WARD OF A MALAYSIAN TERTIARY CARE HOSPITAL”. International Journal of Pharmacy and Pharmaceutical Sciences, Vol. 13, no. 3, Feb. 2021, doi:10.22159/ijpps.2021v13i3.40460.
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