Pharmacist-Led Antimicrobial Stewardship 2.0

A special issue of Pharmacy (ISSN 2226-4787). This special issue belongs to the section "Pharmacy Practice and Practice-Based Research".

Deadline for manuscript submissions: closed (29 February 2024) | Viewed by 14930

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Guest Editor
Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL 36849-5341, USA
Interests: antimicrobial stewardship; urinary tract infections; HIV infection; skin/skin structure infections; pharmacy practice; continuing education
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Special Issue Information

Dear Colleagues,

The increasing threat of antimicrobial resistance is a worldwide problem. In fact, the World Health Organization considers antimicrobial resistance to be one of the top ten public health threats facing humanity. This is associated with numerous untoward consequences, including prolonged hospital stays, increased healthcare expenditures, and even mortality. Although many different factors may contribute to the emergence of antimicrobial resistance, the overuse and misuse of antimicrobials is the predominant factor. With the slow development of novel antimicrobials, few options exist to combat this deadly problem. The best defense is though appropriate antimicrobial stewardship. The Centers for Disease Control and Prevention define antimicrobial stewardship as “the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.” Pharmacists are in the unique position to lead antimicrobial stewardship efforts because of their expertise in pharmacotherapy, drug utilization, and adverse effects associated with pharmacologic therapy. Pharmacists provide, among other things, guidance with limiting the use of broad-spectrum agents and promoting the overall judicious use of antibiotics.

For this Special Issue, we welcome original research articles related to pharmacist-led antimicrobial stewardship. Articles may focus on, but are not limited to, novel approaches to the provision of antimicrobial stewardship, programs that have been successfully implemented, and antimicrobial stewardship in the acute care, long-term care, and outpatient settings. We also welcome commentaries, reviews, and editorials.

Dr. Spencer Durham
Guest Editor

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Keywords

  • antimicrobial stewardship
  • antimicrobial resistance
  • pharmacist
  • pharmacy
  • infectious disease
  • antibiotics
  • clinical pharmacy

Published Papers (8 papers)

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12 pages, 491 KiB  
Article
Evaluation of Oral Amoxicillin/Clavulanate for Urinary Tract Infections Caused by Ceftriaxone Non-Susceptible Enterobacterales
by Madison E. Salam, Meghan Jeffres, Kyle C. Molina, Matthew A. Miller, Misha Huang and Douglas N. Fish
Pharmacy 2024, 12(2), 60; https://doi.org/10.3390/pharmacy12020060 - 1 Apr 2024
Viewed by 1927
Abstract
Urinary tract infections (UTIs) are one of the most common infections and are frequently caused by Gram-negative organisms. The rise of resistant isolates has prompted evaluation of alternative therapies, including amoxicillin-clavulanate which has potent activity against Ambler class A enzymes. This study sought [...] Read more.
Urinary tract infections (UTIs) are one of the most common infections and are frequently caused by Gram-negative organisms. The rise of resistant isolates has prompted evaluation of alternative therapies, including amoxicillin-clavulanate which has potent activity against Ambler class A enzymes. This study sought to evaluate clinical outcomes of patients with ceftriaxone non-susceptible UTIs receiving amoxicillin-clavulanate or standard of care (SOC). This was a single-center, retrospective, cohort study of adult patients with urinary tract infections caused by a ceftriaxone non-susceptible pathogen who received amoxicillin-clavulanate or SOC. The primary outcome was clinical failure at 90 days. Secondary outcomes included time to failure, isolation of a resistant organism, and hospital length of stay. Fifty-nine patients met study inclusion: 26 received amoxicillin/clavulanate and 33 received SOC. Amoxicillin-clavulanate recipients did not have higher failure rates compared to SOC recipients. For patients requiring hospital admission, hospital length of stay was numerically shorter with amoxicillin-clavulanate. The frequency of amoxicillin-clavulanate and carbapenem-resistant organisms did not differ significantly between groups. Amoxicillin-clavulanate may be a useful alternative therapy for the treatment of ceftriaxone non-susceptible Enterobacterales UTIs. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)
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17 pages, 514 KiB  
Article
Assessment of Physicians’ Practice in Implementing Antibiotic Stewardship Program in Najran City, Saudi Arabia: A Cross-Sectional Study
by Nasser Saeed Alqahtani, Maha Mohammed Bilal, Albatoul M. Al Margan, Fatimah Ahmad Albaghrah, Anwar Mana Al Sharyan and Aljawharh Salem M. Alyami
Pharmacy 2024, 12(1), 24; https://doi.org/10.3390/pharmacy12010024 - 1 Feb 2024
Viewed by 1361
Abstract
Introduction: One of the main causes of illness, mortality, and rising medical costs is antimicrobial resistance, which is a global healthcare concern. Objectives: This study explores the practice of physicians toward the effective implementation of Antibiotic Stewardship Programs (ASPs) in Najran city, Saudi [...] Read more.
Introduction: One of the main causes of illness, mortality, and rising medical costs is antimicrobial resistance, which is a global healthcare concern. Objectives: This study explores the practice of physicians toward the effective implementation of Antibiotic Stewardship Programs (ASPs) in Najran city, Saudi Arabia. Methodology: This cross-sectional study was conducted among physicians working at primary care setting in Najran city, Saudi Arabia, between May and August 2023. A self-administered questionnaire was distributed among the physicians composed of three parts: socio-demographic data, a questionnaire about physicians’ practice in the efficacy of ASP, and a questionnaire about physicians’ practice regarding prescribing antibiotics. Results: Of the 128 physicians who participated in the study, 60.2% were males, and 43.8% were aged between 36 and 45 years. Among the practices in implementing the ASP effectively, controlling the source of infection domain received the highest score (mean score: 4.83). Every practice domain mean score was greater than 3, indicating that study participants possessed a moderate level of ASP practice and implementation skills. The overall mean practice score in the effective implementation of ASP was 154.9 ± 25.5 out of 185 points, with good, moderate, and poor practices constituting 67.2%, 28.1%, and 4.7%, respectively. Conclusions: The physicians showed a moderate level of practice for the effective implementation of ASPs in Najran city. The factors significantly associated with increased practice score include older age, male gender, Saudi nationality, handling five or fewer infection cases daily, and infection-initiated antibiotic prescribing treatment managed per day. These findings suggest the need for targeted interventions and educational programs to enhance physicians’ adherence to ASP guidelines and promote appropriate antibiotic prescribing practices, ultimately contributing to global efforts in combating antimicrobial resistance and improving patient outcomes. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)
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10 pages, 258 KiB  
Article
Antibiotic De-Escalation in Critically Ill Patients with Negative Clinical Cultures
by Spencer Roper, Mary Joyce B. Wingler and David A. Cretella
Pharmacy 2023, 11(3), 104; https://doi.org/10.3390/pharmacy11030104 - 16 Jun 2023
Cited by 1 | Viewed by 2498
Abstract
(1) Background: Antibiotics are received by a majority of adult intensive care unit (ICU) patients. Guidelines recommend antibiotic de-escalation (ADE) when culture results are available; however, there is less guidance for patients with negative cultures. The purpose of this study was in investigate [...] Read more.
(1) Background: Antibiotics are received by a majority of adult intensive care unit (ICU) patients. Guidelines recommend antibiotic de-escalation (ADE) when culture results are available; however, there is less guidance for patients with negative cultures. The purpose of this study was in investigate ADE rates in an ICU population with negative clinical cultures. (2) Methods: This single-center, retrospective, cohort study evaluated ICU patients who received broad-spectrum antibiotics. The definition of de-escalation was antibiotic discontinuation or narrowing of the spectrum within 72 h of initiation. The outcomes evaluated included the rate of antibiotic de-escalation, mortality, rates of antimicrobial escalation, AKI incidence, new hospital acquired infections, and lengths of stay. (3) Results: Of the 173 patients included, 38 (22%) underwent pivotal ADE within 72 h, and 82 (47%) had companion antibiotics de-escalated. Notable differences in patient outcomes included shorter durations of therapy (p = 0.003), length of stay (p < 0.001), and incidence of AKI (p = 0.031) in those that underwent pivotal ADE; no difference in mortality was found. (4) Conclusions: The results from this study show the feasibility of ADE in patients with negative clinical cultures without a negative impact on the outcomes. However, further investigation is needed to determine its effect on the development of resistance and adverse effects. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)
6 pages, 614 KiB  
Communication
Antimicrobial Stewardship Practices in a Subset of Community Pharmacies across the United States
by Yuman Lee and Nicole Bradley
Pharmacy 2023, 11(1), 26; https://doi.org/10.3390/pharmacy11010026 - 2 Feb 2023
Cited by 1 | Viewed by 1894
Abstract
Background: Antimicrobial stewardship in the community is essential as most antibiotic prescribing occurs in the outpatient setting. Pharmacists are recognized as co-leaders for implementing efforts to improve antimicrobial use. Objectives: the purpose of this study is to evaluate current antimicrobial stewardship practices in [...] Read more.
Background: Antimicrobial stewardship in the community is essential as most antibiotic prescribing occurs in the outpatient setting. Pharmacists are recognized as co-leaders for implementing efforts to improve antimicrobial use. Objectives: the purpose of this study is to evaluate current antimicrobial stewardship practices in community pharmacies across the United States and identify perceptions and challenges faced by community pharmacists. Methods: a survey based on the Center of Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship was created and distributed. Results: Sixty-one community pharmacists participated in the survey. The majority of pharmacists practiced in chain pharmacies. Based on the responses, a minority of pharmacies met the requirements of the CDC core elements: commitment (27.9%), action (24.6%), tracking and reporting (14.8%), and education and expertise (23% for providing pharmacist resources and 9.8% for providing patient resources). Regarding perception, 67.9% felt antimicrobial stewardship is important in the community and would participate in antimicrobial stewardship activities if the opportunity was provided (88.5%). Challenges faced by community pharmacists include the lack of time, staff, training, and technology support; pushback from prescribers and patients; and the lack of leadership, financial incentives, funding, and legal requirements. Conclusions: many challenges exist in community pharmacies inhibiting the full potential of pharmacists in implementing antimicrobial stewardship. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)
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10 pages, 265 KiB  
Article
Patients’ Perception in Japan Regarding the Appropriate Use of Antimicrobial Drugs: A Questionnaire Survey
by Hikaru Matsui, Shinya Abe, Taku Obara, Tasuku Sato, Shouko Yoshimachi and Kazuhiko Nomura
Pharmacy 2023, 11(1), 12; https://doi.org/10.3390/pharmacy11010012 - 9 Jan 2023
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Abstract
This study sought to investigate the actual status of awareness regarding the appropriate use of antimicrobial drugs among patients of a wide age range who visit dispensing pharmacies in order to explore more effective intervention methods for improving awareness of the appropriate use [...] Read more.
This study sought to investigate the actual status of awareness regarding the appropriate use of antimicrobial drugs among patients of a wide age range who visit dispensing pharmacies in order to explore more effective intervention methods for improving awareness of the appropriate use of antimicrobial drugs for patients. A questionnaire survey was conducted with 1301 patients who visited different Tsuruha Holdings-operated pharmacies between 1 September 2018 and 31 October 2018. Using multiple regression analysis, we calculated scores based on the patients’ answers regarding their knowledge of antimicrobial drugs and antimicrobial resistance and examined factors related to these scores. Of the 1185 respondents who successfully completed the survey (mean age ± SD, 52.5 ± 18.2 years), 37.2% were 60 years old or older, 13.2% had never or were not sure whether they had taken antimicrobial drugs, and 73.2% did not understand the problem of antimicrobial resistance. Older age, the non-usage of drugs and self-reports of the “lack” of knowledge of antimicrobial resistance were identified as the group that needs education regarding the appropriate use of antimicrobial drugs. Intervention studies should be conducted to examine the efficacy of interventions based on these factors. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)

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9 pages, 559 KiB  
Brief Report
The Impact of an Antimicrobial Stewardship Clinical Pharmacy Specialist on Antimicrobial Days of Therapy through Education Driven Policies, Procedures, and Interventions
by Yolanda G. Martinez, MaiCuc Tran, Thomas Roduta, Susan Lam, Todd Price and Stefanie Stramel
Pharmacy 2023, 11(5), 137; https://doi.org/10.3390/pharmacy11050137 - 30 Aug 2023
Viewed by 1308
Abstract
The primary goal of antimicrobial stewardship is to improve patient outcomes and minimize the consequences of antibiotic use. Prospective audit and feedback cannot always be performed by an antimicrobial stewardship program member which is where policies, procedures and education can aid interventions. The [...] Read more.
The primary goal of antimicrobial stewardship is to improve patient outcomes and minimize the consequences of antibiotic use. Prospective audit and feedback cannot always be performed by an antimicrobial stewardship program member which is where policies, procedures and education can aid interventions. The purpose of this study was to evaluate the impact on antimicrobial days of therapy due to a dedicated clinical pharmacy specialist primarily responsible for developing policies and procedures and providing education. A pre-intervention and post-intervention retrospective analysis of antimicrobial days of therapy from September 2019–May 2020 and July 2020–March 2021 was performed. Inclusion criteria consisted of adults receiving IV vancomycin, azithromycin, meropenem, ciprofloxacin, and/or levofloxacin. Excluded criteria consisted of documented interventions that were not related to implemented policies and procedures or performed education and patients receiving antimicrobial surgical prophylaxis. The primary outcome was antimicrobial days of therapy. An average of 3.47 ± 2.46 days (pre-intervention, n = 203) and 3.21 ± 2.52 days (post-intervention, n = 203) were observed for the primary outcome (p < 0.04182). Pharmacists performed 75 interventions pre-intervention and 102 interventions post-intervention (p = 0.0092). The implementation of a dedicated antimicrobial stewardship clinical pharmacy specialist responsible for developing policies, procedures, and education successfully reduced antimicrobial days of therapy and documented interventions. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)
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8 pages, 816 KiB  
Brief Report
Residual Infusion Performance Evaluation (RIPE): A Single-Center Evaluation of Residual Volume Post-Intravenous Eravacycline Infusion
by Alysa J. Baumann, Kerry O. Cleveland, Michael S. Gelfand, Nicholson B. Perkins III, Angela D. Covington and Athena L. V. Hobbs
Pharmacy 2023, 11(2), 75; https://doi.org/10.3390/pharmacy11020075 - 13 Apr 2023
Cited by 1 | Viewed by 1868
Abstract
Intravenous (IV) drugs are administered through infusion pumps and IV administration sets for patients who are seen in healthcare settings. There are multiple areas of the medication administration process that can influence the amount of a drug a patient receives. For example, IV [...] Read more.
Intravenous (IV) drugs are administered through infusion pumps and IV administration sets for patients who are seen in healthcare settings. There are multiple areas of the medication administration process that can influence the amount of a drug a patient receives. For example, IV administration sets that deliver a drug from an infusion bag to a patient vary in terms of length and bore. In addition, fluid manufacturers report that the total acceptable volume range for a 250 mL bag of normal saline can be anywhere from 265 to 285 mL. At the institution chosen for our study, each 50 mg vial of eravacycline is reconstituted using 5 mL of diluent, and the total dose is administered as a 250 mL admixture. This single-center, retrospective, quasi-experimental study evaluated the residual medication volume after the completion of an IV eravacycline infusion in patients admitted during the pre-intervention study period compared to those in the post-intervention study period. The primary outcome of the study was to compare the residual antibiotic volume remaining in the bags following IV infusions of eravacycline before and after the implementation of interventions. The secondary outcomes included the following: comparing the amount of the drug lost in the pre- and post-intervention periods, determining whether the amount of residual volume was affected by nursing shifts (day versus night), and lastly assessing the cost of facility drug waste. On average, approximately 15% of the total bag volume was not infused during the pre-intervention period, which was reduced to less than 5% in the post-intervention period. Clinically, the average estimated amount of eravacycline discarded decreased from 13.5 mg to 4.7 mg in the pre- and post-intervention periods, respectively. Following the statistically significant results of this study, the interventions were expanded at this facility to include all admixed antimicrobials. Further studies are needed to determine the potential clinical impact when patients do not receive complete antibiotic infusions. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)
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7 pages, 1602 KiB  
Brief Report
Leveling Up: Evaluation of IV v. PO Linezolid Utilization and Cost after an Antimicrobial Stewardship Program Revision of IV to PO Conversion Criteria within a Healthcare System
by Jessica Jaggar, Kerry O. Cleveland, Jennifer D. Twilla, Shanise Patterson and Athena L. V. Hobbs
Pharmacy 2023, 11(2), 70; https://doi.org/10.3390/pharmacy11020070 - 5 Apr 2023
Viewed by 1385
Abstract
The CDC’s Core Elements of an Antimicrobial Stewardship Program (ASP) lists intravenous (IV) to oral (PO) conversion as an important pharmacy-based intervention. However, despite the existence of a pharmacist-driven IV to PO conversion protocol, conversion rates within our healthcare system remained low. We [...] Read more.
The CDC’s Core Elements of an Antimicrobial Stewardship Program (ASP) lists intravenous (IV) to oral (PO) conversion as an important pharmacy-based intervention. However, despite the existence of a pharmacist-driven IV to PO conversion protocol, conversion rates within our healthcare system remained low. We aimed to evaluate the impact of a revision to the current conversion protocol on conversion rates, using linezolid as a marker due to its high PO bioavailability and high IV cost. This retrospective, observational study was conducted within a healthcare system composed of five adult acute care facilities. The conversion eligibility criteria were evaluated and revised on 30 November 2021. The pre-intervention period started February 2021 and ended November 2021. The post-intervention period was December 2021 to March 2022. The primary objective of this study was to establish if there was a difference in PO linezolid utilization reported as days of therapy per 1000 days present (DOT/1000 DP) between the pre- and post-intervention periods. IV linezolid utilization and cost savings were investigated as secondary objectives. The average DOT/1000 DP for IV linezolid decreased from 52.1 to 35.4 in the pre- and post-intervention periods, respectively (p < 0.01). Inversely, the average DOT/1000 DP for PO linezolid increased from 38.9 in the pre-intervention to 58.8 for the post-intervention period, p < 0.01. This mirrored an increase in the average percentage of PO use from 42.9 to 62.4% for the pre- and post-intervention periods, respectively (p < 0.01). A system-wide cost savings analysis showed projected total annual cost savings of USD 85,096.09 for the system, with monthly post-intervention savings of USD 7091.34. The pre-intervention average monthly spend on IV linezolid at the academic flagship hospital was USD 17,008.10, which decreased to USD 11,623.57 post-intervention; a 32% reduction. PO linezolid spend pre-intervention was USD 664.97 and increased to USD 965.20 post-intervention. The average monthly spend on IV linezolid for the four non-academic hospitals was USD 946.36 pre-intervention, which decreased to USD 348.99 post-intervention; a 63.1% reduction (p < 0.01). Simultaneously, the average monthly spend for PO linezolid was USD 45.66 pre-intervention and increased to USD 71.19 post-intervention (p = 0.03) This study shows the significant impact that an ASP intervention had on IV to PO conversion rates and subsequent spend. By revising criteria for IV to PO conversion, tracking and reporting results, and educating pharmacists, this led to significantly more PO linezolid use and reduced the overall cost in a large healthcare system. Full article
(This article belongs to the Special Issue Pharmacist-Led Antimicrobial Stewardship 2.0)
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