Half of Prescribed Antibiotics Are Not Needed: A Pharmacist-Led Antimicrobial Stewardship Intervention and Clinical Outcomes in a Referral Hospital in Ethiopia.

Intense antibiotic consumption in Low- and Middle-Income Countries (LMICs) is fueled by critical gaps in laboratory infrastructure and entrenched syndromic management of infectious syndromes. Few data inform the achievability and impact of antimicrobial stewardship interventions, particularly in Sub-Saharan Africa. Our goal was to demonstrate the feasibility of a pharmacist-led laboratory-supported intervention at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, and report on antimicrobial use and clinical outcomes associated with the intervention. Methods: This was a single-center prospective quasi-experimental study conducted in two phases: (i) an intervention phase (November 2017 to August 2018), during which we implemented weekly audit and immediate (verbal and written) feedback sessions on antibiotic prescriptions of patients admitted in 2 pediatric and 2 adult medicine wards, and (ii) a post-intervention phase (September 2018 to January 2019) during which we audited antibiotic prescriptions but provided no feedback to the treating teams. The intervention was conducted by an AMS team consisting of 4 clinical pharmacists (one trained in AMS) and one ID specialist. Our primary outcome was antimicrobial utilization (measured as days of therapy (DOT) per 1,000 patient-days and duration of antibiotic treatment courses); secondary outcomes were length of hospital stay and in-hospital all-cause mortality. A multivariable logistic regression model was used to explore factors associated with all-cause in-hospital mortality. Results: We collected data on 1,109 individual patients (707 during the intervention and 402 in the post-intervention periods). Ceftriaxone, vancomycin, cefepime, meropenem, and metronidazole were the most commonly prescribed antibiotics; 96% of the recommendations made by the AMS team were accepted. The AMS team recommended to discontinue antibiotic therapy in 54% of cases during the intervention period. Once the intervention ceased, total antimicrobial use increased by 51.6% and mean duration of treatment by 4.1 days/patient. Mean LOS stay as well as crude mortality also increased significantly in the post-intervention phase (LOS: 24.1 days vs. 19.8 days; in hospital death 14.7 vs. 6.9%). The difference in mortality remained significant after adjusting for potential confounders. Conclusions: A pharmacist-led AMS intervention focused on duration of antibiotic treatment was feasible and had good acceptability in our setting. Cessation of audit-feedback activities was associated with immediate and sustained increases in antibiotic consumption reflecting a rapid return to baseline (pre-intervention) prescribing practices, and worse clinical outcomes (increased length of stay and in-hospital mortality). Pharmacist-led audit-feedback activities can effectively reduce antimicrobial consumption and result in better-quality care, but require organizational leadership's commitment for sustainable benefits.

Gebretekle GB ，Haile Mariam D ，Abebe Taye W ，Mulu Fentie A ，Amogne Degu W ，Alemayehu T ，Beyene T ，Libman M ，Gedif Fenta T ，Yansouni CP ，Semret M ... -  《Frontiers in Public Health》

Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia.

Gebretekle GB ，Haile Mariam D ，Abebe W ，Amogne W ，Tenna A ，Fenta TG ，Libman M ，Yansouni CP ，Semret M ... -  《PLoS One》

A pharmacist-led prospective antibiotic stewardship intervention improves compliance to community-acquired pneumonia guidelines in 39 public and private hospitals across South Africa.

Pharmacists in low-middle-income countries (LMIC) are few and lack antibiotic stewardship (AS) training. The ability was assessed of non-specialised pharmacists to implement stewardship interventions and improve adherence to the South African community-acquired pneumonia (CAP) guideline in public and private hospitals. This was a multicentre, prospective cohort study of adult CAP patients hospitalised between July 2017 and July 2018. A CAP bundle was developed of seven process measures (diagnostic and AS) that pharmacists used to audit compliance and provide feedback. CAP bundle compliance rates and change in outcome measures [mortality, length of stay (LOS) and infection-related (IR)-LOS] during pre- and post-implementation periods were compared. In total, 2464 patients in 39 hospitals were included in the final analysis. Post-implementation, overall CAP bundle compliance improved from 47·8% to 53·6% (confidence interval [CI] 4·1-7·5, p<0·0001), diagnostic stewardship compliance improved from 49·1% to 54·6% (CI 3·3-7·7, p<0·0001) and compliance with AS process measures from 45·3% to 51·6% (CI 4·0-8·6, p<0·0001). Improved compliance with process measures was significant for five (2 diagnostic, 3 AS) of seven components: radiology, laboratory, antibiotic choice, duration and intravenous to oral switch. There was no difference in mortality between the two phases, [4·4%(55/1247) vs. 3·9%(47/1217); p=0·54], median LOS or IR LOS 6·0 vs. 6·0 days (p=0·20) and 5·0 vs. 5·0 days (p=0·40). Non-specialised pharmacists in public and private hospitals implemented stewardship interventions and improved compliance to SA CAP guidelines. The methodology of upskilling and a shared learning stewardship model may benefit LMIC countries.

van den Bergh D ，Messina AP ，Goff DA ，van Jaarsveld A ，Coetzee R ，de Wet Y ，Bronkhorst E ，Brink A ，Mendelson M ，Richards GA ，Feldman C ，Schellack N ，South African Antibiotic Stewardship Programme Pharmacist Community-acquired Pneumonia Study Alliance ... -  《-》

Implementing outpatient antimicrobial stewardship in a primary care office through ambulatory care pharmacist-led audit and feedback.

This study aimed to determine the impact of a pharmacist-led antimicrobial stewardship program (ASP) intervention on outpatient antibiotic prescribing for upper respiratory tract infections (URIs) and urinary tract infections (UTIs) in a primary care office. The primary outcome of this study was to characterize antibiotic prescribing over time. Secondary outcomes included describing ambulatory care pharmacist (ACP) workload and types of feedback given. A retrospective pilot study was conducted within a primary care office. The office included a 0.6 full-time equivalent ACP and is part of a health system supported by a pharmacist and a physician co-led ASP. Education and guidelines were provided by the ACP and ASP leads before the intervention period August 2017-February 2018. The ACP provided bi-weekly audit of all URI and UTI prescriptions and written feedback to prescribers. During the 7-month intervention period, 1107 prescriptions were audited by the ACP, 825 URI and 282 UTI. The most common reasons for feedback included inappropriate agent (26.3%) or prolonged duration of therapy (24.3%). Guideline-concordant agent prescribed for a UTI increased from 20% at baseline to a median of 69.2%, whereas duration increased from 55% to 70.4%. Guideline-concordant agent prescribed for a URI increased from 43.3% to 86.8%, whereas the median duration of therapy decreased from 10 to 7 days. An ACP-led ASP intervention within a primary care office incorporating audit and feedback improved antibiotic prescribing for URIs and UTIs, including prescribing antibiotics when indicated, guideline-concordant antibiotic selection, and duration of therapy. Pharmacists practicing in ambulatory care settings may serve a vital role in leading successful outpatient ASP interventions.

Burns KW ，Johnson KM ，Pham SN ，Egwuatu NE ，Dumkow LE ... -  《-》

Improving primary care antimicrobial stewardship by implementing a peer audit and feedback intervention in Cape Town community healthcare centres.

De Vries E ，Johnson Y ，Willems B ，Bedeker W ，Ras T ，Coetzee R ，Tembo Y ，Brink A ... -  《-》