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 ... -  《-》

A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy for the treatment of community-acquired pneumonia.

Foolad F ，Huang AM ，Nguyen CT ，Colyer L ，Lim M ，Grieger J ，Li J ，Revolinski S ，Mack M ，Gandhi T ，Wainaina JN ，Eschenauer G ，Patel TS ，Marshall VD ，Nagel J ... -  《-》

Antimicrobial stewardship across 47 South African hospitals: an implementation study.

The available data on antimicrobial stewardship programmes in Africa are scarce. The aims of this study were to assess the implementation of an antimicrobial stewardship programme in a setting with limited infectious disease resources. We implemented a pharmacist-driven, prospective audit and feedback strategy for antimicrobial stewardship on the basis of a range of improvement science and behavioural principles across a diverse group of urban and rural private hospitals in South Africa. The study had a pre-implementation phase, during which a survey of baseline stewardship activities was done. Thereafter, a stepwise implementation phase was initiated directed towards auditing process measures to reduce consumption of antibiotics (prolonged duration, multiple antibiotics, and redundant antibiotic coverage), followed by a post-implementation phase once the model was embedded in each hospital. The effect on consumption was assessed with the WHO index of defined daily doses per 100 patient-days, and the primary outcome (change in antibiotic consumption between phases) was assessed with a linear mixed-effects regression model. We implemented and assessed the antimicrobial stewardship programme between Oct 1, 2009, and Sept 30, 2014. 116 662 patients receiving antibiotics at 47 hospitals during 104 weeks of standardised measurement and feedback, were reviewed, with 7934 interventions by pharmacists recorded for the five targeted measures, suggesting that almost one in 15 prescriptions required intervention. 3116 (39%) of 7934 pharmacist interventions were of an excessive duration. The antimicrobial stewardship programme led to a reduction in mean antibiotic defined daily doses per 100 patient-days from 101·38 (95% CI 93·05-109·72) in the pre-implementation phase to 83·04 (74·87-91·22) in the post-implementation phase (p<0·0001). Health-care facilities with limited infectious diseases expertise can achieve substantial returns through pharmacist-led antimicrobial stewardship programmes and by focusing on basic interventions. None.

Brink AJ ，Messina AP ，Feldman C ，Richards GA ，Becker PJ ，Goff DA ，Bauer KA ，Nathwani D ，van den Bergh D ，Netcare Antimicrobial Stewardship Study Alliance ... -  《-》

Impact and barriers of a pharmacist-led practice with computerized reminders on intravenous to oral antibiotic conversion for community-acquired pneumonia inpatients.

Intravenous to oral (IV-PO) antibiotic conversion, one of the critical elements in antimicrobial stewardship (AMS), is not well implemented in China. Studies on the strategy to apply the IV-PO conversion are needed. Our objective was to evaluate the impact and its barriers of a pharmacist-led practice with computerized reminders on IV-PO antibiotic conversion for community-acquired pneumonia (CAP) inpatients. This was a retrospective, observational pre- and post-intervention study. Interventions were introduced in 2 sequential 12-month phases: Phase 1: pharmacists implemented the conventional practice of reviewing patient charts and medication records every 24 h and verbally informed the prescribers on eligible IV-PO conversions; Phase 2: pharmacists implemented a new intervention practice to inform the prescribers with a computerized reminder in electronic medical record system on eligible IV-PO conversions. The primary outcome was the proportion of patients who converted to oral therapy on the day patients were eligible for the conversion. The secondary outcomes were length of IV antibiotic therapy days, total length of antibiotic therapy days and length of hospital stay. A total of 524 patients were studied (256 in phase 1 and 268 in phase 2). The proportion of patients who converted to oral therapy on the day patients were eligible for the conversion was significantly increased from 34.77% (89/256) in phase 1 to 62.69% (168/268) in phase 2 (p < 0.05). Length of IV antibiotic therapy days in phase 2 was shortened by 1.23 days, which was 5.52 days compared to 6.75 days in phase 1 (p < 0.05). Total length of antibiotic therapy days was 12.05 days in Phase 1, compared to 10.75 days in phase 2 (p > 0.05). Length of hospital stay for patients in phase 2 was significantly shorter, with a difference of 1.38 days (6.02 days vs. 7.40 days, p < 0.05). The most common barrier of not converting IV-PO was the presence of co-morbidity. The pharmacist-led IV-PO antibiotic conversion practice with computerized reminders was successful and feasible in Chinese hospitals. More IV-PO intervention studies in patients with other infections are needed in the future.

Xu S ，Wang X ，Song Z ，Han F ，Zhang C ... -  《-》

An audit of community-acquired pneumonia antimicrobial compliance using an intervention bundle in an Irish hospital.

Hospitalisations with community-acquired pneumonia (CAP) are often not managed in accordance with antimicrobial guidelines. This study aimed to assess whether guideline-driven antimicrobial prescribing for CAP can be improved using an intervention bundle. Secondary measures assessed were hospital length of stay (LOS), mortality, duration of intravenous antibiotics and total antibiotics, improved uptake of appropriate investigations, and documentation of CURB-65 score. A retrospective cohort of hospitalised CAP patients from August-September 2018 was compared with a post-intervention prospective cohort from May-June 2019. The intervention bundle included a mobile audience response system, promotion of the antimicrobial app, development of a physical card with local guidelines, and incorporating CURB-65 into the unscheduled admission proforma. Local guidelines are in keeping with British Thoracic Society CAP guidelines. A total of 69 adult patients (aged >18 years) were included in the study (37 retrospective, 32 prospective). Overall compliance with local CAP guidelines improved from 21.6% to 62.5% (P < 0.001). No difference in initial intravenous antibiotic duration was seen (median 4 days vs. 4 days; P = 0.70) and total antibiotic duration was significantly shorter in the post-intervention group (median 9 days vs. 7 days; P = 0.01). No difference in LOS or mortality was seen between the groups. Documentation of CURB-65 improved from 5.4% to 46.9% (P < 0.001). Uptake of streptococcal urinary antigen testing improved from 18.9% to 40.6% (P = 0.024). A simple, low-cost quality improvement bundle can significantly increase appropriate antimicrobial prescribing and shorten the total antibiotic duration.

O'Kelly B ，Rueda-Benito A ，O'Regan M ，Finan K ... -  《-》