Impact of antimicrobial stewardship program on clinical outcomes in multidrug-resistant Gram-negative bacterial infections at a tertiary care hospital from South India

Background: Increasing bacterial resistance to antimicrobial agents is resulting in high morbidity and mortality. Antimicrobial stewardship (AMS) programs aim at rationale use of antimicrobial agents in clinical settings by development and implementation of antibiotic policy. As the patterns of antimicrobial resistance vary with organism and time, there is a need for periodic surveillance. Aims and Objectives: The aim of the study was to study the impact of AMS program on appropriate use of antimicrobial agents and clinical outcomes in patients with multidrug-resistant Gram-negative bacterial (MDR GNB) infections. Materials and Methods: This is a prospective observational study that included patients diagnosed with multidrug-resistance Gram-negative bacterial infections during June to July 2019. Identification of multidrug-resistant organisms was performed as per clinical and laboratory standards institute guidelines 2016. Information on the use of empirical antibiotic and other antimicrobial agents after culture and sensitivity report were collected and assessed for appropriateness. All the patients were followed up till discharge. Results: From 170 patients, there were 211 specimens sent for culture and sensitivity and 249 pathogens were isolated. The most frequent pathogen isolated was Escherichia coli (42.6%) followed by Klebsiella spp. (22.9%). Isolates were most resistant to cefazolin (86.7%) and ceftriaxone (83.9%), and most sensitive to polymyxin B (100%) and tigecycline (97.2%). All patients were administered antimicrobial agents as per antibiotic policy of the institute and 154 (90.6%) patients have recovered from illness with a mean length of hospital stay of 19.4 ± 6.6 days. Conclusion: Adherence to antimicrobial policy helps in improved outcomes in patients with MDR GNB infections. Hence, the need to implement AMS program in all hospitals.

A prospective, questionnaire-based study to evaluate the knowledge, attitude, and practice of rational use of antibiotics among clinical practitioners in a tertiary care hospital

Background: Irrational antibacterial usage leads to emergence of antibiotic resistance. Hence, to ensure rational prescription regular clinical audits are essential in tertiary care hospitals. Aim and Objective: To assess the knowledge, attitude, and perception of clinician抯 on rational use of antibiotics in a tertiary care hospital. Materials and Methods: The prospective, questionnaire-based study was conducted on clinicians in a tertiary care hospital, after getting approval of the Institutional Ethics Committee to obtain information on rational antibiotic usage and was analyzed using descriptive statistics. Results: The study included 100 clinicians. 95% were aware about Rational antibiotic usage, the ingredients, adverse effects, interactions, contraindications, and cost of the drugs they prescribe and they were also analyzing the culture and sensitivity report before prescription of antibiotics, but only 48% of them were prescribing antibiotics from National List of Essential Medicines, 35% were influenced by patient demands. Around 80% agreed with the usefulness of the feedback given by fellow colleagues on antibiotic decisions. Though 98% of them were aware of the hazards of antibiotic resistance only 68% knew about antibiogram and having antibiotic policy at the workplace. In practice, 95% were showing special interest in proper antibiotic usage, 82% knew the new antibiotics available and 91% were providing proper counseling to patients. 95% suggested the need for training on rational use of medicines and antibiotic policy post MBBS. Conclusion: The clinicians recognized the importance of rational antibiotic use in preventing its resistance thus reducing health care burden on the patients.

Evaluation of cephalosporins utilization and compliance with reference to the hospital antibiotic policy of an Indian tertiary care hospital

Background: Emergence of bacterial resistance in hospital settings due to the liberal use of antibiotics which led to an altered impact on its therapeutic efficacy and outcome, thereby increasing the treatment costs in patients. In this regard the study aims to evaluate the cephalosporins utilization and compliance to the hospital antibiotic policy in general medicine ward.Methods: A prospective observational study was carried out over an eleven-month period in patients prescribed with cephalosporins. Clinical data of inpatients were collected and evaluated by using World Health Organization (WHO) core prescribing indicators and defined daily dose per 100 bed-days. The comparison between the cephalosporins prescribed in the chart records to the recommendations mentioned in the institutional antibiotic policy v.2.0, help to determine the deviations in their usage pattern.Results: A total of 370 patients were enrolled in the study, of which 54.6% were females. Cephalosporins were empirically prescribed in 240 (64.9%) cases. The average number of total antibiotics and cephalosporins per encounter was 1.6 and 1 respectively. Among the total antibiotics, 63.7% were cephalosporins. Third generation cephalosporins (98.4%) were commonly prescribed, with ceftriaxone (93%) in parenteral form for respiratory tract infections (31.9%). Total parenteral antibiotics prescribed were found to be 68.8% of which 88.6% were cephalosporins. Utilization pattern of cephalosporins amounted to be 4.95 DDD/100 bed-days. Overall compliance was achieved in 191 (51.6%) prescriptions.Conclusions: The rate of prescribing of cephalosporins was marginally high. There was a low rate of compliance towards policy which reflects the urgent need for repetitive intervention to comply antibiotic policy.

Antibiotic susceptibility pattern of bacteria isolated from patients of respiratory tract infection in a tertiary care hospital of Eastern India

Background: Respiratory tract infections have been one of the commonest types of infections affecting the Indian population. With antibiotic resistance being a global threat and challenge to healthcare, concerns over skilful and judicious use of existing antibiotics have been on rise. Update on region specific bacterial susceptibility pattern is thus a need. The present study was planned to identify the common pathogens responsible for the respiratory tract infection and their antibiotic susceptibility patterns.Methods: A prospective study was carried out, where subjects with lower respiratory tract (LRT) infection admitted in the Intensive Care Unit in the tertiary care centre in Eastern India during the one-year period were enrolled in the study. Samples such as sputum, suction tip, endotracheal aspirate, bronchial aspirate and pleural fluid were obtained under aseptic precautions and were processed. The bacterial isolates were subjected to susceptibility testing by standard Kirby Bauer disc diffusion methods. The susceptibility patterns of the bacterial pathogens were determined.Results: Out of 234 processed samples, klebsiella (33.44%) was found to be commonest pathogen isolated from all the sites followed by Pseudomonas, staphylococcus and others. Amongst the penicillin group of antibiotics, ampicillin showed highest activity against pseudomonas and E. coli respectively. Antibiotics like penicillin G, ampicillin/sulbactam and amoxicillin/clavulanic acid combination showed lower susceptibility towards most pathogens. Amongst broad spectrum antibiotics, amikacin showed high susceptibility towards pseudomonas species followed by chloramphenicol and tetracycline.Conclusions: With changing trends in microbiological patterns of responsible organisms, knowledge regarding antibiotic susceptibility pattern needs to be regularly revised, thus ensuring prompt initiation of adequate and appropriate antibiotic treatment with better patient outcomes.

A cross sectional study to assess knowledge, attitude and practice of rational antibiotic prescription among resident doctors

Background: Irrational prescription is a major contributor to the antimicrobial resistance. Resident doctors are the major focus of interventional programs aimed at rational prescription of antibiotics. So, their knowledge, attitude and practice regarding rational antibiotic prescription need to be assessed to plan future strategies.Methods: A questionnaire based cross sectional study among interns and resident doctors of a Government Medical College was conducted. Questionnaire consisted of questions to assess knowledge, attitude and practice of resident doctors in rational antibiotic prescriptions and multiple-choice questions to assess practice of hospital antibiotic policy.Results: 80 participants were enrolled in the study. All participants responded to yes or no questions and 47 answered multiple choice questions. 40% were aware of the current hospital antibiotic policy and 29% knew the term antibiotic stewardship. Only 15% were confident in their knowledge on antimicrobial resistance. 87.5% think there is no use in prescribing an antibiotic in common cold. 36.3% overprescribes antibiotics in their daily practice. Only 32.5% practiced de-escalation. 90% were educating patients regarding correct use of antibiotics. 90% send samples for culture and sensitivity but only 22.2% waited for results to start antibiotics.Conclusions: There is a need for approaches that includes implementation of antibiotic policy and to plan for effective teaching programs regarding antibiotic resistance and importance of rational prescription of antibiotics which can improve the quality of antibiotic prescription and minimize antibiotic resistance.

Bacteriology and antibiotic susceptibility pattern of ventilator-associated pneumonia in a tertiary care hospital

Background: Ventilator-associated pneumonia (VAP) is one of the most important hospital-acquired infections. VAP is pneumonia that develops 48 h or more after patients have been intubated and received mechanical ventilation by means of an endotracheal tube or tracheostomy. VAP is usually suspected when an individual develops a new or progressive infiltrates on chest radiograph, leukocytosis, and purulent tracheobronchial secretions. This is diagnosed based on positive end-expiratory pressure, fraction of inspired oxygen, bacteriological evidence, and signs of pulmonary infection. VAP is considered as one of the leading causes of morbidity and mortality in intensive care units (ICUs). Objectives: The objectives of this study were to assess the common pathogenic bacteria causing VAP and to determine its antibiotic susceptibility pattern. Materials and Methods: This study was conducted on 100 patients with clinical diagnosis of VAP. Bacterial culture was done for patient’s endotracheal aspirates. Antibiotic sensitivity test was done for culture-positive cases by Kirby–Bauer disk diffusion method. Results: A total of 72 patients (72%) showed positive culture. Gram-negative bacilli accounted for 91% of the isolated organisms with Acinetobacter species accounting for 40% followed by Pseudomonas species (26%) and Klebsiella pneumoniae (14%). Majority of the organisms were sensitive to imipenem with Acinetobacter being sensitive in 51% cases, Pseudomonas in 56%, and Klebsiella in 42% cases. Conclusion: Surveillance of VAP in ICUs is required to find out common causative organism and its antibiotic susceptibility to different antibiotics. This type of surveillance study is helpful for formulating antibiotic policy that would be more rational to reduce mortality and morbidity associated with VAP.

Impact of an intervention in the use of sequential antibiotic therapy in a Brazilian university hospital

INTRODUCTION: Sequential antibiotic therapy (SAT) is safe and economical. However, the unnecessary use of intravenous (IV) administration usually occurs. The objective of this work was to get to know the effectiveness of an intervention to implement the SAT in a teaching hospital in Brazil. METHODS: This was a prospective and interventional study, historically controlled, and was conducted in the Hospital de Clínicas, Universidade Federal de Uberlândia, State of Minas Gerais, Brazil, a high complexity teaching hospital having 503 beds. In each of the periods, from 04/04/05 to 07/20/05 (pre-intervention) and from 09/24/07 to 12/20/07 (intervention), 117 patients were evaluated. After the pre-intervention period, guidelines were developed which were implemented during the intervention period along with educational measures and a reminder system added to the patients’ prescription. RESULTS: In the pre-intervention and intervention periods, the IV antibiotics were used as treatment for a average time of 14.8 and 11.8 days, respectively. Ceftriaxone was the antibiotic most prescribed in both periods (23.4% and 21.6% respectively). Starting from the first prescription of antibiotics, the average length of hospitalization time was 21.8 and 17.5 days, respectively. The SAT occurred only in 4 and 5 courses of treatment, respectively, and 12.8% and 18.8% of the patients died in the respective periods. CONCLUSIONS: Under the presented conditions, the evaluated intervention strategy is ineffective in promoting the exchange of the antibiotic administration from IV to oral treatment (SAT).

"The Chennai declaration" Recommendations of "A roadmap- to tackle the challenge of antimicrobial resistance" - A join meeting of medical societies of India.

"A Roadmap to Tackle the Challenge of Antimicrobial Resistance - A Joint meeting of Medical Societies in India" was organized as a pre-conference symposium of the 2 nd annual conference of the Clinical Infectious Disease Society (CIDSCON 2012) at Chennai on 24 th August. This was the first ever meeting of medical societies in India on issue of tackling resistance, with a plan to formulate a road map to tackle the global challenge of antimicrobial resistance from the Indian perspective. We had representatives from most medical societies in India, eminent policy makers from both central and state governments, representatives of World Health Organization, National Accreditation Board of Hospitals, Medical Council of India, Drug Controller General of India, and Indian Council of Medical Research along with well-known dignitaries in the Indian medical field. The meeting was attended by a large gathering of health care professionals. The meeting consisted of plenary and interactive discussion sessions designed to seek experience and views from a large range of health care professionals and included six international experts who shared action plans in their respective regions. The intention was to gain a broad consensus and range of opinions to guide formation of the road map. The ethos of the meeting was very much not to look back but rather to look forward and make joint efforts to tackle the menace of antibiotic resistance. The Chennai Declaration will be submitted to all stake holders.

Short Term Urinary Catheterized Patients in Intensive Care Unit (ICU) – A Need to Screen.

Catheter-Associated Urinary Tract Infection (CAUTI) is the second most commonly reported healthcare associated infection, accounting for upto 40% of all nosocomial infections. Silent catheter associated bacteriuria comprises a huge reservoir of resistant organism in hospitals particularly in critical care units. We prospectively studied 100 newly short term catheterized patients in a tertiary care hospital. Samples collected on day three and daily thereafter for semi quantitative urine culture and pus cell count. Antibiotic sensitivity was tested using Kirby-Bauer disc diffusion method. Out of hundred patients, 32 showed growth on fifth day and remaining 68 samples were culture negative up to seventh day. None of the culture positive samples had pus cells. Escherichia coli (35%) was the predominant isolate followed by Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterococcus faecium, Candida spp (15% each) and Coagulase negative Staphylococcus (5%). Among the Gram negative organisms, four strains of Escherichia coli and two strains of Klebsiella pneumonia were Extended Spectrum Beta Lactamases (ESBL) producers and 33.3% were Multidrug resistant Pseudomonas aeruginosa. Multidrug resistant pathogens in an asymptomatic short term catheterized patient are a major reservoir in hospitals. This emphasizes the importance of periodic surveillance for nosocomial infections in hospital and the periodic screening will also help us to frame antibiotic policy in a new tertiary care hospital.

Cost Awareness and Containment : OPD Pharmaceutical Services of a Speciality Hospital

A major share of the hospital budget gets consumed in maintaining its pharmacy services. The cost consumption pattern of different group of medicines is directly related to the prescription load and prescription pattern. The Medical Officers and specialists of the hospital have got all important role in rational prescription in term of current therapeutics and saving on over prescription. A study carried out in a tertiary level super-speciality hospital indicated that the total cost of medicine per OPD day and cost of antibiotics work out to be Rs. 45291 and Rs. 11974 on an average, respectively. The average cost per prescription of OPD was up to Rs. 123.75.