Appropriate antibiotic use reduces length of hospital stay.

Objectives: To define appropriate antibiotic use in hospitalized adults treated for a bacterial infection, we previously developed and validated a set of six generic quality indicators (QIs) covering all steps in the process of antibiotic use. We assessed the association between appropriate antibiotic use, defined by these QIs, and length of hospital stay (LOS). Methods: An observational multicentre study in 22 hospitals in the Netherlands included 1890 adult, non-ICU patients using antibiotics for a suspected bacterial infection. Performance scores were calculated for all QIs separately (appropriate or not), and a sum score described performance on the total set of QIs. We divided the sum scores into two groups: low (0%-49%) versus high (50%-100%). Multilevel analyses, correcting for confounders, were used to correlate QI performance (single and combined) with (log-transformed) LOS and in-hospital mortality. Results: The only single QI associated with shorter LOS was appropriate intravenous-oral switch (geometric means 6.5 versus 11.2 days; P < 0.001). A high sum score was associated with a shorter LOS in the total group (10.1 versus 11.2 days; P = 0.002) and in the subgroup of community-acquired infections (9.7 versus 10.9 days; P = 0.007), but not in the subgroup of hospital-acquired infections. We found no association between performance on QIs and in-hospital mortality or readmission rate. Conclusions: Appropriate antibiotic use, defined by validated process QIs, in hospitalized adult patients with a suspected bacterial infection appears to be associated with a shorter LOS and therefore positively contributes to patient outcome and healthcare costs.

Quality indicators to measure appropriate antibiotic use in hospitalized adults.

BACKGROUND: An important requirement for an effective antibiotic stewardship program is the ability to measure appropriateness of antibiotic use. The aim of this study was to develop quality indicators (QIs) that can be used to measure appropriateness of antibiotic use in the treatment of all bacterial infections in hospitalized adult patients. METHODS: A RAND-modified Delphi procedure was used to develop a set of QIs. Potential QIs were retrieved from the literature. In 2 questionnaire mailings with an in-between face-to-face consensus meeting, an international multidisciplinary expert panel of 17 experts appraised and prioritized these potential QIs. RESULTS: The literature search resulted in a list of 24 potential QIs. Nine QIs describing recommended care at patient level were selected: (1) take 2 blood cultures, (2) take cultures from suspected sites of infection, (3) prescribe empirical antibiotic therapy according to local guideline, (4) change empirical to pathogen-directed therapy, (5) adapt antibiotic dosage to renal function, (6) switch from intravenous to oral, (7) document antibiotic plan, (8) perform therapeutic drug monitoring, and (9) discontinue antibiotic therapy if infection is not confirmed. Two QIs describing recommended care at the hospital level were also selected: (1) a local antibiotic guideline should be present, and (2) these local guidelines should correspond to the national antibiotic guidelines. CONCLUSIONS: The selected QIs can be used in antibiotic stewardship programs to determine for which aspects of antibiotic use there is room for improvement. At this moment we are testing the clinimetric properties of these QIs in 1800 hospitalized patients, in 22 Dutch hospitals.

Development of quality indicators for antimicrobial treatment in adults with sepsis.

BACKGROUND: Outcomes in patients with sepsis are better if initial empirical antimicrobial use is appropriate. Several studies have shown that adherence to guidelines dictating appropriate antimicrobial use positively influences clinical outcome, shortens length of hospital stay and contributes to the containment of antibiotic resistance.Quality indicators (QIs) can be systematically developed from these guidelines to define and measure appropriate antimicrobial use. We describe the development of a concise set of QIs to assess the appropriateness of antimicrobial use in adult patients with sepsis on a general medical ward or Intensive Care Unit (ICU). METHODS: A RAND-modified, five step Delphi procedure was used. A multidisciplinary panel of 14 experts appraised and prioritized 40 key recommendations from within the Dutch national guideline on antimicrobial use for adult hospitalized patients with sepsis (http://www.swab.nl/guidelines). A procedure to select QIs relevant to clinical outcome, antimicrobial resistance and costs was performed using two rounds of questionnaires with a face-to-face consensus meeting between the rounds over a period of three months. RESULTS: The procedure resulted in the selection of a final set of five QIs, namely: obtain cultures; prescribe empirical antimicrobial therapy according to the national guideline; start intravenous drug therapy; start antimicrobial treatment within one hour; and streamline antimicrobial therapy. CONCLUSION: This systematic, stepwise method, which combined evidence and expert opinion, led to a concise and therefore feasible set of QIs for optimal antimicrobial use in hospitalized adult patients with sepsis. The next step will entail subjecting these quality indicators to an applicability test for their clinimetric properties and ultimately, using these QIs in quality-improvement projects. This information is crucial for antimicrobial stewardship teams to help set priorities and to focus improvement.

[Comprehensive quality indicators for measuring hospital antibiotic use]. / Generieke kwaliteitsindicatoren voor antibioticagebruik in het ziekenhuis.

As in other countries, the growing resistance to antimicrobial drugs is also taking place in the Netherlands; the primary cause being the total consumption of antibiotics. Given the steady decline in the discovery of new antimicrobials, better use of agents currently available is warranted. Guidelines describing appropriate antimicrobial therapy play an important role; however, such guidelines are not optimally used in daily practice. Quality indicators can be used to assess the quality of antibiotic treatment and evaluate the impact of interventions aimed at improving care. Quality indicators used for evaluating treatment of infections of the respiratory and urinary tracts are developed previously. A comprehensive set of indicators that could be used to assess the quality of hospital antibiotic use for all bacterial infections has not yet been developed. A new project has recently been started in the Netherlands called 'The development of Reliable generic quality Indicators for the optimalisation of ANTibiotic use in the hospital' (RIANT study) for developing such a set of comprehensive indicators.

Urological and nephrological findings of renal ectopia.

PURPOSE: Urological characteristics of renal ectopia have been addressed previously but little is known about the functional consequences. We sought to study renal function, blood pressure, proteinuria and urological abnormalities in children with renal ectopia. As a secondary objective, we compared these parameters between simple and crossed ectopia. MATERIALS AND METHODS: For this retrospective, single center, observational study we reviewed case documents and radiological records. We also analyzed longitudinal data on blood pressure, proteinuria and kidney function. RESULTS: Renal ectopia was diagnosed in 41 cases, of which 26 (63%) were simple renal ectopia, ie unilateral pelvic kidney. In 32% of patients the diagnosis was made during prenatal screening. Median patient age was 0.24 years at diagnosis and 7.7 years at the most recent control visit. Associated urological abnormalities were found in 66% of patients. Voiding cystourethrography was performed in all patients, with vesicoureteral reflux shown in 13. In 8 of 10 cases with unilateral reflux the condition manifested in the orthotopic kidney. The relative function of the ectopic kidney on dimercapto-succinic acid scan was 38%, and in 22% of patients glomerular filtration rate was less than 90 ml per minute per 1.73 m(2). Albuminuria and proteinuria were absent in most cases. Longitudinal analysis of blood pressure, glomerular filtration rate and albuminuria revealed a stable course for all parameters. No substantial difference was observed between simple and crossed renal ectopia. CONCLUSIONS: Our data suggest no adverse effects on blood pressure or kidney function in children with renal ectopia. However, periodic followup seems warranted, at least until young adulthood.