| Bozkurt et al., Turkey, 2014 [241] |
Principally educational interventions to improve appropriate antibiotic use for SSIs. These included:
Series of meetings with physicians from each clinic organized by the Infection Control Committee Daily visits from the Infection Control Nurse and twice weekly visits from the Infectious Diseases Control Specialist—more if compliance with agreed guidelines was low Observations regularly shared with the group
|
Use of appropriate antibiotics increased from 51% to 63.4% of cases Duration of antibiotic use improved from 10.3% to 59.4% of cases Total cost of antibiotics in the medical units, surgical units and ICUs decreased by 32.5%, 38.6% and 11.1%, respectively, over the time of the study
|
| Hou et al., China, 2014 [242] |
A number of interventions were undertaken to improve antibiotic utilization in ICUs as part of ASPs. These included:
Education—all healthcare professionals trained on antimicrobial-stewardship relevant knowledge as well as developing a new antibiotic formulary Engineering—Physicians had strict regulations surrounding antibiotic prescribing including restrictions surrounding quinolones. Target of 40 DDDs/100 patient-days for the hospital and 120 for the ICU, with regular feedback to the Director of the Unit
|
Total antibiotic consumption in the hospital decreased from 69.69 DDDs/100 patient-days to 50.76 DDDs between April and August 2011; and in the ICU decreased from 197.65 to 143.41 DDDs/100 patient-days Significant improvements in resistance to amikacin, ceftazidime, ciprofloxacin, ceftriaxone, gentamicin, ofloxacin and piperacillin in Enterobacteriaceae and resistance to ceftazidime, imipenem, and meropenem in non-fermenting Gram-negative rods Rates of no prescribing of antibiotics initially or just a single antibiotic prescription significantly increased (p < 0.001)
|
| Amdany et al., Kenya, 2014 [243] |
Principally an educational initiative to enhance the use of oral vs. IV metronidazole including education, audit and feedback |
Post-implementation audit showed an increase of more than 40% compliance in all the four criteria utilized to assess an increase in oral use As a result, reduced costs, patient discomfort and possible iatrogenic infections
|
| Yang et al., China, 2014 [244] |
Education and Engineering interventions to improve antibiotic use for SSIs. These included the Introduction of a Drug Rational Usage Guideline System (DRUGS) vs. paper-based guidelines to enhance adherence to surgical prophylaxis guidelines |
Timing of the initial dose improved from 32.9% of patients with antibiotics instigated within 30 min to 2 h pre incision to 85.8% post-intervention (statistically significant) Average length of stay decreased from 7.00 days with paper-based guidelines to 2.55 days with DRUGS Average cost of antibiotics prescribed decreased from ¥3481 with paper-based guidelines to ¥1693 with DRUGS
|
| Okumura et al., Brazil, 2015/2016 [245,246] |
Primarily Education comparing the outcomes from two different ASP approaches among patients in the general ward and ICU:
Bundled ASP including clinical pharmacist chart review, discussions with microbiologists/infectious disease physicians, education of physicians and continuous follow-up of pertinent physicians until clinical resolution/discharge Conventional ASP involving a clinical pharmacist chart review and discussions with infectious disease physician
|
DDDs/1000 patient-days decreased from 557.2 to 417 (p < 0.05) in the bundled ASP group Mortality decreased in the bundled ASP group (p < 0.01) and the risk difference was 10.8% (95% CI: 2.41–19.14) The bundled strategy though was overall more expensive at US$2119.70/patient; however, more cost-effective
|
| Saied et al., Egypt, 2015 [247] |
Principally Education and Engineering to improve antibiotic use of SSIs. These included
2 day training curriculum course for pertinent surgeons On-the-job training provided to junior surgeons and residents Wall-mounted poster developed to remind prescribers of the optimal timing and duration of antibiotic administration for SAP Regular audit and feedback meetings orchestrated by the senior surgeon in the hospital (3 of 5 participating hospitals)
|
The optimal timing of the first dose improved significantly in the 3 hospitals subject to the intervention—increasing from 6.7% of pertinent patients to 38.7% (p < 0.01) All hospitals involved showed a significant rise in the optimal duration of surgical prophylaxis—overall increase of 3–28% across the hospitals (p < 0.01)
|
| Ntumba et al., Kenya, 2015 [248] |
Principally Education and Engineering to improve the use of antibiotics in relation to SSIs. These included:
Local adaptation of guidelines Creation and tools for advocacy, training, and leadership around appropriate SAP
|
|
| Apisarnthanarak et al., Thailand, 2015 [249] |
This ASP principally involved Education with a 12 h training course run by infectious diseases clinical pharmacists (IDCPs) with physicians looking after patients in medical wards coupled with an option for infectious diseases consultations (IDCs), daily rounds with ICDPs, or both if wished, with a control (Usual Standard of Care) group |
For patients with input from the IDCP group or the IDCP plus IDC group vs. controls, they were:
Less likely to be prescribed inappropriate antibiotics (p < 0.001) Have greater de-escalation of antibiotics (p < 0.001) Received antibiotics <7 days (p < 0.001) Have shorter lengths of stay (p < 0.001)
|
| Boyles et al., South Africa, 2017 [250] |
Principally Education over a sustained period for this ASP Intervention comprising online education materials, a dedicated antibiotic prescription chart and weekly dedicated ward rounds
|
Total antibiotic consumption fell from 1046 DDDs/1000 patient-days in 2011 (control period) to 868 by 2013 and remained at this level for the next 2 years—driven by a reduction in IV antibiotic use, particularly ceftriaxone Inflation-adjusted cost savings on antibiotics were SA Rand of 3.2 million over 4 years
|
| Brink et al., South Africa, 2017) [251] |
Education and Engineering. Key activities driven by hospital pharmacists included:
Recording current SSI rates and developing a SAP ‘toolkit’ Testing and revising the SAP guidelines and toolkits at pilot sites prior to their launch at regional training and institutional workshops Obtaining consensus and endorsement from key professionals in the hospital through adapting and modifying guidelines where appropriate Choosing at least one or more surgical procedures to audit including recording pre-intervention SAP practices and trends for the chosen surgeries Subsequently measure compliance to agreed four process measures over a 4-week period and feedback
|
Timely administration of antibiotics increased to 56.4% of surgical patients (p < 0.0001) Antibiotic choice consistent with the guidelines increased to 95.9% of patients and the duration of prophylaxis was now appropriate among 93.9% of patients
|
| Allegranzi et al., Kenya, Uganda, Zambia, and Zimbabwe, 2018 [252] |
Principally Education and Engineering to improve antibiotic prescribing for SSIs. This included:
5 planned visits to each hospital in the four African countries during the study period supported by a range of educational tools Local teams identified key areas of concern with preventing SSIs to concentrate on through monitoring an agreed range of SAP indicators (six pre-identified ones including skin preparation and optimal timing of prophylaxis) Subsequent launch activities of pertinent tools and indicators alongside monitoring/feedback to improve prescribing
|
Appropriate use of SAP improved from 12.8% (baseline) to 39.1% of patients (p < 0.0001) among the studied hospitals Cumulative SSI incidence decreased from a baseline of 8.0% to 3.8% post-intervention (p < 0.0001)
|
| Khdour et al., Palestine, 2018 [253] |
Principally education—the ASP team drew up new antibiotic guidelines for the empiric treatment of common infections within the ICU Clinical pharmacists subsequently performed the initial review of subsequent treatment and made therapeutic recommendations if needed which were reviewed by the ASP team on the 2nd, 4th and 7th days, allowing for CST findings. Subsequent interventions were recommended by the ASP team if needed Four months of pre-ASP data were compared with 4 months of post-ASP data to assess the impact
|
High acceptance of ASP team recommendations (78.4%)—most accepted were dose optimization (87.0%) and de-escalation (84.4%) ASP interventions significantly reduces antimicrobial use—from 87.3 DDDs/100 beds vs. 66.1 DDDs/100 beds p < 0.001) Median length of stay was significantly reduced post-ASP—down from 11 (3–21) to 7 (4–19) days (p < 0.01)
|
| Abubakar et al., Nigeria, 2019 [254] |
Principally Education and Engineering to improve antibiotic prescribing for the prevention of SAP. This included:
Development and dissemination of an agreed departmental protocol for SAP, presented and agreed before its adoption to enhance subsequent adoption rates Educational meetings with key clinicians to enhance uptake of agreed protocols combined with wall mounted posters Regular audit and feedback meetings using baseline data
|
Patients in the postintervention period were 5.6 times more likely to receive SAP within 60 min before the incision vs. pre-intervention (p < 0.001) The rate of redundant antibiotic prescriptions was reduced by 19.1%
|
| Karaali et al., Turkey, 2019 [255] |
Multiple activities to improve antibiotic prescribing for SSIs including Education, and Engineering. These incorporated:
Local guidelines updated by two members of the infection control committee One general surgery team leader appointed to be responsible for improving SAP as part of ASPs in their group Periodic training sessions to supervise and regulate SAP by surgical team leaders Instigation of a new protocol, whereby clean and clean-contaminated cases would not be given SAP for longer than 24 h and that discharge prescriptions would not include antibiotics. However, no verbal or written sanctions were imposed for abuse
|
Compliance with SAP guidance significantly increasing from 55.6% to 64.5% of patients (p < 0.05)—although differences between surgical types Significant reduction in the extent of prolonged prophylaxis (beyond 24 h) from 60.2% of patients pre intervention to 7.5% post-intervention (p < 0.05) Extent of antibiotic prescribing after discharge reduced to 9.4% of patients down from 80.6% of patients pre-intervention (p < 0.05) However, limited impact on the timing of first antibiotic dose—increasing from 81.9% of patients to 83.7%
|
| Mahmoudi et al., Iran, 2019 [256] |
Principally Education and Engineering to improve SAP:
Revising SAP guidelines following meetings between a clinical pharmacist and the surgical department with senior clinical pharmacists delivering lectures about SAP to key members of the surgical departments Clinical pharmacists participating in ward rounds, attending recovery rooms and communicating with surgeons when guidelines not followed Clinical pharmacists providing educational materials Rationality of SAP continually evaluated during the perioperative period in accordance with agreed guidelines with clinical pharmacists communicated any concerns directly with relevant physicians
|
Rate of antibiotic prescribing beyond 48 h appreciably improved to just 5.7% of patients—down from 92.1% of patients pre-intervention Appropriateness of antibiotic use increased to 91.4% of patients from 30.1% pre-intervention Mean cost of antibiotics decreased more than 11-fold and length of stay decreased from an average of 5.14 days pre-intervention to 4.33 days (p < 0.001) post-intervention
|
| Xiao et al., China, 2020 [257] |
Multiple activities include Education, Engineering, Economics and Enforcement over a 6-year campaign:
Hospitals were encouraged to establish ASTs with healthcare authorities promoting education and training programs for medical staff Health authorities also supervised hospitals and issued penalties including personal warnings and dismissals, as well as downgraded hospitals Prescription rights were withdrawn where serious protocol violations observed
|
Over the six years—2016 vs. 2010:
Proportion of outpatients and surgical patients who received antibiotics decreased from 19.5% to 8.5% and from 97.9% to 38.3% respectively Overall antibiotic use decreased from 85.3 ± 29.8 DDDs/100 patient days to 48.5 ± 8.0 Antibiotic procurement expenditure declined from 22.3% of total drug procurement costs to 12.1% Incidence of methicillin-resistant Staphylococcus aureus isolates decreased from 54.4% to 34.4% in 2016); similarly, for carbapenem-resistant Pseudomonas aeruginosa isolates from 30.8% to 22.3%
|
| Mardani et al., Iran, 2020 [258] |
Principally education for this ASP comprising:
Continuous educational programs for nurses and physicians employed in different wards of the hospital An inter-disciplinary ASP team performed a weekly scrutiny of treatment for patients based on their electronic medical records and provided feedback include reduction in multiple antibiotic use and dosage changes
|
Reduction in MDR cases in the year post-intervention from 145 and 75 (p = 0.011) Significant reduction in all positive blood cultures (p = 0.001) Significant reduction in meropenem use (p = 0.043) as well as a significant reduction generally in antibiotic consumption, multidrug-resistant organisms and CDIs
|
| van den Bergh et al., South Africa, 2020 [259] |
Principally education to improve compliance to agreed guidelines:
A Community Acquired Pneumonia (CAP) bundle was developed including seven process measures (including admission criteria, drug choice, dose and length) and three outcome measures (including length of stay and mortality) that pharmacists used to audit compliance to the bundle and provide feedback Training sessions were conducted on the CAP and implementing ASPs within hospitals. After each learning session, a checklist of essential activities and deadlines was provided to each pharmacist Baseline data were collected to identify areas for improvement. In a four-week period after the learning sessions, pharmacists applied the learnt ideas to improve compliance to the CAP guidelines and ways to give feedback to address identified gaps to improve future compliance with multi-disciplinary team members and hospital leadership
|
2464 patients from 39 hospitals were included with the ASP showing positive results: CAP bundle compliance improved to 53.6% from 47.8% to 53.6% (p < 0.0001) Diagnostic stewardship compliance improved to 54.6% from 49.1% of patients (p < 0.0001) Improved compliance with process measures was significant for five of the seven components. These include choice and dose of antibiotics prescribed as well as IV to oral switch However, there was no significant difference in mortality or median length of stay pre- and post-intervention The study represents the first collaboration between public and private sector hospitals in ASPs in South Africa
|
