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Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs.

ABSTRACT: The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was -19.1% (95% confidence interval [CI] = -30.1 to -7.5), and the use of restricted antimicrobial agents decreased by -26.6% (95% CI = -52.3 to -0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was -39.5% (95% CI = -72.5 to -6.4). The use of broad-spectrum antibiotics (-18.5% [95% CI = -32 to -5.0] for carbapenems and -14.7% [95% CI = -27.7 to -1.7] for glycopeptides), the overall antimicrobial cost (-33.9% [95% CI = -42.0 to -25.9]), and the hospital length of stay (-8.9% [95% CI = -12.8 to -5]) decreased. Among hospital pathogens, the implementation of ASPs was associated with a decrease in infections due to methicillin-resistant Staphylococcus aureus (risk difference [RD] = -0.017 [95% CI = -0.029 to -0.005]), imipenem-resistant Pseudomonas aeruginosa (RD = -0.079 [95% CI = -0.114 to -0.040]), and extended-spectrum beta-lactamase Klebsiella spp. (RD = -0.104 [95% CI = -0.153 to -0.055]). Notably, these improvements were not associated with adverse outcomes, since the all-cause, infection-related 30-day mortality and infection rates were not significantly different after implementation of an ASP (RD = -0.001 [95% CI = -0.009 to 0.006], RD = -0.005 [95% CI = -0.016 to 0.007], and RD = -0.045% [95% CI = -0.241 to 0.150], respectively). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.

SUBMITTER: Karanika S

PROVIDER: S-EPMC4958232 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs.

Karanika Styliani S Paudel Suresh S Grigoras Christos C Kalbasi Alireza A Mylonakis Eleftherios E

Antimicrobial agents and chemotherapy 20160722 8

The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of ...[more]

PMID: 27246783

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Project description:Background:Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods:MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18?years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results:Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions:Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Project description:ImportanceAntimicrobial resistance continues to spread rapidly at a global scale. Little evidence exists on the association of antimicrobial stewardship programs (ASPs) with the consumption of antibiotics across health care and income settings.ObjectiveTo synthesize current evidence regarding the association between antimicrobial stewardship programs and the consumption of antibiotics globally.Data sourcesPubMed, Web of Science, and Scopus databases were searched from August 1, 2010, to Aug 1, 2020. Additional studies from the bibliography sections of previous systematic reviews were included.Study selectionOriginal studies of the association of ASPs with antimicrobial consumption across health care and income settings. Animal and environmental studies were excluded.Data extraction and synthesisFollowing the Preferred Reporting Items in Systematic Reviews and Meta-Analyses guideline, the pooled association of targeted ASPs with antimicrobial consumption was measured using multilevel random-effects models. The Effective Public Health Practice Project quality assessment tool was used to assess study quality.Main outcomes and measuresThe main outcome measures were proportion of patients receiving an antibiotic prescription and defined daily doses per 100 patient-days.ResultsOverall, 52 studies (with 1 794 889 participants) measured the association between ASPs and antimicrobial consumption and were included, with 40 studies conducted in high-income countries and 12 in low- and middle-income countries (LMICs). ASPs were associated with a 10% (95% CI, 4%-15%) reduction in antibiotic prescriptions and a 28% reduction in antibiotic consumption (rate ratio, 0.72; 95% CI, 0.56-0.92). ASPs were also associated with a 21% (95% CI, 5%-36%) reduction in antibiotic consumption in pediatric hospitals and a 28% reduction in World Health Organization watch groups antibiotics (rate ratio, 0.72; 95% CI, 0.56-0.92).Conclusions and relevanceIn this systematic review and meta-analysis, ASPs appeared to be effective in reducing antibiotic consumption in both hospital and nonhospital settings. Impact assessment of ASPs in resource-limited settings remains scarce; further research is needed on how to best achieve reductions in antibiotic use in LMICs.

Project description:BACKGROUND AND OBJECTIVES:Infections caused by multidrug-resistant organisms and Clostridium difficile are associated with substantial morbidity and mortality as well as excess costs. Antimicrobial exposure is the leading cause for these infections. Approximately 30% of antimicrobial doses administered in outpatient hemodialysis facilities are considered unnecessary. Implementing an antimicrobial stewardship program in outpatient hemodialysis facilities aimed at improving prescribing practices would have important clinical and economic benefits. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:We developed a decision analytic model of antimicrobial use on the clinical and economic consequences of implementing a nationwide antimicrobial stewardship program in outpatient dialysis facilities. The main outcomes were total antimicrobial use, infections caused by multidrug-resistant organisms and C. difficile, infection-related mortality, and total costs. The analysis considered all patients on outpatient hemodialysis in the United States. The value of implementing antimicrobial stewardship programs, assuming a 20% decrease in unnecessary antimicrobial doses, was calculated as the incremental differences in clinical end points and cost outcomes. Event probabilities, antimicrobial regimens, and health care costs were informed by publicly available sources. RESULTS:On a national level, implementation of antimicrobial stewardship programs was predicted to result in 2182 fewer infections caused by multidrug-resistant organisms and C. difficile (4.8% reduction), 629 fewer infection-related deaths (4.6% reduction), and a cost savings of $106,893,517 (5.0% reduction) per year. The model was most sensitive to clinical parameters as opposed to antimicrobial costs. CONCLUSIONS:The model suggests that implementation of antimicrobial stewardship programs in outpatient dialysis facilities would result in substantial reductions in infections caused by multidrug-resistant organisms and C. difficile, infection-related deaths, and costs.

Project description:BackgroundHospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed.ObjectiveThe objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population.MethodA systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded.ResultsFrom electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%).ConclusionsMedical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population.

Dataset Information

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs.

Publications

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs.

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