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      The effect of antibiotic stewardship interventions with stakeholder involvement in hospital settings: a multicentre, cluster randomized controlled intervention study

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          Abstract

          Background

          There is limited evidence from multicenter, randomized controlled studies to inform planning and implementation of antibiotic stewardship interventions in hospitals.

          Methods

          A cluster randomized, controlled, intervention study was performed in selected specialities (infectious diseases, pulmonary medicine and gastroenterology) at three emergency care hospitals in Western Norway. Interventions applied were audit with feedback and academic detailing. Implementation strategies included co-design of interventions with stakeholders in local intervention teams and prescribers setting local targets for change in antibiotic prescribing behaviour. Primary outcome measures were adherence to national guidelines, use of broad-spectrum antibiotics and change in locally defined targets of change in prescribing behaviour. Secondary outcome measures were length of stay, 30-day readmission, in-hospital- and 30-day mortality.

          Results

          One thousand eight hundred two patients receiving antibiotic treatment were included. Adherence to guidelines had an absolute increase from 60 to 66% for all intervention wards ( p = 0.04). Effects differed across specialties and pulmonary intervention wards achieved a 14% absolute increase in adherence ( p = 0.003), while no change was observed for other specialties. A pulmonary ward targeting increased use of penicillin G 2 mill IU × 4 for pneumonia and COPD exacerbations had an intended increase of 30% for this prescribing behaviour ( p < 0.001).

          Conclusions

          Pulmonary wards had a higher increase in adherence, independent of applied intervention. The effect of antibiotic stewardship interventions is dependent on how and in which context they are implemented. Additional effects of interventions are seen when stakeholders discuss ward prescribing behaviour and agree on specific targets for changes in prescribing practice.

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          Most cited references8

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          The Relationship between Antimicrobial Use and Antimicrobial Resistance in Europe

          In Europe, antimicrobial resistance has been monitored since 1998 by the European Antimicrobial Resistance Surveillance System (EARSS). We examined the relationship between penicillin nonsusceptibility of invasive isolates of Streptococcus pneumoniae (an indicator organism) and antibiotic sales. Information was collected on 1998-99 resistance data for invasive isolates of S. pneumoniae to penicillin, based on surveillance data from EARSS and on outpatient sales during 1997 for beta-lactam antibiotics and macrolides. Our results show that in Europe antimicrobial resistance is correlated with use of beta-lactam antibiotics and macrolides.
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            The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance.

            The threat to human health posed by antibiotic resistance is of growing concern. Many commensal and pathogenic organisms have developed resistance to well established and newer antibiotics. The major selection pressure driving changes in the frequency of antibiotic resistance is the volume of drug use. However, establishing a quantitative relationship between the frequency of resistance and volume of drug use has proved difficult. Using population genetic methods and epidemiological observations, we report an analysis of the influence of the selective pressure imposed by the volume of drug use on temporal changes in resistance. Analytical expressions are derived to delineate key relationships between resistance and drug consumption. The analyses indicate that the time scale for emergence of resistance under a constant selective pressure is typically much shorter than the decay time after cessation or decline in the volume of drug use and that significant reductions in resistance require equally significant reductions in drug consumption. These results highlight the need for early intervention once resistance is detected.
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              Antibiotic stewardship: does it work in hospital practice? A review of the evidence base

              J.M. Prins (2017)
              Guidelines for developing and implementing stewardship programmes include recommendations on appropriate antibiotic use to guide the stewardship team's choice of potential stewardship objectives. They also include recommendations on behavioural change interventions to guide the team's choice of potential interventions to ensure that professionals actually use antibiotics appropriately in daily practice.
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                Author and article information

                Contributors
                +47 48090504 , jannicke.slettli.wathne@sav.no
                lars.kare.selland.kleppe@sus.no
                stig.harthug@helse-bergen.no
                Hege.Salvesen.Blix@fhi.no
                Roy.Miodini.Nilsen@hvl.no
                e.charani@imperial.ac.uk
                +41 22 791 4630 , ismith@who.int
                Journal
                Antimicrob Resist Infect Control
                Antimicrob Resist Infect Control
                Antimicrobial Resistance and Infection Control
                BioMed Central (London )
                2047-2994
                10 September 2018
                10 September 2018
                2018
                : 7
                : 109
                Affiliations
                [1 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Department of Clinical Science, , University of Bergen, ; Bergen, Norway
                [2 ]ISNI 0000 0000 9753 1393, GRID grid.412008.f, Norwegian Advisory Unit for Antibiotic Use in Hospitals, Department of Research and Development, , Haukeland University Hospital, ; Jonas Lies vei 65, N-5021 Bergen, Norway
                [3 ]Department of Quality and Development, Hospital Pharmacies Enterprise in Western Norway, Bergen, Norway
                [4 ]ISNI 0000 0004 0627 2891, GRID grid.412835.9, Department of Infectious Diseases and Unit for Infection Prevention and Control, Department of Research and Education, , Stavanger University Hospital, ; Stavanger, Norway
                [5 ]ISNI 0000 0001 1541 4204, GRID grid.418193.6, Department of Drug Statistics, , Norwegian Institute of Public Health, ; Oslo, Norway
                [6 ]GRID grid.477239.c, Faculty of Health and Social Sciences, , Western Norway University of Applied Sciences, ; Bergen, Norway
                [7 ]ISNI 0000 0001 2113 8111, GRID grid.7445.2, NHIR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, , Imperial College, ; London, UK
                [8 ]ISNI 0000000121633745, GRID grid.3575.4, Innovation, Access and Use, Department of Essential Medicines and Health Products, , World Health Organization (WHO), ; Avenue Appia 20, 1211 Geneva 27, Switzerland
                Author information
                http://orcid.org/0000-0002-0828-2909
                Article
                400
                10.1186/s13756-018-0400-7
                6131848
                30214718
                cd04ec69-3819-4f7c-a8a1-eea1809fdb51
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 21 May 2018
                : 26 August 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100005029, Helse Vest Regionalt Helseføretak;
                Award ID: HV1199
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100000272, National Institute for Health Research;
                Award ID: HPRU-2012-10047
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2018

                Infectious disease & Microbiology
                antibiotic stewardship,intervention,crct,audit with feedback,academic detailing,hospital,goal setting

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