Monday, 31 August 2015

Microbial resistance: a Triple Aim example

To continue "Antibiotics: resistance and costs" post, given the importance of the subject, in this post I want to present the template design that may be helpful to those responsible for infection control in hospitals.

In 2007 two American scientific societies published a guide to deploying Antimicrobial Stewardship Programs (ASP) in health institutions. Five years later, three Spanish scientific societies adapted those guidelines and laid the foundations of the Programs for Optimizing Antimicrobials Use (PROA in Spanish).
These methodological developments are relevant because there is enough evidence to believe that management programs reduce antimicrobial resistance and costs. Therefore, with the rationalization (not rationing) of antimicrobial use we’re faced with a clear example of Triple Aim program. Remember that a Triple Aim program is a program that, in a balanced way, achieves three types of objectives: improved clinical outcomes, enhanced the patients’ experience and reduced costs.

The issue of antimicrobial resistance

A review of seven studies (first bibliographic list at the end of post) shows that policies for using antimicrobial resistance prime the microorganisms’ resistance and therefore are responsible for the related difficulties in clinical management in the resulting situations.

The issue of cost reduction

Another review of 8 evaluative studies (second reference list at the end of post) regarding the impact on the ASP deployment costs in health institutions, shows that the savings can range from 10% to 69%. The variability in these results is understandable because, logically, the finally achieved costs reduction depends on the starting position of the hospital and the intensity of the intervention program.

What is an ASP?

An Antibiotic Stewardship Program is a corporate-level project that aims to combat antimicrobial resistance. The deployment of an ASP requires hospitals to have an infection committee motivated to lead the project, a working group of specialists to be responsible for its management and a commitment from the hospital management who, thus involves the entire organization.

The ASP template to assess the degree of development of the program in each institution

If you consult the ASP and PROA documents cited in the introduction of the post you’ll find the elements to generate a matrix with 7 dimensions and 3 levels of development of an anti-resistance program, logically with a degree of detail higher that the one that can be seen below:

Let's exemplify with the PROA matrix for a hospital A:

As you can see, this matrix is ​​a good helping tool for defining specific organizational development objectives of an ASP, in accord to each of the 7 dimensions analyzed and the desired developmental level.

Three ideas to be remembered: a) microbial resistances are induced through clinical action, b) the savings achieved through a rational use of antimicrobials program will offset at least the required investment and c) educational interventions are the most effective (I advise you to consult reference 8 of the second bibliography list).

(A thank you to Dr. Esther Calbo, infectious disease internist of the Mutua de Terrassa, for choosing the documentary sources of this post).

The 7 selected articles on microbial resistance:
  1. McGowan JE. Antimicrobial resistance in hospital organisms and its relation to antibiotic use. Rev Infect Dis 1983; 5:1033–48.
  2. Monroe S, Polk R. Antimicrobial use and bacterial resistance. Curr Opin Microbiol 2000; 3:496–501.
  3. Barbosa TM, Levy SB. The impact of antibiotic use on resistance development and persistence. Drug Resistance Updates 2000; 3:303–11.
  4. Paterson DL. “Collateral damage” from cephalosporin or quinolone antibiotic therapy. Clin Infect Dis 2004; 38(Suppl 4):S341–5.
  5. Impact of Quinolone Restriction on Resistance Patterns of Escherichia coli Isolated from Urine by Culture in a Community Setting Bat Sheva Gottesman, Yehuda Carmeli, Pnina Shitrit, and Michal Chowers. Clinical Infectious Diseases 2009; 49:869–75.
  6. Impact of Antibiotic Use on Carbapenem Resistance in Pseudomonas aeruginosa: Is There a Role for Antibiotic Diversity? C. Plüss-Suard, A. Pannatier, A. Kronenberg, K. Mühlemann, G. Zanettif. Antimicrobial Agents and Chemotherapy. April 2013 Volume 57 Number 4: 1709–1713.
  7. Chen I-L, Lee C-H, Su L-H, Tang Y-F, Chang S-J, et al. (2013) Antibiotic Consumption and Healthcare-Associated Infections Caused by Multidrug-Resistant Gram-Negative Bacilli at a Large Medical Center in Taiwan from 2002 to 2009: Implicating the Importance of Antibiotic Stewardship. PLoS ONE 8(5): e65621. doi:10.1371/journal.pone.0065621.

The 8 selected articles on the costs impact of PROAs:
  1. Ng CK, Wu TC, Chan WM, Leung YS, Li CK, Tsang DN, Leung GM. Clinical and economic impact of an antibiotics stewardship programme in a regional hospital in Hong Kong. Qual Saf Health Care. 2008 Oct;17(5):387-92. The staff provision required to set in motion an ASP has been compensated by the savings on the antimicrobian expenses.
  2. Agwu AL, Lee CK, Jain SK, Murray KL, Topolski J, Miller RE, Townsend T, Lehmann CU. A World Wide Web-based antimicrobial stewardship program improves efficiency, communication, and user satisfaction and reduces cost in a tertiary care paediatric medical centre. Clin Infect Dis. 2008 Sep 15;47(6):747-53. An ASP reduced  the  allowance of  antimicrobials  by 11,6%.
  3. Nowak MA, Nelson RE, Breidenbach JL, Thompson PA, Carson PJ. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health Syst Pharm. 2012 Sep 1;69(17):1500-8. An ASP saved 103.787$ per year, the equivalent of  14.156$ per each thousand hospital stays.
  4. Beardsley JR, Williamson JC, Johnson JW, Luther VP, Wrenn RH, Ohl CC. Show me the money: long-term financial impact of an antimicrobial stewardship program. Infect Control Hosp Epidemiol. 2012 Apr;33(4):398-400. An ASP generated a saving estimated in a range between 0,9 y 2,0 M$ per year.
  5. Magedanz L, Silliprandi EM, dos Santos RP. Impact of the pharmacist on a multidisciplinary team in an antimicrobial stewardship program: a quasi-experimental study. Int J Clin Pharm. 2012 Apr;34(2):290-4. An ASP reduced the antimicrobial spending by 69%.
  6. 6. Malani AN, Richards PG, Kapila S, Otto MH, Czerwinski J, Singal B. Clinical and economic outcomes from a community hospital's antimicrobial stewardship program. Am J Infect Control. 2013 Feb;41(2):145-8. An ASP reduced the costs of antimicrobials by 15,2%, the equivalent of  228.911$.
  7. Sick AC, Lehmann CU, Tamma PD, Lee CK, Agwu AL. Sustained savings from a longitudinal cost analysis of an internet-based preapproval antimicrobial stewardship program. Infect Control Hosp Epidemiol. 2013 Jun;34(6):573-80. The antibiotics costs have been reduced by  9,75% during the first year of  intervention, and the accumulated savings during the 6 years  of the study amounted to 1,7 M$.
  8. Cisneros JM, Neth O, Gil-Navarro MV, Lepe JA, Jiménez-Perrilla F, et al. Global impact of an educational antimicrobial stewardship programme on prescribing practice in a tertiary hospital centre. Clin Microbiol Infect. 2014 Jan;20(1):82-8. doi: 10.1111/1469-0691.12191. Epub 2013 Mar 20. The Hospital Virgen del Rocio in Seville reduced the inappropriate use of antibiotics from 53% to 26% and the corresponding costs by 42% with an ASP focused on prescribers’ training activities on.

Jordi Varela 

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