A multidisciplinary antimicrobial stewardship programme safely decreases the duration of broad-spectrum antibiotic prescription in Singaporean adult renal patients
Introduction
In the past decade, antimicrobial resistance among Gram-negative bacteria (GNB) has emerged as a major healthcare concern [1]. This phenomenon has been associated with antimicrobial exposure. Antimicrobial stewardship programmes (ASPs) have been identified as a key strategy in reducing inappropriate antimicrobial use. In Singapore, multidisciplinary ASPs have been implemented in most major hospitals since 2008. These hospitals employ a multipronged strategy, including a prospective audit/feedback approach, formulary restrictions, and use of guidelines and computerised clinical decision support systems [2], [3].
To date, several studies have shown that ASPs can improve the appropriateness of prescribing [2], [4]. However, most of these studies reported the impact of ASPs across several disciplines and did not focus on a single patient group. In Singapore, patients with chronic kidney disease (CKD) are of particular concern as kidney disease has reached pandemic proportions [5]. Because of alterations in immune response and frequent healthcare exposures, patients with kidney diseases have an increased risk of infections [6]. Thus, clinicians may favour early empirical prescription of broad-spectrum antibiotics, which can translate to an increased misuse of antibiotics. Unfortunately, to date there is no study describing the role and impact of ASPs in renal patients in an inpatient setting.
In Singapore General Hospital (SGH), a hospital-wide ASP has been in place since 2008. In this study, the role of the ASP team was examined specifically in renal patients in SGH, and the impact of the ASP on antibiotic prescription and on patient outcomes was evaluated.
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Study setting
This was a retrospective review of all patients whose broad-spectrum antibiotic prescription was audited by the ASP team in the Renal Medicine Department of SGH, a 1600-bed acute tertiary care hospital in Singapore, from January 2010 to December 2011. The SGH Renal Medicine Department has the most comprehensive nephrological service in Singapore, admitting patients with CKD, end-stage renal disease (ESRD) and those requiring renal transplantation. During the audit period, patients in the Renal
Patient demographics and antibiotic use
From January 2010 to December 2011, a total of 2084 audits in 1243 patients were conducted (Table 1). More than one-half (680/1243; 54.7%) of the patients had ESRD and were on chronic renal replacement therapy; 156 patients (12.6%) were kidney transplant patients on immunosuppressive therapy.
Among the audited antibiotics, TZP (1244/2084; 59.7%) was most commonly prescribed, followed by meropenem (406/2084; 19.5%). Antibiotics were most commonly prescribed for pneumonia (557/2084; 26.7%) and
Discussion
Singapore has the fifth highest incidence of kidney disease globally and this has many implications on antibiotic use [7]. Patients with ESRD are at increased risk of infection owing to frequent healthcare utilisation, loss of cutaneous barriers from insertion of dialysis catheters, and alterations in the immune system [6]. Whilst less is known about patients with CKD, it has been suggested that the physiological effects of kidney dysfunction are a continuum [6]. Acute infections contribute
Conclusion
Specific barriers to appropriate antibiotic prescription exist for different patient types; identification of these barriers is essential for the design of targeted interventions. In this study, we described the role of an ASP in renal patients and identified two major barriers to appropriate antibiotic use: (i) difficulties in discriminating infectious from non-infectious aetiologies; and (ii) difficulties in dosing of antibiotics. These findings highlighted the need for targeted
Funding
None.
Competing interests
None declared.
Ethical approval
This study was approved by the SingHealth Institutional Ethics Review Board [CIRB 2010/114/E]. The need for informed consent was waived as ASP operations constituted routine practice.
Acknowledgments
The authors thank the Singapore General Hospital Antimicrobial Stewardship Programme (ASP) team for their efforts in patient review.
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