A multidisciplinary antimicrobial stewardship programme safely decreases the duration of broad-spectrum antibiotic prescription in Singaporean adult renal patients

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Highlights

  • We describe the impact of a multidisciplinary antimicrobial stewardship programme (ASP) in renal patients.

  • One-quarter of antibiotics prescribed in renal patients were deemed inappropriate.

  • Most ASP recommendations involved discontinuing antibiotics or adjusting doses.

  • Acceptance of ASP interventions was associated with reduced duration of antibiotics.

Abstract

Patients with chronic kidney disease have increased risk of infections. Thus, physicians may favour prolonged broad-spectrum antibiotic use. Studies focused on antimicrobial stewardship programmes (ASPs) in renal patients are currently lacking. Here we describe the role of a multidisciplinary ASP and the impact of ASP interventions in renal patients. A multidisciplinary ASP was initiated at a tertiary hospital in Singapore. Patients prescribed broad-spectrum parenteral antibiotics were identified daily and were subjected to prospective review with immediate concurrent feedback. ASP data from January 2010 to December 2011 were analysed for all renal patients. Outcome measures included the duration and appropriateness of antibiotics, intervention acceptance rates, cost savings and safety outcomes. A total of 2084 antibiotic courses were reviewed, of which 24% were inappropriate, with meropenem most commonly prescribed inappropriately (31.0%). The commonest reasons for inappropriate use were wrong choice (51.0%) and wrong duration (21.4%). In total, 634 recommendations were made, with high acceptance rates (73.3%). Recommendations to discontinue antibiotics (33.4%) and to optimise doses (17.2%) comprised the bulk of ASP work. A mean reduction of −1.28 days of antibiotic use was observed among patients with interventions accepted versus those rejected (P < 0.001), with direct cost savings of SGD$90,045. No difference in 30-day mortality (P = 0.91) was observed between the accepted and rejected intervention groups. In conclusion, a multidisciplinary ASP resulted in a shorter duration of antibiotic use without compromising safety in renal patients. Continued effort is needed to produce a long-term impact on antibiotic prescription and resistance.

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.

Section snippets

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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