Antimicrobial stewardship intervention safely reduces antibiotic UTI use in frail older adults

3rd March 2023

An RCT of an antimicrobial stewardship intervention reduced antibiotic use for suspected urinary tract infections in frail older adults

The introduction of an antimicrobial stewardship intervention to older adult care facilities, significantly reduced the level of antibiotic prescribing for frail older adults with a suspected urinary tract infection according to the findings of a cluster, randomised trial by European researchers.

Antimicrobial resistance poses a global, major threat to human health and is recognised as a leading cause of deaths around the world. Older and frail adults are often prescribed antibiotics for a urinary tract infection (UTI) and often in the presence of non-specific symptoms such as confusion. Moreover, the presence of asymptomatic bacteriuria is a common finding which has become recognised as an important contributor to inappropriate antimicrobial use that ultimately promotes emergence of antimicrobial resistance. To date antibiotic stewardship interventions in long-term care facilities suggest that such programs collectively suggest potential to reduce antimicrobial use though the available interventions vary considerably with respect to design and intensity.

In the current study, researchers made use of a multifaceted antibiotic stewardship intervention that included a decision tool for appropriate use of antibiotics for a UTI and which was previously developed by an international expert team. The researchers wanted to find out if the intervention was effective in reducing antibiotic prescribing for suspected urinary tract infections in various older adult care settings, in comparison to usual care, in several European countries. The team used a pragmatic, parallel, cluster randomised controlled trial, with a 5 month baseline data collection period and a 7 month follow-up. They set the primary outcome as the number of antibiotic prescriptions for a suspected UTI per person-year, whereas secondary outcomes focused on the level of complications, hospital admissions and all-cause mortality.

Antimicrobial stewardship and treatment of suspected urinary tract infections

A total of 1,041 participants with a mean age of 86.3 years (70.9% female) were included and of whom, 502 were randomised to the antibiotic stewardship intervention.

During the baseline period, there was no difference in the level of antibiotic prescribing for a suspected UTI in the two groups (0.50 per person year vs 0.44 per person year, intervention vs usual care). However, during the follow-up period, the corresponding rates were 0.27 per person-year (intervention ) and 0.58 per person-year (usual care). This equated to an adjusted rate ratio of 0.42 (95% CI 0.26 – 0.68, p < 0.001).

Furthermore, there were no differences between groups with respect to either complications, hospital admissions or all-cause mortality.

The authors concluded that their antimicrobial stewardship intervention safely reduced antibiotic prescribing for a suspected UTI in frail older adults.

Citation
Hartman EAR et al. Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries. BMJ 2023

Pharmacist-led antimicrobial stewardship ensures appropriate prescribing in EDs

2nd February 2022

Pharmacist-led antimicrobial stewardship within emergency departments appears to be effective and improve adult antibiotic prescribing

Pharmacist-led antimicrobial stewardship with emergency departments is associated with more appropriate antibiotic prescribing in adults who present with a range of infectious conditions. This was the conclusion of a systematic review and meta-analysis by a team from the Department of Pharmacy and the Department of Emergency Medicine, Mayo Clinic, Minnesota, US.

Research from the US suggests that an estimated 30% of outpatient, oral antibiotic prescriptions may have been inappropriate, highlighting a need for effective antimicrobial stewardship programs within an emergency departments. However, one systematic review addressing this topic concluded that while such interventions may improve patient care, the optimal combination of interventions is unclear. While the review did not consider pharmacist-led interventions, other reviews have demonstrated that within an inpatient setting, pharmacist-led educational antimicrobial stewardship interventions are effective at increasing guideline compliance and reducing duration of antimicrobial therapy. Although prior research has demonstrated that a clinical pharmacist within an emergency department is of value, the impact of a pharmacist-led antimicrobial stewardship program within emergency departments remains unknown.

For the present study, the US team set their primary aim as an assessment of the impact of pharmacist-led antimicrobial stewardship interventions, on the appropriateness of antibiotic prescribing within emergency care settings. The secondary aim was to assess the impact of any such interventions on time to culture review, time to appropriate antibiotics and emergency care return rates.

Findings

The literature review identified 22 studies including 5,062 patients that were suitable for analysis, the majority of which were retrospective observational cohorts, including before and after assessments though there were no randomised, controlled trials.

The nature of the studies varied and interventions included pharmacist-led culture reviews, the presence of a pharmacist in the department, pharmacist directed clinical algorithms, clinician education and one prospective antibiotic review.

In an assessment of appropriate versus inappropriate antibiotics, the pooled odds ratio (OR) was 3.47 (95% CI 2.39 – 5.03) when chosen by a pharmacist during the intervention. For specific conditions, appropriate antibiotic selection was more appropriate with pharmacist involvement for pneumonia (OR = 3.74) and urinary tract infections (OR = 1.76).

In subgroup analysis, the presence of a pharmacist led to improvements in each of the areas examined. For example, pharmacist presence within the department for antibiotic selection was better than no pharmacist for appropriate antibiotic selection (OR = 3.13), culture review (OR = 2.22) and pharmacist directed algorithms and clinical education (OR = 5.23).

However, the time to culture review and time to patient contact were no different with or without a pharmacists, although the time to appropriate antibiotic was significantly shorter in the presence of a pharmacist (mean difference 18.86 hours).

The authors concluded that the presence of a pharmacist or pharmacist-led antimicrobial stewardship interventions appeared effective for ensuring appropriate prescribing of antibiotics in adult patients presenting to emergency departments despite how the majority of included studies had a moderate risk of bias.

Citation

Kooda K et al. Impact of Pharmacist-Led Antimicrobial Stewardship on Appropriate Antibiotic Prescribing in the Emergency Department: A Systematic Review and Meta-Analysis Ann Emerg Med 2022