- Email: [email protected]
Pattern of systemic antibiotic use among hospitalized patients in a general hospital in Saudi Arabia
Journal Pre-proof Pattern of systemic antibiotic use among hospitalized patients in a general hospital in Saudi Arabia Jaffar A. Al-Tawfiq, Ali H. Al-Homoud PII:
S1477-8939(20)30072-7
DOI:
https://doi.org/10.1016/j.tmaid.2020.101605
Reference:
TMAID 101605
To appear in:
Travel Medicine and Infectious Disease
Received Date: 21 October 2019 Revised Date:
19 February 2020
Accepted Date: 22 February 2020
Please cite this article as: Al-Tawfiq JA, Al-Homoud AH, Pattern of systemic antibiotic use among hospitalized patients in a general hospital in Saudi Arabia, Travel Medicine and Infectious Disease (2020), doi: https://doi.org/10.1016/j.tmaid.2020.101605. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
CRediT author statement
JAT: conceptual design, data analysis, drafted the first manuscript
AH: collected the data, wrote the methods
Both authors finalized the manuscript
Pattern of Systemic Antibiotic Use among Hospitalized Patients in a General Hospital in Saudi Arabia Jaffar A. Al-Tawfiq 1,2,3* and Ali H. Al-Homoud4
1
Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare,
Dhahran, Saudi Arabia, 2Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; 3Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 4Pharmacy Services Division, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
Dr. Jaffar A. Al-Tawfiq* P.O. Box 76; Room A-428-2, Building 61, Dhahran Health Center, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia. E-mail address: [email protected]; [email protected] Tel: +966-13-870-3524; Fax: +966-13-870-3790
All authors have no conflicts of interest Key words: Point Prevalence Study; antimicrobial audit; antimicrobial stewardship; antibiotics
1
Abstract: Background: The emergence of antimicrobial resistance of many bacteria is a significant drawback of antimicrobial use. A key measure to assess antimicrobial use is point prevalence study. Methods: This is a point prevalence study of all hospitalized patients at Johns Hopkins Aramco Healthcare, a 350-bed hospital, and was conducted at two-points from January 2017 to January 2019. We recorded systemic antibiotics and the indications for the use as prophylactic, empiric, and definite therapy. Result: Of the 489 hospitalized patients whom were included, 200 (40%) were on systemic antibiotics. Of the total antibiotics, 72% were empiric, 17 (8.5) were on prophylactic antibiotics, and 17.5% were definite therapy, according to hospital guidelines.
Most commonly used
antibiotics were meropenem (18%), cefazolin (10%), and ceftriaxone (8%).
Of included
patients, 29.4% were on a single antibiotic, 10% on two antibiotics, and 1.4% were on three antibiotics. Of patients receiving an antibiotic that could be given orally, only 41.4% received oral therapy. Conclusion: A large percentage of patients were on empiric antimicrobial therapy and areas for further improvements in antimicrobial stewardship includes intravenous to oral switch, evaluating the need for combination therapy, restrictions, education and putting appropriate use guidelines.
2
Introduction: We are facing an increased rate of antimicrobial resistance of many bacteria and this increase is not associated with a parallel increase in the development of new antibi microbial agents. There is a continued selective pressure of antimicrobial agents due to prolonged and inappropriate use [1]. Overuse of antimicrobial agents is associated with increased resistance globally. There is a global trend of increasing antimicrobial resistance in Gram positive and Gram-negative organisms. In the Middle East, surveillance studies indicated increased antimicrobial resistance mainly among Gram-negative bacilli. One such strategy is antibiotic stewardship and the ability to have a measurement of antibiotic usage such as the point prevalence of antibiotic usage. In order to improve a process, it is important to measure the process to further enhance the capacity of the process. Absence or incomplete data about the utilization pattern of antimicrobial usage is considered a barrier to the positive progress and execution of an effective antimicrobial stewardship program [2]. In addition, auditing antimicrobial use further augment other elements of antimicrobial stewardship programs [3].
There are limited studies from Saudi Arabia
regarding point prevalence and utilization of antibiotics. In the Kingdom of Saudi Arabia, one study evaluated point prevalence in a number of hospitals [4]. Another study evaluated antibiotic prescribing pattern among outpatient patients, and systemic antimicrobial agents among hospitalized patients, and evaluated defined daily dose of carbapenems [5]. Here, we present a point prevalence study to measure the pattern of use of antibiotics based on indications and compare the findings to those already published. Materials and Methods:
3
This is a point prevalence study of all hospitalized patients at Johns Hopkins Aramco Healthcare (JHAH) which is a 350-bed hospital. The study utilized a point-prevalence study and was conducted at two-points from January 2017 to January 2019, these were designated as . We reviewed all hospitalized patients and recorded the antibiotics being used. Data were gathered by reviewing the patients’ case notes, microbiology laboratory results and medication charts. We recorded the service as medical, surgical or critical care unit. The indication for antibiotic therapy was classified as prophylactic, empiric, or definite therapy. Patients undergoing same day treatment, surgery or endoscopy were excluded. We conducted a second review after three months. The study was approved by the Institutional Review Board in our institution. Results: During the study periods, we performed two point-prevalence study three months apart. There were 489 hospitalized patients and of those 200 (40%) were on systemic antibiotics (Table 1). We excluded three patients who were on therapy for tuberculosis (1 and 2 in the first and second review, respectively). There was no difference on the use of antibiotics between the two study periods. Of the total patients on antibiotics, 72% were on empiric therapy, 17 (8.5) were on prophylactic antibiotics, and 17.5% were on definite therapy, according to hospital guidelines and there was no difference between the study periods. Of all included patients, 29.4% were on a single antibiotic, 10% on two antibiotics, and 1.4% were on three antibiotics (Table 1). Thus, combination therapy was used for 11.4% of all patients representing 28% of patients who were on antimicrobial therapy. The top ten used antimicrobial therapy is shown in figure 1 and the most commonly used antibiotics were meropenem (18%), cefazolin (10%), and ceftriaxone (8%) (Figure 1).
The most commonly used antibiotics per category were: cefazolin (70%) for
prophylaxis, meropenem (21%) for empiric therapy, and vancomycin (15%) for definitive 4
therapy. Of the patients receiving an antibiotic that could be given orally, only 41.4% received oral therapy.
The percentage of patients who received antibiotics was 50% for intensive care
units, 37.2% for medical units, 38.5% for surgical units and 57% for pediatric wards. Discussion: During the study period, 40% of the patients were on systemic antibiotics. Similarly, a point prevalence study in 8 hospitals in Egypt showed that the prevalence of antibiotic use was 32.9%– 91.7% [6]. In a study from Brazil, Venezuela, Mexico, and Colombia, about 50% (47-63%) were on one or more antimicrobial agent [7]. In a study from Swedish Pediatric hospitals, 36% of children were on antimicrobial therapy [8] and 50% of surveyed children in Italy were on antimicrobial therapy [9]. In a study from Turkey, antibiotic use was recorded among 44% of patients [10]. The percentage of patients on antibiotics was 57% among 1750 patients in India [11] and 70.6% of 711 surveyed patients in Botswana were receiving antimicrobial therapy [12]. In a study from Kosovo, 43% of adults and 58% of pediatric patients received at least one antibiotic during hospital stay [13]. Another study from India sowed 32% were on antimicrobial therapy [2]. We found that vancomycin use was in 15% of patients on definitive antimicrobial therapy. It is important to note that the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in our hospital was 6% of all S. aureus isolates [14]. And that the prevalence of MRSA in Saudi Arabia ranges from 15% to 58% [15]. Thus, this prevalence of MRSA may explain the use of vancomycin. We found that 11.4% of all surveyed patients were on a combination therapy compared to 28.4% in a study from Egypt [6]. In that study, 61% of antibiotics were used as a prophylaxis compared
5
to 8.5% in our hospital. Carbapenems use was 12-16% in one study from countries of Latin America [7]. On another hand, cefotaxime and metronidazole were the most common antibiotics used in public hospitals compared to ceftriaxone in private hospitals in Botswana [12]. In addition, the use of antibiotics among surgical patients was compared to 71% in a study from Ghana [16]compared to 24% in a study from Turkey [10]. Thus, there is variable usage of different antimicrobial therapy in the different studies reflecting the pattern of antimicrobial usage. It had been suggested that point prevalence studies may correlate with monthly DDDs [17]. We did not specifically assess the correlation between usage of antibiotics and the monthly DDD in this study. However, we previously shown that the DDD/100 patient-days for variable antimicrobials were as follow: ciprofloxacin (parenteral) 82.6, cefazolin 6.2, imipenem-enzyme inhibitor 5.2, and vancomycin 2.97 [18]. And we had shown that there was a discordant findings of DDD compared to DOT, and DDD/100 bed-days compared to DOT/100 bed-days [19]. In a study of community acquired pneumonia in Saudi Arabia, there was variable use of empiric antimicrobial agents [20]. This phenomena is not limited to any geographic location and many strategies were proposed to curtail antimicrobial resistance [21]. One component of antimicrobial stewardship is intravenous-to-oral conversion (IV to PO). Of the patients receiving an antibiotic that could be given orally, only 41.4% received oral therapy indicating the potential for IV-to-PO switch. IV to PO switch includes sequential conversion, IV-to-PO switch, and step-down therapy [22]. In the current study, the majority of patients were on parenteral antibiotics. Similarly, in previous studies parenteral antibiotic use was 31-80% [2,23]. In one study, 17.5-53.8% of patients on IV antimicrobials were felt to be inappropriate [24]. And another study showed 46% of IV fluoroquinolone-days to be inappropriate [25]. One study showed slight improvements in the oral administration of fluoroquinolone 60.6% to 65.3% 6
before and after an intervention, respectively [26]. We found that many of the patients who are on IV therapy are receiving an antibiotic with the potential for IV-to-PO switch such indicating an area of importance to target for antimicrobial stewardship. There are few concerns among prescribers regarding this strategy [27]. This switch is considered a low hanging fruit for antimicrobial stewardship [25]. However, the main reason for this switch is probably related to the cost of antimicrobial agents rather than the increase in antimicrobial resistance. In conclusion, we showed that 40% were receiving antimicrobial therapy.
Continued
surveillance is needed to monitor antimicrobial utilization and to correlate the data with the development of resistance in order to enhance antimicrobial stewardship program [28]. It had been suggested that continued auditing and feedback improves the process of stewardship programs [29,30].
Further improvements in antimicrobial stewardship should include
intravenous to oral switch, evaluating the need for combination therapy, restrictions, education and putting appropriate use guidelines. In addition, a much more detailed rationale for antibiotic stewardship should include evidence supporting the benefits of stewardship, and suggestions on alternative practices for clinicians.
7
References: [1]
Davies J, Davies D. Origins and evolution of antibiotic resistance. Microbiol Mol Biol Rev 2010;74:417–33. doi:10.1128/MMBR.00016-10.
[2]
Najmi A, Sadasivam B, Jhaj R, Atal S, Kumar S, Santenna C. A pilot point prevalence study of antimicrobial drugs in indoor patients of a teaching hospital in Central India. J Fam Med Prim Care 2019;8:2212. doi:10.4103/jfmpc.jfmpc_430_19.
[3]
Schuts EC, Hulscher MEJL, Mouton JW, Verduin CM, Stuart JWTC, Overdiek HWPM, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016;16:847–56. doi:10.1016/S14733099(16)00065-7.
[4]
Al Matar M, Enani M, Binsaleh G, Roushdy H, Alokaili D, Al Bannai A, et al. Point prevalence survey of antibiotic use in 26 Saudi hospitals in 2016. J Infect Public Health 2019;12:77–82. doi:10.1016/j.jiph.2018.09.003.
[5]
Al-Tawfiq JA, Alawami AH. A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic. Ann Thorac Med 2017;12:51–4. doi:10.4103/18171737.197779.
[6]
Talaat M, Saied T, Kandeel A, El-Ata G, El-Kholy A, Hafez S, et al. A Point Prevalence Survey of Antibiotic Use in 18 Hospitals in Egypt. Antibiotics 2014;3:450–60. 8
doi:10.3390/antibiotics3030450. [7]
Huerta-Gutiérrez R, Braga L, Camacho-Ortiz A, Díaz-Ponce H, García-Mollinedo L, Guzmán-Blanco M, et al. One-Day Point Prevalence of Healthcare-Associated Infections and Antimicrobial Use in four Countries of Latin America. Int J Infect Dis 2019;86:157– 66. doi:10.1016/j.ijid.2019.06.016.
[8]
Luthander J, Bennet R, Nilsson A, Eriksson M. Antimicrobial Use in a Swedish Pediatric Hospital: Results From Eight Point-prevalence Surveys Over a 15-Year Period (20032017). Pediatr Infect Dis J 2019;38:929–33. doi:10.1097/INF.0000000000002393.
[9]
Ciofi Degli Atti ML, D’Amore C, Ceradini J, Paolini V, Ciliento G, Chessa G, et al. Prevalence of antibiotic use in a tertiary care hospital in Italy, 2008-2016. Ital J Pediatr 2019;45:63. doi:10.1186/s13052-019-0645-7.
[10]
Guclu E, Ogutlu A, Karabay O, Demirdal T, Erayman I, Hosoglu S, et al. Antibiotic consumption in Turkish hospitals; a multi-centre point prevalence study. J Chemother 2017;29:19–24. doi:10.1080/1120009X.2016.1156893.
[11]
Singh SK, Sengupta S, Antony R, Bhattacharya S, Mukhopadhyay C, Ramasubramanian V, et al. Variations in antibiotic use across India: multi-centre study through Global Point Prevalence survey. J Hosp Infect 2019. doi:10.1016/j.jhin.2019.05.014.
[12]
Anand Paramadhas BD, Tiroyakgosi C, Mpinda-Joseph P, Morokotso M, Matome M, Sinkala F, et al. Point prevalence study of antimicrobial use among hospitals across Botswana; findings and implications. Expert Rev Anti Infect Ther 2019;17:535–46. doi:10.1080/14787210.2019.1629288.
9
[13]
Krasniqi S, Versporten A, Jakupi A, Raka D, Daci A, Krasniqi V, et al. Antibiotic utilisation in adult and children patients in Kosovo hospitals. Eur J Hosp Pharm 2019;26:146–51. doi:10.1136/ejhpharm-2017-001363.
[14]
Al-Tawfiq JA. Incidence and epidemiology of methicillin-resistant Staphylococcus aureus infection in a Saudi Arabian Hospital, 1999-2003. Infect Control Hosp Epidemiol 2006;27:1137–9.
[15]
Nazeer A, Al-Tawfiq JA. Methicillin-resistant Staphylococcus aureus metrics for patients in Saudi Arabia. J Infect Dev Ctries 2012;6.
[16]
Bediako-Bowan AAA, Owusu E, Labi A-K, Obeng-Nkrumah N, Sunkwa-Mills G, Bjerrum S, et al. Antibiotic use in surgical units of selected hospitals in Ghana: a multicentre point prevalence survey. BMC Public Health 2019;19:797. doi:10.1186/s12889019-7162-x.
[17]
Lee SB, Thirion DJG, Irfan N, Sung M, Brooks A, Al-Mutawa F, et al. Antimicrobial utilization data: Does point prevalence data correlate with defined daily doses? Infect Control Hosp Epidemiol 2019;40:920–1. doi:10.1017/ice.2019.154.
[18]
Al-Tawfiq JA. Changes in the pattern of hospital intravenous antimicrobial use in Saudi Arabia, 2006-2008. Ann Saudi Med 2012;32:517–20.
[19]
Momattin H, Al-Ali AY, Mohammed K, Al-Tawfiq JA. Benchmarking of antibiotic usage: An adjustment to reflect antibiotic stewardship program outcome in a hospital in Saudi Arabia. J Infect Public Health 2018;11:310–3. doi:10.1016/j.jiph.2017.08.008.
[20]
Al-Tawfiq JA, Momattin H, Hinedi K. Empiric Antibiotic Therapy in the Treatment of
10
Community-acquired Pneumonia in a General Hospital in Saudi Arabia. J Glob Infect Dis 2019;11:69–72. doi:10.4103/jgid.jgid_84_18. [21]
Al-Tawfiq JA, Stephens G, Memish ZA. Inappropriate antimicrobial use and potential solutions: a Middle Eastern perspective. Expert Rev Anti Infect Ther 2010;8:765–74. doi:10.1586/eri.10.56.
[22]
Shrayteh ZM, Rahal MK, Malaeb DN. Practice of switch from intravenous to oral antibiotics. Springerplus 2014;3:717. doi:10.1186/2193-1801-3-717.
[23]
de With K, Allerberger F, Amann S, Apfalter P, Brodt H-R, Eckmanns T, et al. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2016;44:395–439. doi:10.1007/s15010-016-0885-z.
[24]
Buyle FM, Metz-Gercek S, Mechtler R, Kern W V, Robays H, Vogelaers D, et al. Prospective multicentre feasibility study of a quality of care indicator for intravenous to oral switch therapy with highly bioavailable antibiotics. J Antimicrob Chemother 2012;67:2043–6. doi:10.1093/jac/dks145.
[25]
Jones M, Huttner B, Madaras-Kelly K, Nechodom K, Nielson C, Bidwell Goetz M, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs? Infect Control Hosp Epidemiol 2012;33:362–7. doi:10.1086/664767.
[26]
Thompson C, Zahradnik M, Brown A, Gina Fleming D, Law M. The use of an IV to PO clinical intervention form to improve antibiotic administration in a community based hospital. BMJ Qual Improv Reports 2015;4:u200786.w2247. doi:10.1136/bmjquality.u200786.w2247. 11
[27]
Béïque L, Zvonar R. Addressing Concerns about Changing the Route of Antimicrobial Administration from Intravenous to Oral in Adult Inpatients. Can J Hosp Pharm 2015;68:318–26. doi:10.4212/cjhp.v68i4.1472.
[28]
MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005;18:638–56. doi:10.1128/CMR.18.4.638-656.2005.
[29]
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016:ciw118. doi:10.1093/cid/ciw118.
[30]
Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017;2:CD003543. doi:10.1002/14651858.CD003543.pub4.
12
Table 1: Number of antibiotics per specified period First point-prevalence Second point-prevalence Combined points No antibiotics
143 (59)
146 (59)
289 (59)
One antibiotic
65 (26.8)
79 (32)
144 (29.4)
29 (12)
20 (8)
49 (10)
5 (2)
2 (0.8)
7 (1.4)
242
247
489
Two antibiotics Three antibiotics Total
13
Figure 1: A bar graph showing the percentage of commonly used antimicrobial agents
CIPROFloxacin ampicillin, cefoTAXIME MEROpenem, levo vancomycin piperacillin-tazobactam levoFLOXACIN cefTRIAXone ceFAZolin MEROpenem 0
2
4
6
8
14
10
12
14
16
18
20
15
S1477-8939(20)30072-7
DOI:
https://doi.org/10.1016/j.tmaid.2020.101605
Reference:
TMAID 101605
To appear in:
Travel Medicine and Infectious Disease
Received Date: 21 October 2019 Revised Date:
19 February 2020
Accepted Date: 22 February 2020
Please cite this article as: Al-Tawfiq JA, Al-Homoud AH, Pattern of systemic antibiotic use among hospitalized patients in a general hospital in Saudi Arabia, Travel Medicine and Infectious Disease (2020), doi: https://doi.org/10.1016/j.tmaid.2020.101605. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
CRediT author statement
JAT: conceptual design, data analysis, drafted the first manuscript
AH: collected the data, wrote the methods
Both authors finalized the manuscript
Pattern of Systemic Antibiotic Use among Hospitalized Patients in a General Hospital in Saudi Arabia Jaffar A. Al-Tawfiq 1,2,3* and Ali H. Al-Homoud4
1
Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare,
Dhahran, Saudi Arabia, 2Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; 3Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 4Pharmacy Services Division, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
Dr. Jaffar A. Al-Tawfiq* P.O. Box 76; Room A-428-2, Building 61, Dhahran Health Center, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia. E-mail address: [email protected]; [email protected] Tel: +966-13-870-3524; Fax: +966-13-870-3790
All authors have no conflicts of interest Key words: Point Prevalence Study; antimicrobial audit; antimicrobial stewardship; antibiotics
1
Abstract: Background: The emergence of antimicrobial resistance of many bacteria is a significant drawback of antimicrobial use. A key measure to assess antimicrobial use is point prevalence study. Methods: This is a point prevalence study of all hospitalized patients at Johns Hopkins Aramco Healthcare, a 350-bed hospital, and was conducted at two-points from January 2017 to January 2019. We recorded systemic antibiotics and the indications for the use as prophylactic, empiric, and definite therapy. Result: Of the 489 hospitalized patients whom were included, 200 (40%) were on systemic antibiotics. Of the total antibiotics, 72% were empiric, 17 (8.5) were on prophylactic antibiotics, and 17.5% were definite therapy, according to hospital guidelines.
Most commonly used
antibiotics were meropenem (18%), cefazolin (10%), and ceftriaxone (8%).
Of included
patients, 29.4% were on a single antibiotic, 10% on two antibiotics, and 1.4% were on three antibiotics. Of patients receiving an antibiotic that could be given orally, only 41.4% received oral therapy. Conclusion: A large percentage of patients were on empiric antimicrobial therapy and areas for further improvements in antimicrobial stewardship includes intravenous to oral switch, evaluating the need for combination therapy, restrictions, education and putting appropriate use guidelines.
2
Introduction: We are facing an increased rate of antimicrobial resistance of many bacteria and this increase is not associated with a parallel increase in the development of new antibi microbial agents. There is a continued selective pressure of antimicrobial agents due to prolonged and inappropriate use [1]. Overuse of antimicrobial agents is associated with increased resistance globally. There is a global trend of increasing antimicrobial resistance in Gram positive and Gram-negative organisms. In the Middle East, surveillance studies indicated increased antimicrobial resistance mainly among Gram-negative bacilli. One such strategy is antibiotic stewardship and the ability to have a measurement of antibiotic usage such as the point prevalence of antibiotic usage. In order to improve a process, it is important to measure the process to further enhance the capacity of the process. Absence or incomplete data about the utilization pattern of antimicrobial usage is considered a barrier to the positive progress and execution of an effective antimicrobial stewardship program [2]. In addition, auditing antimicrobial use further augment other elements of antimicrobial stewardship programs [3].
There are limited studies from Saudi Arabia
regarding point prevalence and utilization of antibiotics. In the Kingdom of Saudi Arabia, one study evaluated point prevalence in a number of hospitals [4]. Another study evaluated antibiotic prescribing pattern among outpatient patients, and systemic antimicrobial agents among hospitalized patients, and evaluated defined daily dose of carbapenems [5]. Here, we present a point prevalence study to measure the pattern of use of antibiotics based on indications and compare the findings to those already published. Materials and Methods:
3
This is a point prevalence study of all hospitalized patients at Johns Hopkins Aramco Healthcare (JHAH) which is a 350-bed hospital. The study utilized a point-prevalence study and was conducted at two-points from January 2017 to January 2019, these were designated as . We reviewed all hospitalized patients and recorded the antibiotics being used. Data were gathered by reviewing the patients’ case notes, microbiology laboratory results and medication charts. We recorded the service as medical, surgical or critical care unit. The indication for antibiotic therapy was classified as prophylactic, empiric, or definite therapy. Patients undergoing same day treatment, surgery or endoscopy were excluded. We conducted a second review after three months. The study was approved by the Institutional Review Board in our institution. Results: During the study periods, we performed two point-prevalence study three months apart. There were 489 hospitalized patients and of those 200 (40%) were on systemic antibiotics (Table 1). We excluded three patients who were on therapy for tuberculosis (1 and 2 in the first and second review, respectively). There was no difference on the use of antibiotics between the two study periods. Of the total patients on antibiotics, 72% were on empiric therapy, 17 (8.5) were on prophylactic antibiotics, and 17.5% were on definite therapy, according to hospital guidelines and there was no difference between the study periods. Of all included patients, 29.4% were on a single antibiotic, 10% on two antibiotics, and 1.4% were on three antibiotics (Table 1). Thus, combination therapy was used for 11.4% of all patients representing 28% of patients who were on antimicrobial therapy. The top ten used antimicrobial therapy is shown in figure 1 and the most commonly used antibiotics were meropenem (18%), cefazolin (10%), and ceftriaxone (8%) (Figure 1).
The most commonly used antibiotics per category were: cefazolin (70%) for
prophylaxis, meropenem (21%) for empiric therapy, and vancomycin (15%) for definitive 4
therapy. Of the patients receiving an antibiotic that could be given orally, only 41.4% received oral therapy.
The percentage of patients who received antibiotics was 50% for intensive care
units, 37.2% for medical units, 38.5% for surgical units and 57% for pediatric wards. Discussion: During the study period, 40% of the patients were on systemic antibiotics. Similarly, a point prevalence study in 8 hospitals in Egypt showed that the prevalence of antibiotic use was 32.9%– 91.7% [6]. In a study from Brazil, Venezuela, Mexico, and Colombia, about 50% (47-63%) were on one or more antimicrobial agent [7]. In a study from Swedish Pediatric hospitals, 36% of children were on antimicrobial therapy [8] and 50% of surveyed children in Italy were on antimicrobial therapy [9]. In a study from Turkey, antibiotic use was recorded among 44% of patients [10]. The percentage of patients on antibiotics was 57% among 1750 patients in India [11] and 70.6% of 711 surveyed patients in Botswana were receiving antimicrobial therapy [12]. In a study from Kosovo, 43% of adults and 58% of pediatric patients received at least one antibiotic during hospital stay [13]. Another study from India sowed 32% were on antimicrobial therapy [2]. We found that vancomycin use was in 15% of patients on definitive antimicrobial therapy. It is important to note that the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in our hospital was 6% of all S. aureus isolates [14]. And that the prevalence of MRSA in Saudi Arabia ranges from 15% to 58% [15]. Thus, this prevalence of MRSA may explain the use of vancomycin. We found that 11.4% of all surveyed patients were on a combination therapy compared to 28.4% in a study from Egypt [6]. In that study, 61% of antibiotics were used as a prophylaxis compared
5
to 8.5% in our hospital. Carbapenems use was 12-16% in one study from countries of Latin America [7]. On another hand, cefotaxime and metronidazole were the most common antibiotics used in public hospitals compared to ceftriaxone in private hospitals in Botswana [12]. In addition, the use of antibiotics among surgical patients was compared to 71% in a study from Ghana [16]compared to 24% in a study from Turkey [10]. Thus, there is variable usage of different antimicrobial therapy in the different studies reflecting the pattern of antimicrobial usage. It had been suggested that point prevalence studies may correlate with monthly DDDs [17]. We did not specifically assess the correlation between usage of antibiotics and the monthly DDD in this study. However, we previously shown that the DDD/100 patient-days for variable antimicrobials were as follow: ciprofloxacin (parenteral) 82.6, cefazolin 6.2, imipenem-enzyme inhibitor 5.2, and vancomycin 2.97 [18]. And we had shown that there was a discordant findings of DDD compared to DOT, and DDD/100 bed-days compared to DOT/100 bed-days [19]. In a study of community acquired pneumonia in Saudi Arabia, there was variable use of empiric antimicrobial agents [20]. This phenomena is not limited to any geographic location and many strategies were proposed to curtail antimicrobial resistance [21]. One component of antimicrobial stewardship is intravenous-to-oral conversion (IV to PO). Of the patients receiving an antibiotic that could be given orally, only 41.4% received oral therapy indicating the potential for IV-to-PO switch. IV to PO switch includes sequential conversion, IV-to-PO switch, and step-down therapy [22]. In the current study, the majority of patients were on parenteral antibiotics. Similarly, in previous studies parenteral antibiotic use was 31-80% [2,23]. In one study, 17.5-53.8% of patients on IV antimicrobials were felt to be inappropriate [24]. And another study showed 46% of IV fluoroquinolone-days to be inappropriate [25]. One study showed slight improvements in the oral administration of fluoroquinolone 60.6% to 65.3% 6
before and after an intervention, respectively [26]. We found that many of the patients who are on IV therapy are receiving an antibiotic with the potential for IV-to-PO switch such indicating an area of importance to target for antimicrobial stewardship. There are few concerns among prescribers regarding this strategy [27]. This switch is considered a low hanging fruit for antimicrobial stewardship [25]. However, the main reason for this switch is probably related to the cost of antimicrobial agents rather than the increase in antimicrobial resistance. In conclusion, we showed that 40% were receiving antimicrobial therapy.
Continued
surveillance is needed to monitor antimicrobial utilization and to correlate the data with the development of resistance in order to enhance antimicrobial stewardship program [28]. It had been suggested that continued auditing and feedback improves the process of stewardship programs [29,30].
Further improvements in antimicrobial stewardship should include
intravenous to oral switch, evaluating the need for combination therapy, restrictions, education and putting appropriate use guidelines. In addition, a much more detailed rationale for antibiotic stewardship should include evidence supporting the benefits of stewardship, and suggestions on alternative practices for clinicians.
7
References: [1]
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Table 1: Number of antibiotics per specified period First point-prevalence Second point-prevalence Combined points No antibiotics
143 (59)
146 (59)
289 (59)
One antibiotic
65 (26.8)
79 (32)
144 (29.4)
29 (12)
20 (8)
49 (10)
5 (2)
2 (0.8)
7 (1.4)
242
247
489
Two antibiotics Three antibiotics Total
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Figure 1: A bar graph showing the percentage of commonly used antimicrobial agents
CIPROFloxacin ampicillin, cefoTAXIME MEROpenem, levo vancomycin piperacillin-tazobactam levoFLOXACIN cefTRIAXone ceFAZolin MEROpenem 0
2
4
6
8
14
10
12
14
16
18
20
15