Antimicrobial stewardship program in China’s tertiary hospitals in 2018: a nationwide cross-sectional online survey

doi:10.5246/jcps.2021.12.086

Abstract

Abstract:

In the present study, we aimed to assess the development of the antimicrobial stewardship (AMS) program in China’s tertiary hospitals to identify the potential challenges for the AMS program and provide references and benchmarks for strategic policymaking. A nationwide cross-sectional study was conducted online by sending questionnaires to tertiary hospitals under China Antimicrobial Resistance Surveillance System (CARSS). The questionnaire included 5 sections regarding structure, technical support, antimicrobial use management, antimicrobial use surveillance, and education. Descriptive statistics were used for data analysis. Of the 1044 tertiary hospitals under CARSS, 13.4% (140) hospitals participated in the study. Among them, 99.3% (139/140) set up the AMS program. The hospital president (82.1%, 115/140) and medical service department (59.3%, 83/140) were responsible for AMS outcomes in most hospitals. Structured antimicrobial formulary restriction management was adopted by 99.3% (139/140) hospitals. Infectious disease department, infection control department, and microbiological laboratories were established in 87.1% (122/140), 99.3% (139/140) and 100% (140/140) hospitals, respectively. Up to 85.6% (124/140) hospitals applied clinical pathways, and 33.6% (47/140) hospitals implemented hospital-specific guidelines for infectious diseases. Outpatient prescription auditing, inpatient prescription auditing, and prophylactic antimicrobial prescription auditing of aseptic operation were performed in 99.3% (139/140), 98.6% (138/140) and 95.7% (134/140) hospitals, respectively. Up to 97.1% (136/140) hospitals participated in antimicrobial use surveillance network, and 99.3% (139/140) hospitals established the specialized management of carbapenem and tigecycline. Staff education and public education were provided with various ways and frequencies in 100% (140/140) and 90.0% (126/140) hospitals, respectively. AMS programs in China’s tertiary hospitals were primarily headed by hospital presidents and involved collaboration among various disciplines and administrative departments. More efforts should be put to further promote and strengthen the development of hospital-specific guidelines and the establishment of a progress and outcome evaluation system.

Key words: Antimicrobial stewardship, Antimicrobial resistance, Tertiary hospitals, China, Cross-sectional online survey

Supporting:

Yue Zhou, Haishaerjiang Wushouer, Xi Zhang, Jiajia Feng, Likai Lin, Bo Zheng, Xiaodong Guan, Luwen Shi. Antimicrobial stewardship program in China’s tertiary hospitals in 2018: a nationwide cross-sectional online survey[J]. Journal of Chinese Pharmaceutical Sciences, 2021, 30(12): 994-1007.

Figures/Tables 6

Table 1. Structure of AMS program.

Table 2. Technical support of AMS program.

Table 3. Antimicrobial use management of AMS program.

Table 4. Antimicrobial use surveillance of AMS program.

Table 5. Education of AMS program.

References 42

[1]	Spellberg, B.; Bartlett, J.G.; Gilbert, D.N. The future of antibiotics and resistance. N. Engl. J. Med. 2013, 368, 299–302.
[2]	World Health Organization. Antimicrobial resistance: global report on surveillance 2014. This article can be found online at https://www.who.int/drugresistance/documents/surveillancereport/en/.
[3]	AMR Review. Tackling a crisis for the health and wealth of nations. This article can be found online at https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the% 20health%20and%20wealth%20of%20nations_1.pdf.
[4]	Schuts, E.C.; Hulscher, M.E.J.L.; Mouton, J.W.; Verduin, C.M.; Stuart, J.W.T.C.; Overdiek, H.W.P.M.; van der Linden, P.D.; Natsch, S.; Hertogh, C.M.P.M.; Wolfs, T.F.W.; Schouten, J.A.; Kullberg, B.J.; Prins, J.M. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect. Dis. 2016, 16, 847–856.
[5]	Davey, P.; Marwick, C.A.; Scott, C.L.; Charani, E.; McNeil, K.; Brown, E.; Gould M.; Ramsay, C.R.; Michie, S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane. Database. Syst. Rev. 2017. This article can be found online at http://doi.wiley.com/10.1002/14651858.CD003543.pub4.
[6]	Barlam, T.F.; Cosgrove, S.E.; Abbo, L.M.; MacDougall, C.; Schuetz, A.N.; Septimus, E.J.; Srinivasan, A.; Dellit, T.H.; Falck-Ytter, Y.T.; Fishman, N.O.; Hamilton, C.W.; Jenkins, T.C.; Lipsett, P.A.; Malani, P.N.; May, L.S.; Moran, G.J.; Neuhauser, M.M.; Newland, J.G.; Ohl, C.A.; Samore, M.H.; Seo, S.K.; Trivedi, K.K. 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, 62, e51–e77.
[7]	Society for Healthcare Epidemiology of America, America, I.D.S.O.; Society, P.I.D. Policy statement on antimicrobial stewardship by the society for healthcare epidemiology of America (SHEA), the infectious diseases society of America (IDSA), and the pediatric infectious diseases society (PIDS). Infect. Control. Hosp. Epidemiol. 2012, 33, 322–327.
[8]	Pollack, L.A.; Srinivasan, A. Core elements of hospital antibiotic stewardship programs from the centers for disease control and prevention. Clin. Infect. Dis. 2014, 59, S97–S100.
[9]	Pollack, L.A.; Plachouras, D.; Gruhler, H.; Sinkowitz-Cochran R. Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) Summary the modified Delphi process for common structure and process indicators for hospital antimicrobial stewardship programs. 2015. This article can be found online at https://www.cdc.gov/drugresistance/pdf/summary_of_tatfar_recommendation_1.pdf.
[10]	Xiao, Y.H. Antimicrobial stewardship in China: systems, actions and future strategies. Clin. Infect. Dis. 2018, 67, S135–S141.
[11]	Guiding Principles of Clinical Application of Antibiotics. 2015. This article can be found online at http://www.gov.cn/xinwen/2015-08/27/content_2920799.htm.
[12]	National Action Plan to Contain Antimicrobial Resistance (2016-2020). 2016. This article can be found online at http://www.gov.cn/xinwen/2016-08/25/content_5102348.htm.
[13]	Regulations for Antimicrobials Clinical Use. 2012. This article can be found online at http://www.gov.cn/flfg/2012-05/08/content_2132174.htm.
[14]	Graber, C.J.; Jones, M.M.; Chou, A.F.; Zhang, Y.; Goetz, M.B.; Madaras-Kelly, K.; Samore, M.H.; Glassman, P.A. Association of inpatient antimicrobial utilization measures with antimicrobial stewardship activities and facility characteristics of veterans affairs medical centers. J. Hosp. Med. 2017, 12, 301–309.
[15]	Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use-Guidance-NICE. This article can be found online at https://www.nice.org.uk/ guidance/ng15.
[16]	CARSS. This article can be found online at http://www.carss.cn/.
[17]	National Health and Family Planning Commission of People’s Republic of China. China Health Statistics Yearbook. Beijing: Peking Union Medical College Press; 2019.
[18]	Kamel, C.; McGahan, L.; Mierzwinski-Urban, M.; Embil, J. Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections: A Systematic Review of the Clinical Evidence and Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. 2011. This article can be found online at http://www.ncbi.nlm.nih.gov/books/NBK174549/.
[19]	Notification on further strengthening the management of antimicrobial use and antimicrobial resistance confinement. This article can be found online at http://www.nhc.gov.cn/yzygj/s7659/201703/d2f580480cef4ab1b976542b550f36cf. shtml.
[20]	Nhan, D.; Lentz, E.J.M.; Steinberg, M.; Bell, C.M.; Morris, A.M. Structure of antimicrobial stewardship programs in leading US hospitals: findings of a nationwide survey. Open Forum Infect. Dis. 2019, 6, ofz104.
[21]	Kallen, M.C.; Ten Oever, J.; Prins, J.M.; Kullberg, B.J.; Schouten, J.A.; Hulscher, M.E.J.L. A survey on antimicrobial stewardship prerequisites, objectives and improvement strategies: systematic development and nationwide assessment in Dutch acute care hospitals. J. Antimicrob. Chemother. 2018, 73, 3496–3504.
[22]	Howard, P.; Pulcini, C.; Levy Hara, G.; West, R.M.; Gould, I.M.; Harbarth, S.; Nathwani, D.; ESCMID Study Group for Antimicrobial Policies (ESGAP), ISC Group on Antimicrobial Stewardship An international cross-sectional survey of antimicrobial stewardship programmes in hospitals. J. Antimicrob. Chemother. 2015, 70, 1245–1255.
[23]	Livorsi, D.J.; Heintz, B.; Jacob, J.T.; Krein, S.L.; Morgan, D.J.; Perencevich, E.N. Audit and feedback processes among antimicrobial stewardship programs: a survey of the society for healthcare epidemiology of America research network. Infect. Control. Hosp. Epidemiol. 2016, 37, 704–706.
[24]	Doron, S.; Nadkarni, L.; Lyn Price, L.; Kenneth Lawrence, P.; Davidson, L.E.; Evans, J.; Garber, C.; Snydman, D.R. A nationwide survey of antimicrobial stewardship practices. Clin. Ther. 2013, 35, 758–765.e20.
[25]	Pedersen, C.A.; Schneider, P.J.; Santell, J.P. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing: 2001. Am. J. Health. Syst. Pharm. 2001, 58, 2251–2266.
[26]	Weier, N.M.; Tebano, G.; Thilly, N.; Demoré, B.; Pulcini, C.; Zaidi, S.T.R. Pharmacist participation in antimicrobial stewardship in Australian and French hospitals: a cross-sectional nationwide survey. J. Antimicrob. Chemother. 2018, 73, 804–813.
[27]	MacDougall, C.; Polk, R.E. Antimicrobial stewardship programs in health care systems. Clin. Microbiol. Rev. 2005, 18, 638–656.
[28]	Paskovaty, A.; Pflomm, J.M.; Myke, N.; Seo, S.K. A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century. Int. J. Antimicrob. Agents. 2005, 25, 1–10.
[29]	Zhou, J.; Ma, X. A survey on antimicrobial stewardship in 116 tertiary hospitals in China. Clin. Microbiol. Infect. 2019, 25, 759. e9–759.e14.
[30]	Guiding Principles of Clinical Pathway (Polit). This article can be found online at http://www.gov.cn/gzdt/2009-10/16/content_1441548.htm.
[31]	Clinical pathway of diseases (2019). This article can be found online at http://www.nhc.gov.cn/yzygj/s7659/202001/b3c9e097b0c1471a969d7a63be471759.shtml.
[32]	Carratalà, J.; Garcia-Vidal, C.; Ortega, L.; Fernández-Sabé, N.; Clemente, M.; Albero, G.; López, M.; Castellsagué, X.; Dorca, J.; Verdaguer, R.; Martínez-Montauti, J.; Manresa, F.; Gudiol, F. Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: a randomized controlled trial. Arch. Intern. Med. 2012, 172, 922–928.
[33]	Hauck, L.D.; Adler, L.M.; Mulla, Z.D. Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann. Epidemiol. 2004, 14, 669–675.
[34]	Marrie, T.J. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. JAMA. 2000, 283, 749.
[35]	Newman, R.E.; Hedican, E.B.; Herigon, J.C.; Williams, D.D.; Williams, A.R.; Newland, J.G. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012, 129, e597–e604.
[36]	Dellit, T.H.; Chan, J.D.; Skerrett, S.J.; Nathens, A.B. Development of a guideline for the management of ventilator-associated pneumonia based on local microbiologic findings and impact of the guideline on antimicrobial use practices. Infect. Control. Hosp. Epidemiol. 2008, 29, 525–533.
[37]	Ibrahim, E.H.; Ward, S.; Sherman, G.; Schaiff, R.; Fraser, V.J.; Kollef, M.H. Experience with a clinical guideline for the treatment of ventilator-associated pneumonia. Crit. Care Med. 2001, 29, 1109–1115.
[38]	Jenkins, T.C.; Knepper, B.C.; Sabel, A.L.; Sarcone, E.E.; Long, J.A.; Haukoos, J.S.; Morgan, S.J.; Biffl, W.L.; Steele, A.W.; Price, C.S.; Mehler, P.S.; Burman, W.J. Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess. Arch Intern. Med. 2011, 171, 1072–1079.
[39]	Pollack, L.A.; van Santen, K.L.; Weiner, L.M.; Dudeck, M.A.; Edwards, J.R.; Srinivasan, A. Antibiotic stewardship programs in US acute care hospitals: findings from the 2014 national healthcare safety network annual hospital survey. Clin. Infect. Dis. 2016, 63, 443–449.
[40]	Vlahović-Palčevski, V.; Dumpis, U.; Mitt, P.; Gulbinovič, J.; Struwe, J.; Palčevski, G.; Štimac, D.; Lagergren, Å.; Bergman, U. Benchmarking antimicrobial drug use at university hospitals in five European countries. Clin. Microbiol. Infect. 2007, 13, 277–283.
[41]	Polk, R.E.; Fox, C.; Mahoney, A.; Letcavage, J.; MacDougall, C. Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin. Infect. Dis. 2007, 44, 664–670.
[42]	Elseviers, M.; Wettermark, B.; Almarsdóttir, A.B.; Andersen, M.; Benko, R.; Bennie, M.; Eriksson, I.; Godman, B.; Krska, J.; Poluzzi, E.; Taxis, K.; Vlahović-Palčevski, V.; Stichele, R.V. Drug utilization research [M]. Chichester, UK: John Wiley & Sons, Ltd, 2016.