In 2008, the Scottish Antimicrobial Prescribing Group (SAPG) was established to coordinate a national antimicrobial stewardship programme. In 2009 SAPG led participation in a European point prevalence survey (PPS) of hospital antibiotic use. We describe how SAPG used this baseline PPS as the foundation for implementation of measures for improvement in antibiotic prescribing.
In 2009 data for the baseline PPS were collected in accordance with the European Surveillance of Antimicrobial Consumption [ESAC] protocol. This informed the development of two quality prescribing indicators: compliance with antibiotic policy in acute admission units and duration of surgical prophylaxis. From December 2009 clinicians collected these data on a monthly basis. The prescribing indicators were reviewed and further modified in March 2011. Data for the follow up PPS in September 2011 were collected as part of a national PPS of healthcare associated infection and antimicrobial use developed using ECDC protocols.
In the baseline PPS data were collected in 22 (56%) acute hospitals. The frequency of recording the reason for treatment in medical notes was similar in Scotland (75.9%) and Europe (75.7%). Compliance with policy (81.0%) was also similar to Europe (82.5%) but duration of surgical prophylaxis <24hr (68.6%), was higher than in Europe (48.1%, OR: 0.41, p<0.001). Following the development and implementation of the prescribing indicators monthly measurement and data feedback in admission units illustrated improvement in indication documented of ≥90% and compliance with antibiotic prescribing policy increasing from 76% to 90%. The initial prescribing indicator in surgical prophylaxis was less successful in providing consistent national data as there was local discretion on which procedures to include. Following a review and a focus on colorectal surgery the mean proportion receiving single dose prophylaxis exceeded the target of 95% and the mean proportion compliant with policy was 83%. In the follow up PPS of 2011 indication documented (86.8%) and policy compliant (82.8%) were higher than in baseline PPS.
The baseline PPS identified priorities for quality improvement. SAPG has demonstrated that implementation of regularly reviewed national prescribing indicators, acceptable to clinicians, implemented through regular systematic measurement can drive improvement in quality of antibiotic use in key clinical areas. However, our data also show that the ESAC PPS method may underestimate the proportion of surgical prophylaxis with duration <24hr.
Antimicrobial stewardship; Quality improvement; Prescribing indicators; Point prevalence survey; Antibiotic; Hospital prescribing; Surgical prophylaxis
Cancer mortality data reflect disease incidence and the effectiveness of treatment. Incidence data, however, reflect the burden of disease in the population and indicate the need for prevention measures, diagnostic services and cancer treatment facilities. Monitoring of targets mandates that both be considered. The Scottish Cancer Target, established in 1991, proposed that a reduction of 15% in mortality from cancer in the under-65s should be achieved between 1986 and 2000. Each year in Scotland approximately 8300 persons under 65 are diagnosed with cancer and 4500 die from the disease. The most common malignancies, in terms of both incident cases and deaths, in the under-65s, are lung and large bowel cancer in males, and breast, large bowel and lung cancer in females. A decrease of 6% in the number of cancer cases diagnosed in males under 65 is predicted between 1986 and 2000, whereas the number of cases in females in the year 2000 is expected to remain at the 1986 level. In contrast, substantial reductions in mortality are expected for both sexes: 17% and 25% in males and females respectively. Demographic changes will influence the numbers of cancer cases and deaths in the Scottish population in the year 2000. However, long-term trends in the major risk factors, such as smoking, are likely to be the most important determinants of the future cancer burden.
Background: To evaluate how Scotland's smokefree law impacted self-reported secondhand smoke (SHS) exposure in hospitality venues, workplaces and in people's homes. In addition, we examine changes in support for the law, pub and restaurant patronage, smoking cessation indicators and whether any observed changes varied by socioeconomic status. Methods: A quasi-experimental longitudinal telephone survey of nationally representative samples of smokers and non-smokers interviewed before the Scottish law (February to March 2006) and 1 year later after the law (March 2007) in Scotland (n = 705 smokers and n = 417 non-smokers) and the rest of the UK (n = 1027 smokers and n = 447 non-smokers) where smoking in public places was not regulated at the time. Results: Dramatic declines in the observance of smoking in pubs, restaurants and workplaces were found in Scotland relative to the rest of the UK. The change in the percent of smokers reporting a smokefree home and number of cigarettes smoked inside the home in the evening was comparable in Scotland and the rest of the UK. Support for smokefree policies increased to a greater extent in Scotland than in the rest of the UK. Self-reported frequency of going to pubs and restaurants was generally comparable between Scotland and the rest of the UK; however, non-smokers in Scotland were more likely to frequent pubs more often. No differences in smoking cessation indicators were observed between countries. Conclusion: The Scottish smokefree law has been successful in decreasing secondhand smoke exposure while causing none of the hypothesized negative outcomes.
Scotland; smokefree; international tobacco control
The potential contribution nurses can make to the management of antimicrobials within an in-patient setting could impact on the development of antimicrobial resistance (AMR) and healthcare associated infections (HCAIs). Current initiatives promoting prudent antimicrobial prescribing and management have generally failed to include nurses, which subsequently limits the extent to which these strategies can improve patient outcomes. For antimicrobial stewardship (AS) programmes to be successful, a sustained and seamless level of monitoring and decision making in relation to antimicrobial therapy is needed. As nurses have the most consistent presence as patient carer, they are in the ideal position to provide this level of service. However, for nurses to truly impact on AMR and HCAIs through increasing their profile in AS, barriers and facilitators to adopting this enhanced role must be contextualised in the implementation of any initiative.
Antimicrobial drug resistance; nurse; healthcare associated infection; Clostridium difficile
Generation Scotland: the Scottish Family Health Study aims to identify genetic variants accounting for variation in levels of quantitative traits underlying the major common complex diseases (such as cardiovascular disease, cognitive decline, mental illness) in Scotland.
Generation Scotland will recruit a family-based cohort of up to 50,000 individuals (comprising siblings and parent-offspring groups) across Scotland. It will be a six-year programme, beginning in Glasgow and Tayside in the first two years (Phase 1) before extending to other parts of Scotland in the remaining four years (Phase 2). In Phase 1, individuals aged between 35 and 55 years, living in the East and West of Scotland will be invited to participate, along with at least one (and preferably more) siblings and any other first degree relatives aged 18 or over. The total initial sample size will be 15,000 and it is planned that this will increase to 50,000 in Phase 2. All participants will be asked to contribute blood samples from which DNA will be extracted and stored for future investigation. The information from the DNA, along with answers to a life-style and medical history questionnaire, clinical and biochemical measurements taken at the time of donation, and subsequent health developments over the life course (traced through electronic health records) will be stored and used for research purposes. In addition, a detailed public consultation process will begin that will allow respondents' views to shape and develop the study. This is an important aspect to the research, and forms the continuation of a long-term parallel engagement process.
As well as gene identification, the family-based study design will allow measurement of the heritability and familial aggregation of relevant quantitative traits, and the study of how genetic effects may vary by parent-of-origin. Long-term potential outcomes of this research include the targeting of disease prevention and treatment, and the development of screening tools based on the new genetic information. This study approach is complementary to other population-based genetic epidemiology studies, such as UK Biobank, which are established primarily to characterise genes and genetic risk in the population.
We have investigated factors influencing the survival of women with early breast cancer in Scotland. In a retrospective study, clinical, treatment and 'service' factors, e.g. surgical case load, deprivation and geographical area (health board of first treatment) were recorded from hospital records. A total of 2148 women with invasive breast cancer diagnosed in 1987 were identified from the Scottish Cancer Registry, of whom 1619 without metastases at diagnosis underwent surgery as part of their primary treatment. In a multivariate analysis, clinical factors (age, clinical stage, pathological tumour size, node status and oestrogen receptor status) all influenced survival. After allowing for these clinical factors, surgical case load and deprivation did not have statistically significant effects on survival. By contrast, health board did affect survival. This was explained in part by the selection of patients for surgery. There appeared, however, to be a residual effect that may be related to differences in the use of adjuvant systemic treatment among the different health boards. We conclude that, in Scotland, geographical variation in both surgical and non-surgical treatment has a greater effect on variability in survival for women with breast cancer than surgical case load and deprivation.
Details of 1123 patients registered in Scotland between 1983 and 1990 for testicular cancer under the Scottish Cancer Registration Scheme were obtained and compared with registrations within the five Scottish oncology centres. Some registration discrepancies were identified. Twenty-eight cancer registrations (2.5%) were coded to the wrong site, 29 patients seen at oncology centres had no cancer registration and 14 cancer registrations had the wrong histology. Five hundred and twenty-seven patients with testicular non-seminomatous germ cell tumours (NSGCT) and 567 with testicular seminoma were identified. Referral rates to specialist oncology centres for testicular germ cell tumours were measured by period and health board area of residence. For the whole study period 92% of NSGCT and 93% of seminoma patients were referred to specialist centres for treatment. Referral rates for different health board areas of residence were not significantly different. This study shows that within Scotland the majority of patients with testicular NSGCT and seminoma are referred to specialist centres, and suggests referral rates of around 92% are underestimates. Access is not related to area of residence.
The government's proposal to introduce drug budgets will compel general practitioners to consider the financial consequences of prescribing. A survey was carried out of general practitioner principals in Grampian and a sample elsewhere in Scotland to examine their attitudes towards considering costs when prescribing and assess the accuracy of their knowledge of drug costs. Most general practitioners agreed that costs should be borne in mind when choosing medicines but their knowledge of drug costs was often inaccurate. Only one third of estimates were correct to within 25% of the actual cost, and there was a tendency to overstate the cost of cheap drugs and understate the cost of expensive ones. Some general practitioners were not aware of the relative prices of competing products or proprietary products and generic equivalents. The findings highlight the importance of providing general practitioners with readily accessible and up to date information on drug costs if prescribing budgets are to work.
Recurrent Clostridium difficile infection (CDI) is one of the most difficult problems in healthcare infection control. We evaluated the risk factors associated with recurrence in patients with CDI. A retrospective cohort study of 84 patients with CDI from December 2008 through October 2010 was performed at Pusan National University Yangsan Hospital. Recurrence occurred in 13.1% (11/84) of the cases and in-hospital mortality rate was 7.1% (6/84). Stool colonization with vancomycin-resistant enterococci (VRE) (P = 0.006), exposure to more than 3 antibiotics (P = 0.009), low hemoglobin levels (P = 0.025) and continued use of previous antibiotics (P = 0.05) were found to be more frequent in the recurrent group. Multivariate analysis indicated that, stool VRE colonization was independently associated with CDI recurrence (odds ratio, 14.519; 95% confidence interval, 1.157-182.229; P = 0.038). This result suggests that stool VRE colonization is a significant risk factor for CDI recurrence.
Clostridium difficile; Recurrence; Risk factors; VRE
Promoting the appropriate use of antimicrobials is a core value of antimicrobial stewardship. Prospective audit and feedback constitute an effective strategy for reducing the cost and use of antimicrobials, as well as their adverse effects, such as infection with Clostridium difficile.
To evaluate the antimicrobial stewardship program in the intensive care unit at the authors’ hospital, in order to determine the cost and utilization of antimicrobials, as well as the rate of nosocomially acquired C. difficile infection.
An infectious diseases team, consisting of a physician and a pharmacist, performed prospective audit and feedback during a pilot study (April to June 2010). The team met with the intensive care unit team daily to discuss optimization of therapy. The cost and utilization of antimicrobial drugs, as well as rates of C. difficile infection, were compared between the pilot period and the same period during the previous year (April to June 2009). For 3 months after the pilot phase (i.e., July to September 2010), the strategy was continued 3 days per week.
After introduction of the antimicrobial stewardship program, there was a significant reduction in the cost of antimicrobial drugs: $27 917 less than during the same period in the previous year, equivalent to a reduction of $15.45 (36.2%) per patient-day ($42.63 versus $27.18). Utilization of broad-spectrum antipseudomonal antimicrobial agents was also significantly lower, declining from 63.16 to 38.59 defined daily doses (DDDs) per 100 patient-days (reduction of 38.9%). After the pilot period, the rate declined further, to 28.47 DDDs/100 patient-days. During the pilot period, there were no cases of C. difficile infection, and in the post-pilot period, there was 1 case (overall rate 0.42 cases/1000 patient-days). This rate was lower than (but not significantly different from) the rate for April to September 2009 (1.87 cases/1000 patient-days). There were no differences in mortality rate or severity of illness.
The antimicrobial stewardship program in this community hospital was associated with significant decreases in antimicrobial costs and in utilization of antipseudomonal antimicrobial agents and a nonsignificant decrease in the rate of C. difficile infection. Knowledge exchange, peer-to-peer communication, and decision support, key factors in this success, will be applied in implementing the antimicrobial stewardship program throughout the hospital.
antimicrobial stewardship; prospective audit and feedback; Clostridium difficile; gestion responsable des antimicrobiens; vérification prospective et rétroaction; Clostridium difficile
Antimicrobial stewardship programs in hospitals seek to optimize antimicrobial prescribing in order to improve individual patient care as well as reduce hospital costs and slow the spread of antimicrobial resistance. With antimicrobial resistance on the rise worldwide and few new agents in development, antimicrobial stewardship programs are more important than ever in ensuring the continued efficacy of available antimicrobials. The design of antimicrobial management programs should be based on the best current understanding of the relationship between antimicrobial use and resistance. Such programs should be administered by multidisciplinary teams composed of infectious diseases physicians, clinical pharmacists, clinical microbiologists, and infection control practitioners and should be actively supported by hospital administrators. Strategies for changing antimicrobial prescribing behavior include education of prescribers regarding proper antimicrobial usage, creation of an antimicrobial formulary with restricted prescribing of targeted agents, and review of antimicrobial prescribing with feedback to prescribers. Clinical computer systems can aid in the implementation of each of these strategies, especially as expert systems able to provide patient-specific data and suggestions at the point of care. Antibiotic rotation strategies control the prescribing process by scheduled changes of antimicrobial classes used for empirical therapy. When instituting an antimicrobial stewardship program, a hospital should tailor its choice of strategies to its needs and available resources.
As part of a national co-ordinated and multifaceted response to the excess suicide rate, the Choose Life initiative, the Highland Choose Life Group launched an ambitious programme of training for National Health Service (NHS), Council and voluntary organisation staff. In this study of the dissemination and implementation of STORM (Skills-based Training On Risk Management), we set out to explore not only the outcomes of training, but key factors involved in the processes of diffusion, dissemination and implementation of the educational intervention.
Participants attending STORM training in Highland Region provided by 12 trained facilitators during the period March 2004 to February 2005 were recruited. Quantitative data collection from participants took place at three time points; immediately before training, immediately post-training and six months after training. Semi-structured telephone interviews were carried out with the training facilitators and with a sample of course participants 6 months after they had been trained. We have utilized the conceptual model described by Greenhalgh and colleagues in a Framework analysis of the data, for considering the determinants of diffusion, dissemination and implementation of interventions in health service delivery and organization.
Some 203 individuals completed a series of questionnaire measures immediately pre (time 1) and immediately post (time 2) training and there were significant improvements in attitudes and confidence of participants. Key factors in the diffusion, dissemination and implementation process were the presence of a champion or local opinion leader who supported and directed the intervention, local adaptation of the materials, commissioning of a group of facilitators who were provided with financial and administrative support, dedicated time to provide the training and regular peer-support.
Features that contributed to the success of STORM were related to both the context (the multi-dimensional support provided from the host organisation and the favourable policy environment) and the intervention (openness to local adaptation, clinical relevance and utility), and the dynamic interaction between context and the intervention.
In the UK, all ethnic minority groups have higher rates of diabetes than the general population. Although there have been a number of projects to assess diabetic care amongst minority ethnic groups in the United Kingdom, little is known about the extent to which the needs of ethnic minority groups are actually met by the National Health Service (NHS) Scotland. Therefore we conducted this study to understand of the current situation for diabetes care available to minority ethnic groups in Scotland.
We conducted this cross-sectional study in all health boards in Scotland. A questionnaire was designed based on expert comments. It was completed by Local Health Care Cooperatives (LHCC) managers, chairs, diabetes specialist nurses and public health practitioners.
57 of questionnaires were returned (response rate = 69.5%). Of these LHCCs, 71% responded that diabetes was part of their LHCC plan. However 69% answered that ethnic group was not recorded by community services and GPs, and 80% of LHCCs did not monitor trends of complications of diabetes by ethnic group.
Improvement is needed in quality, completeness, and availability of minority ethnic group data for diabetes at a national level, particularly if NHS Primary Care Organisations are to be responsible for providing diabetes care as laid out in the Scottish Diabetes Framework.
Current estimates of CDI prevalence in the US based on ICD-9-CM codes may be falsely elevated, indicating that a national standardized CDI surveillance system is warranted.
Background. US estimates of the Clostridium difficile infection (CDI) burden have utilized International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Whether ICD-9-CM code rank order affects CDI prevalence estimates is important because the National Hospital Discharge Survey (NHDS) and the Nationwide Inpatient Sample (NIS) have varying limits on the number of ICD-9-CM codes collected.
Methods. ICD-9-CM codes for CDI (008.45), C. difficile toxin assay results, and dates of admission and discharge were collected from electronic hospital databases for adult patients admitted to 4 hospitals in the United States from July 2000 through June 2006. CDI prevalence per 1000 discharges was calculated and compared for NHDS and NIS limits and toxin assay results from the same hospitals. CDI prevalence estimates were compared using the χ2 test, and the test of equality was used to compare slopes.
Results. CDI prevalence measured by NIS criteria was significantly higher than that measured using NHDS criteria (10.7 cases per 1000 discharges versus 9.4 cases per 1000 discharges; P < .001) in the 4 hospitals. CDI prevalence measured by toxin assay results was 9.4 cases per 1000 discharges (P = .57 versus NHDS). However, the CDI prevalence increased more rapidly over time when measured according to the NHDS criteria than when measured according to toxin assay results (β= 1.09 versus 0.84; P = .008).
Conclusions. Compared with the NHDS definition, the NIS definition captured 12% more CDI cases and reported significantly higher CDI rates. Rates calculated using toxin assay results were not different from rates calculated using NHDS criteria, but CDI prevalence appeared to increase more rapidly when measured by NHDS criteria than when measured by toxin assay results.
Background and objectives
Although ethnic group variations in cancer exist, no multiethnic, population-based, longitudinal studies are available in Europe. Our objectives were to examine ethnic variation in all-cancer, and lung, colorectal, breast and prostate cancers.
Design, setting, population, measures and analysis
This retrospective cohort study of 4.65 million people linked the 2001 Scottish Census (providing ethnic group) to cancer databases. With the White Scottish population as reference (value 100), directly age standardised rates and ratios (DASR and DASRR), and risk ratios, by sex and ethnic group with 95% CI were calculated for first cancers. In the results below, 95% CI around the DASRR excludes 100. Eight indicators of socio-economic position were assessed as potential confounders across all groups.
For all cancers the White Scottish population (100) had the highest DASRRs, Indians the lowest (men 45.9 and women 41.2) and White British (men 87.6 and women 87.3) and other groups were intermediate (eg, Chinese men 57.6). For lung cancer the DASRRs for Pakistani men (45.0), and women (53.5), were low and for any mixed background men high (174.5). For colorectal cancer the DASRRs were lowest in Pakistanis (men 32.9 and women 68.9), White British (men 82.4 and women 83.7), other White (men 77.2 and women 74.9) and Chinese men (42.6). Breast cancer in women was low in Pakistanis (62.2), Chinese (63.0) and White Irish (84.0). Prostate cancer was lowest in Pakistanis (38.7), Indian (62.6) and White Irish (85.4). No socio-economic indicator was a valid confounding variable across ethnic groups.
The ‘Scottish effect’ does not apply across ethnic groups for cancer. The findings have implications for clinical care, prevention and screening, for example, responding appropriately to the known low uptake among South Asian populations of bowel screening might benefit from modelling of cost-effectiveness of screening, given comparatively low cancer rates.
OBJECTIVE—To establish national clinical guidelines and integrated care pathways for five conditions (tuberous sclerosis (TS), Huntington's disease (HD), myotonic dystrophy (MD), neurofibromatosis type 1 (NF1), and Marfan syndrome (MS)) and audit their use in Scotland.
DESIGN—Systematic review of published reports followed by consensus conferences to prepare clinical guidelines and integrated care pathways. Structured review of medical records before and after introduction of integrated care pathways to document changes in practice. Survey of staff views on procedures adopted.
SETTING—All four clinical genetics centres in Scotland.
RESULTS—Project resulted in reduced variation in practice across centres, improved data recording in medical records, and improved communication with other professional groups. A very poor evidence base for management of patients with the conditions studied was found.
CONCLUSIONS—A collaborative structure for undertaking clinical research would improve the evidence base for current practice. National discussion of the boundaries of responsibility of care for the long term management of patients with these disorders is required. The integrated care pathway approach shows promise as a means of facilitating the development of audit within clinical genetics services.
Keywords: clinical guidelines; audit; evidence based medicine; care pathways
Men's apparent resistance to recommended health practices and their engagement with ‘high-risk’ behaviours has been associated with an increased risk of morbidity or mortality. Recent work has highlighted the need to think critically about the health-promoting behaviours that men appear reluctant to engage in, as well as examining those they embrace, and explore the gendered meanings that men attribute to their beliefs and behaviours. This article presents men's discussions of the ‘practices of masculinity’ and examines their relation to, and implications for, men's health-related behaviours as articulated in 15 focus group discussions (59 participants in total). The data capture both the experiences of men who felt pressured to engage in behaviours that may be harmful to their health in order to appear masculine and the accounts of those who regarded themselves as freer to embrace salutogenic health practices. Less is known about the circumstances that might encourage men to re-think their engagement in performances of masculinity that have potentially detrimental effects on their health. The data presented here suggest that ageing, illness, and fatherhood were some of the experiences that prompted men to re-evaluate their health practices.
sociology of health; health behaviour; identity
To estimate the effect of human immunodeficiency virus (HIV) infection on general practice, a postal survey was undertaken of one in three of all principals in Scotland. Of the 834 general practitioners who responded (78% response rate), 31% were working in practices with patients known to be infected with HIV. The estimated prevalence of known HIV infection in general practice was 19 per 100,000 population, and the estimated annual consultation rate for HIV related problems (including consultations by the 'worried well') was seven per 1000 population. Both statistics showed considerable variation between health boards, with peaks in Lothian and Tayside. Few practices had drawn up policies relevant to HIV infection, and the use of procedures for controlling infection was variable. Policies about HIV and for infection control tended to be more common in areas where the prevalence of HIV infection was higher. Most respondents were offering both opportunistic health education and counselling about HIV infection, especially to patients at high risk. Although general practitioners are responding positively to the increasing demands of HIV infection, there is an urgent need for policies, both national and local, to guide specific aspects of practice.
Clostridium difficile is an emerging pathogen that causes C difficile-associated diarrhea, an important nosocomial infection. Control of this infection remains a challenge, and much needs to be determined about the antimicrobial resistance of the organism, antibiotic stewardship, contamination of the patient environment, and various host factors that determine susceptibility or resistance to infection. A national symposium focusing on C difficile infections, the Clostridium difficile Symposium on Emerging Issues and Research, was hosted on November 23, 2004, by the Department of Medical Microbiology and Infectious Diseases at the University of Manitoba, Winnipeg, Manitoba, in partnership with the Canadian Institutes of Health Research. This symposium, which aimed to summarize key research issues regarding C difficile infections in Canada, had the following objectives: to provide a forum for learning and discussion about C difficile and its impact on the health of Canadians; to identify the key research issues that should be addressed; and to explore potential research funding opportunities and collaboration. The present report summarizes key research issues identified for C difficile infections in Canada by addressing four major themes: diagnosis and surveillance, infection prevention and control, antibiotic stewardship, and clinical management.
Clostridium difficile; Diarrhea; Research issues
Compare Clostridium difficile infection (CDI) rates using a traditional definition [i.e. diagnosed > 48 hours after admission, healthcare-onset CDI (HO/CDI)] versus expanded definitions, including both HO/CDI cases and community-onset CDI cases diagnosed ≤ 48 hours from admission who were hospitalized in the previous 30 or 60 days [healthcare facility-associated (HCFA)-30 and HCFA-60]. Determine if differences exist between patients with CDI onset in the community versus healthcare setting.
Tertiary acute-care facility.
Medicine patients diagnosed with CDI from 1/1/04 through 12/31/05.
CDI cases were classified as HO/CDI, HCFA-30, and/or HCFA-60. Patient demographics and medication exposures were obtained. The CDI incidence per the definitions, CDI rate variability, patient demographics, and medication exposures were compared.
The HO/CDI rate (1.6 cases/1000 patient days) was significantly lower than the HCFA-30 (2.4) and the HCFA-60 (2.6) rates (p<0.01, both). There was good correlation between the HO/CDI rate and both the HCFA-30 and HCFA-60 rates (correlation=0.69 and 0.70, p<0.01 both). There were no months where the CDI rate was > 3 SD from the mean. Patients with community-onset CDI were less likely to have received a fourth-generation cephalosporin (p=0.02) or IV vancomycin (p=0.01) while hospitalized.
Expanded definitions identify more patients with CDI. There is good correlation between traditional and expanded CDI definitions; therefore it is unclear if expanded surveillance is necessary to identify an abnormal change in CDI rates. Cases that met the expanded definitions were less like to have fourth-generation cephalosporin and vancomycin exposure.
Clostridium difficile; surveillance; hospitals
Antimicrobial stewardship has been promoted as a key strategy for coping with the problems of antimicrobial resistance and Clostridium difficile. Despite the current call for stewardship in community hospitals, including smaller community hospitals, practical examples of stewardship programs are scarce in the reported literature. The purpose of the current report is to describe the implementation of an antimicrobial stewardship program on the medical-surgical service of a 100-bed community hospital employing a core strategy of post-prescriptive audit with intervention and feedback.
For one hour twice weekly, an infectious diseases physician and a clinical pharmacist audited medical records of inpatients receiving systemic antimicrobial therapy and made non-binding, written recommendations that were subsequently scored for implementation. Defined daily doses (DDDs; World Health Organization Center for Drug Statistics Methodology) and acquisition costs per admission and per patient-day were calculated monthly for all administered antimicrobial agents.
The antimicrobial stewardship team (AST) made one or more recommendations for 313 of 367 audits during a 16-month intervention period (September 2009 – December 2010). Physicians implemented recommendation(s) from each of 234 (75%) audits, including from 85 of 115 for which discontinuation of all antimicrobial therapy was recommended. In comparison to an 8-month baseline period (January 2009 – August 2009), there was a 22% decrease in defined daily doses per 100 admissions (P = .006) and a 16% reduction per 1000 patient-days (P = .013). There was a 32% reduction in antimicrobial acquisition cost per admission (P = .013) and a 25% acquisition cost reduction per patient-day (P = .022).
An effective antimicrobial stewardship program was implemented with limited resources on the medical-surgical service of a 100-bed community hospital.
Antimicrobial stewardship; ASP; Small community hospital
To characterize the temporal progression of the monthly incidence of Clostridium difficile infections (CDIs) and to determine whether the incidence of CDI is related to the incidence of seasonal influenza.
A retrospective study of patients in the Nationwide Inpatient Sample during the period from 1998 through 2005.
We identified all hospitalizations with a primary or secondary diagnosis of CDI with use of International Classification of Diseases, 9th Revision, Clinical Modification codes, and we did the same for influenza. The incidence of CDI was modeled as an autoregression about a linear trend. To investigate the association of CDI with influenza, we compared national and regional CDI and influenza series data and calculated cross-correlation functions with data that had been prewhitened (filtered to remove temporal patterns common to both series). To estimate the burden of seasonal CDI, we developed a proportional measure of seasonal CDI.
Time-series analysis of the monthly number of CDI cases reveals a distinct positive linear trend and a clear pattern of seasonal variation (R2 = 0.98). The cross-correlation functions indicate that influenza activity precedes CDI activity on both a national and regional basis. The average burden of seasonal (ie, winter) CDI is 23%.
The epidemiologic characteristics of CDI follow a pattern that is seasonal and associated with influenza, which is likely due to antimicrobial use during influenza seasons. Approximately 23% of average monthly CDI during the peak 3 winter months could be eliminated if CDI remained at summer levels.
To assess the contemporary caseload of NHS plastic surgeons.
Analysis of routinely collected NHS hospital activity data relating to the financial year 2005–2006.
Main outcome measures
Number of inpatient/day-case episodes and bed-days by principal diagnosis and main operative procedure.
During the study period, 12,844 inpatient and 9439 day-case episodes were recorded in 19,166 patients, accounting for 36,300 bed-days. There were more female patients, especially among middle-age groups. Socioeconomic deprivation was more common than expected (P < 0.0001), especially among younger age groups and male patients. In terms of episodes, the most common categories of diagnosis were neoplasms (28.4%) and injuries, including burns (22.4%). However, injuries accounted for a higher proportion of bed-days (37.3%) than neoplasms (23.8%). Only approximately half of all surgical procedures were assigned to the skin chapter of the OPCS-4 classification.
Despite some limitations, this study provides an insight into the current caseload of NHS plastic surgeons working in Scotland. The data suggest that cosmetic surgery for purely aesthetic reasons represents a relatively small part of NHS plastic surgery activity in Scotland, and that the majority of caseload is in reconstructive plastic surgery.
A multi-national working group on antibiotic stewardship, from the International Society of Chemotherapy, put together ten recommendations to physicians prescribing antibiotics to outpatients. These recommendations are: (1) use antibiotics only when needed; teach the patient how to manage symptoms of non-bacterial infections; (2) select the adequate ATB; precise targeting is better than shotgun therapy; (3) consider pharmacokinetics and pharmacodynamics when selecting an ATB; use the shortest ATB course that has proven clinical efficacy; (4) encourage patients’ compliance; (5) use antibiotic combinations only in specific situations; (6) avoid low quality and sub-standard drugs; prevent prescription changes at the drugstore; (7) discourage self-prescription; (8) follow only evidence-based guidelines; beware those sponsored by drug companies; (9) rely (rationally) upon the clinical microbiology lab; and (10) prescribe ATB empirically – but intelligently; know local susceptibility trends, and also surveillance limitations.
antibiotic stewardship; antibiotic resistance; guidelines; generic antibiotics; self-prescription; treatment compliance
It is believed that Clostridium difficile infection (CDI) contributes to a prolongation of length of stay (LOS). Recent literature suggests that models previously used to determine LOS due to infection have overestimated LOS, compared to newer statistical models. The purpose of this review is to understand the impact that CDI has on LOS and in doing so, describe the methodological approaches used.
First, to investigate and describe the reported prolongation of LOS in hospitalised patients with CDI. Second, to describe the methodologies used for determining excess LOS.
An integrative review method was used. Papers were reviewed and analysed individually and themes were combined using integrative methods.
Findings from all studies suggested that CDI contributes to a longer LOS in hospital. In studies that compared persons with and without CDI, the difference in the LOS between the two groups ranged from 2.8days to 16.1days. Potential limitations with data analysis were identified, given that no study fully addressed the issue of a time-dependent bias when examining the LOS. Recent literature suggests that a multi-state model should be used to manage the issue of time-dependent bias.
Studies examining LOS attributed to CDI varied considerably in design and data collected. Future studies examining LOS related to CDI and other healthcare associated infections should consider capturing the timing of infection in order to be able to employ a multi-state model for data analysis.
Clostridium difficile infection; Clostridium difficile associated diarrhoea; Cost; Healthcare associated infection; Length of stay; Time dependent bias