Between the 1st July 2018 and the 30th June 2019, among a total number of 689 patients admitted in the Vascular Surgery ward for at least 48 hours, 108 (15.67%) patients received at least one evaluation from the ID consultant, for a maximum of six different evaluations for a single patient. The median age was 71 (IQR 63–78) and 79 (73.15%) were males. The most prevalent underlying disease was of cardiovascular aetiology, followed by diabetes and metabolic comorbidities (Table 2).
Overall, we performed 186 ID consultations. The most prevalent infectious condition evaluated during our interventions was ABSSSI and/or surgical site infection, accounting for 52 patients (48.15%), followed by HAP (15 patients, 13.89%) (Table 2).
Table 2
Characteristics of patients evaluated in the Vascular Surgery ward.
Variables
|
Overall (N = 108)
|
Age (y), median (IQR)
|
71 (63–78)
|
Gender (male), n (%)
|
79 (73.15)
|
Comorbidities
|
Cardiovascular, n (%)
|
102 (94.44)
|
Diabetes, n (%)
|
48 (44.44)
|
Haematologic, n (%)
|
5 (4.63)
|
HCV, n (%)
|
4 (3.70)
|
HIV, n (%)
|
1 (0.93)
|
Immunologic, n (%)
|
4 (3.70)
|
Metabolic, n (%)
|
59 (54.63)
|
Neurologic, n (%)
|
4 (3.70)
|
Oncologic, n (%)
|
3 (2.78)
|
Osteoarticular, n (%)
|
3 (2.78)
|
Respiratory, n (%)
|
15 (13.89)
|
Urologic, n (%)
|
17 (15.74)
|
Type of condition evaluated
|
ABSSSI and/or surgical site infection, n (%)
|
52 (48.15)
|
Bacteremia, n (%)
|
2 (1.85)
|
Diabetic foot infection, n (%)
|
10 (9.26)
|
Hospital-acquired pneumonia, n (%)
|
15 (13.89)
|
Intra-abdominal infection, n (%)
|
7 (6.48)
|
No infection/colonization, n (%)
|
13 (12.04)
|
Sepsis, n (%)
|
1 (0.93)
|
Septic arthritis and/or osteomyelitis, n (%)
|
6 (5.55)
|
Urinary tract infection, n (%)
|
2 (1.85)
|
Regarding the outcomes of the ID interventions, those bringing to a de-escalation of an ongoing antimicrobial therapy were the most prevalent, accounting for 39 consultations (20.97%), followed by decisions to start an antimicrobial therapy (34 consultations, 18.28%) and to escalate (32 consultations, 17.20%). Antimicrobial treatments were left unmodified in 31 evaluations (16.67%), interrupted or not recommended in 22 and 16 consultations, respectively (11.83 and 8.60%). Finally, antimicrobial choices and dosages were modified in 9 and 3 evaluations (4.84 and 1.61%, respectively) (Figure 1). As a result, antimicrobial drugs were interrupted, not prescribed or de-escalated in 77 consultations (41.4%).
Occurrence of MRDO isolates.
Between period A and B, we reported a statistically significant decrease of isolates of carbapenem-resistant Pseudomonas aeruginosa (p-value 0.003, Table 3). Occurrence of ESBL-producing enteric Gram-negative bacteria also decreased but not significantly. Remarkably, during the intervention period no Clostridioides difficile infections were reported.
Table 3 Summary of the study outcomes.
|
Period A
(1st July 2017 – 30th June 2018)
|
Period B
(1st July 2018 – 30th June 2019)
|
p-value
|
Occurrence of MDRO infections
|
|
|
|
Carbapenem-resistant Pseudomonas aeruginosa, n
|
7
|
1
|
<0.01
|
Clostridioides difficile, n
|
2
|
0
|
0.10
|
ESBL-producing enteric Gram-negative bacteria, n
|
18
|
14
|
0.59
|
Length of in-hospital stay, mean
|
9.46
|
9.8
|
0.60
|
All-cause in-hospital mortality, n (%)
|
19 (2.68)
|
15 (2.15)
|
0.50
|
Antibiotic consumption
|
|
|
|
Carbapenems, DDD 100 patient/days, mean
|
4.53
|
1.51
|
0.01
|
Daptomycin, DDD 100 patient/days, mean
|
2.64
|
0.05
|
<0.01
|
Clindamycin, DDD 100 patient/days, mean
|
0.33
|
3.34
|
<0.01
|
Antibiotic costs, euros
|
54,876.44
|
21,777.26
|
0.03
|
Abbreviations: ESBL: extended-spectrum beta-lactamase.
Secondary outcomes.
No statistically significant changes before and after the implementation of the ASP in the Vascular Surgery ward were observed in terms of length of stay and all-cause in-hospital mortality (Table 3).
During the 12-month period following the start of the ASP, we noticed an improvement in the antimicrobial prescription appropriateness. More precisely, our intervention was particularly effective in reducing the administration of carbapenems, daptomycin and linezolid. The monthly mean DDDs of carbapenems decreased from 4.53 to 1.51 (p-value 0.01) and daptomycin DDDs from 2.64 to 0.05 (p-value <0.01, see Table 3). Linezolid DDDs also diminished from 0.49 to 0.26 (p-value 0.43, data not shown).
Glycopeptides, specifically vancomycin, were used as anti-MRSA agents in place of daptomycin, so we noticed a non-statistically significant increase of administered DDDs in concomitance with our intervention (p-value 0.14, data not shown). Consumptions of both trimethoprim/sulfametoxazole (TMP/SMX) and fluoroquinolones increased non significantly. TMP/SMX DDDs increased from 3,953 to 7,191 (p-value 0.0584, data not shown) whereas fluoroquinolones DDDs increased from 9,1893 to 13,408 (p-value 0.2553, data not shown). Oral fosfomycin was introduced in the clinical practice of the Vascular Surgery ward to treat uncomplicated lower urinary tract infections, in place of beta-lactams. In particular, DDDs increased from 0 to 0.65 (p-value 0.0258, data not shown). Clindamycin use increased significantly, from a DDDs mean of 0.33 to 3.34 (p-value 0.0007, data not shown).
Penicillins had a non-significant increase of administration, from 33,92 to 36.91 DDDs (p-value 0.9372, data not shown), as third-generation cephalosporins, which moved from 3,52 to 4,29 DDDs (p-value 0.6649, data not shown). As regards antifungals, we noticed a non-significant decrease of DDDs from 0.23 to 0.15 (p-value 0.96, data not shown).
During the intervention period, a significant reduction in antimicrobial costs was observed. In particular, the total cost of antimicrobial drugs prescribed in the Vascular Surgery ward after the start of the ASP was equal to 21.777,26 €, with a net difference of 33.099,18 € (60,31%; p value 0.03, see Table 3) compared to the previous twelve months (54.876,44 €).