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“Enforcing surveillance of antimicrobial resistance and antibiotic use to drive stewardship: a quality improvement intervention in the paediatric area of the Verona University Hospital”
Full text linkBackground: Gli interventi di Stewardship Antibiotica (AS) in ambito pediatrico sono ancora poco standardizzati per metodologia, parametri di valutazione ed esiti clinici da considerare. Di seguito si riportano i risultati dello studio ENSURE (ENforcing SUrveillance of antimicrobial Resistance and antibiotic usE to drive stewardship), uno studio quasi-sperimentale volto a migliorare l’appropriatezza delle prescrizioni antimicrobiche nell’area medica pediatrica attraverso la fornitura di linee guida per il trattamento specificamente disegnate secondo i dati di sorveglianza microbiologica raccolti a livello locale. Materiali e metodi: L’intervento di AS è stato condotto nell’Area medica pediatrica di un ospedale di terzo livello nel periodo Marzo 2021 - Giugno 2023. Gli elementi chiave dell’intervento sono stati: 1) fase intensiva iniziale (Marzo 2021 - Maggio 2021) effettuata da uno specialista infettivologo che lavorava a tempo pieno nel reparto di interesse, per osservazione e riscontro dei bisogni di formazione in ambito di antibioticoterapia; 2) elaborazione di linee guida di terapia antibiotica disegnate “su misura”, secondo i dati di suscettibilità microbiologica locale, fornite al personale prescrittore in Gennaio 2022 e consultabili anche tramite un applicativo personalizzato (Firstline.org); 3) fase di follow-up di 18 mesi (Febbraio 2022 - Giugno 2023) con metodologia “audit e feedback”. L’endpoint primario valutato è stato il consumo di antibiotici sistemici (classe ATC J01), stimato mediante i parametri “Dosi giornaliere definite” (DDD), “Giorni di terapia” (DOT) e “Durata della terapia” (LOT), normalizzati per 1000 pazienti/giorno (*1000 PD), nei 18 mesi successivi all’intervento (anno 2022-2023) confrontati con dati di controllo storico di 12 mesi pre-pandemia da virus SARS-COV2 (anno 2019), con metodologia descrittiva e con analisi statistica mediante “Interrupted Time Series Analysis” (ITSA). Gli endpoint secondari dello studio sono stati: 1) distribuzione del consumo di antibiotici per classe AWaRe di OMS; 2) valutazione dell’appropriatezza della terapia (tramite audit e feedback); 3) durata della degenza (length of stay - LOS); 4) mortalità intra-ospedaliera; 5) prevalenza di microorganismi multi-resistenti (MDR). Risultati: È stata documentata una significativa riduzione del consumo di antibiotici, sia in termini di DDD *1000 PD, sia come DOT e LOT *1000 PD. Raffrontando i dati per semestre al fine di tenere conto anche delle attese fluttuazioni per stagionalità, si è osservato un decremento pari al 55% nel parametro DDD totali normalizzate *1000 PD (140 vs 312) tra I semestre 2022 e I semestre 2019, del 47% (203 vs 385) tra II semestre 2022 e II semestre 2019 e del 22% (243 vs 312) tra I semestre 2023 e I semestre 2019. Si è osservato inoltre un decremento del parametro DOT totali normalizzate *1000 PD pari al 63% (DOT 270 vs 724) tra I semestre 2022 e I semestre 2019, del 55% (DOT 370 vs 830) tra II semestre 2022 e II semestre 2019 e del 50% (DOT 359 vs 724) tra I semestre 2023 e I semestre 2019. Un decremento in LOT medio *1000 PD del 48% (LOT 232 vs 450) si è rilevato tra I semestre 2022 e I semestre 2019, del 32% (LOT 319 vs 472) tra II semestre 2022 e II semestre 2019 e del 30% (LOT 313 vs 450) tra I semestre 2023 e I semestre 2019. L’analisi ITS ha evidenziato significatività statistica (p<0,01) per le differenze in fase pre- versus post-intervento per tutti i 3 parametri di valutazione dei consumi (DDD, DOT, LOT). Una modifica nelle abitudini prescrittive con maggior utilizzo di antibiotici di classe “Access” rispetto a “Watch” si è resa evidente in fase post-intervento nel corso dell’anno 2022-2023. Il rapporto “Access to Watch” per DDD medio *1000 PD per semestre di rilevazione risultava in incremento progressivo dal I semestre 2019 (ratio: 0,6) al II semestre 2022 (ratio: 1,8), con decremento nel I semestre 2023 (ratio: 0,8), mantenendo tuttavia valori superiori alla fase pre-intervento. LOS e mortalità intraospedaliera sono rimasti stabili nella fase pre- e post-intervento. La prevalenza di infezioni da microrganismi MDR è rimasta stabile e molto bassa nella fase pre- e post-intervento (anno 2019: 9%; anno 2022 e 2023: 7%). Si è osservato invece un incremento della prevalenza di microrganismi Escherichia coli isolati da urinocoltura che risultavano resistenti alla terapia prevista da linee guida (anno 2019: 18%; anno 2022: 34%; I semestre 2023: 40%), con assoluta preponderanza dei resistenti ad amoxicillina-acido clavulanico. Durante la fase di follow-up post-intervento sono state condotti 42 audit con valutazione di 713 pazienti, 214 dei quali risultavano in terapia antibiotica (proporzione media: I semestre anno 2022 - 29%; II semestre anno 2022 - 32%; I semestre anno 2023 - 29%). In fase post-intervento le prescrizioni risultavano appropriate secondo le linee guida in un’alta proporzione di soggetti, con andamento costantemente migliorativo nel corso del periodo di follow-up (I semestre anno 2022: 84%; II semestre anno 2022: 89%; I semestre anno 2023: 93%). Limiti dello studio: L’inclusione nello studio di un gruppo di controllo ed un braccio di “non intervento” avrebbe potuto essere di supporto nella valutazione dell’impatto di eventuali fattori confondenti (ad es. cambiamento del patient mix, indisponibilità di alcuni principi attivi...). Tuttavia, tale evenienza non è stata prevista nel disegno dello studio in quanto tutti i settori di Area medica pediatrica di A.O.U.I. Verona sono stati contemporaneamente coinvolti nello studio e nessun altro reparto con caratteristiche comparabili era disponibile in loco come gruppo di controllo. Conclusioni: Nel presente studio l’intervento di AS è risultato associato ad un miglioramento nell’adeguatezza delle prescrizioni antibiotiche e ad una significativa riduzione del consumo totale di antibiotici, nonché al consolidamento di un’attitudine prescrittiva che privilegiasse, ogniqualvolta possibile, la scelta di antibiotici di classe “Access”. Gli strumenti elettronici specificamente disegnati a supporto del personale prescrittore hanno svolto un ruolo importante nel promuovere il rispetto delle linee guida e nel garantire la sostenibilità a lungo termine degli obiettivi conseguiti. Il monitoraggio periodico dei profili di resistenza dei microorganismi a livello locale è indispensabile in prospettiva di eventuali congrui adeguamenti delle linee guida di trattamento antimicrobico empirico.Background: Antibiotic Stewardship (AS) interventions in paediatric settings are still poorly standardised in terms of methodology, assessment parameters and the clinical outcomes to be considered. Below are the results of the ENSURE (ENforcing SUrveillance of antimicrobial Resistance and Antibiotic UsE to Drive Stewardship) study, a quasi-experimental study aimed at improving the appropriateness of antimicrobial prescriptions in the paediatric setting by providing treatment guidelines specifically designed in accordance with locally-collected microbiological surveillance data. Materials and methods: The AS intervention was carried out in the Paediatric medical area of a tertiary referral hospital between March 2021 and June 2023. The key elements of the intervention were: 1) an initial intensive phase (March 2021 - May 2021) conducted by an infectious diseases specialist working full time in the unit in question, in order to observe and identify the training needs regarding antibiotic therapy; 2) processing of customised therapy guidelines drawn up in accordance with local microbiological susceptibility data, provided to prescribing personnel in January 2022 and that were also available for consultation using a customised app (Firstline.org); 3) 18-month follow-up phase (February 2022 - June 2023) utilising the “audit and feedback” method. The primary endpoint assessed was consumption of systemic antibiotics (class ATC J01), as calculated using the parameters “Defined daily doses” (DDD), “Days of therapy” (DOT) and “Length of therapy” (LOT), normalised to 1000 patient-days (*1000 PD), for the 18 months following the intervention (period 2022-2023) compared with historical control data for a 12-month period prior to the SARS-COV2 pandemic (2019), using a descriptive method and statistical analysis by means of “Interrupted Time Series Analysis” (ITSA). The secondary endpoints of the study were: 1) distribution of the consumption of antibiotics by WHO AWaRe class; 2) therapeutic appropriateness assessment (using the audit and feedback method); 3) length of stay (LOS); 4) in- hospital mortality; and 5) prevalence of multi-drug resistant (MDR) micro-organisms. Results: A consistent reduction in the consumption of antibiotics was recorded, in terms of both DDD *1000 PD, and DOT and LOT *1000 PD. Comparing the data by semesters in order to also take into consideration the expected seasonal fluctuations, the parameter total DDD normalised to *1000 PD decreased by 55% (140 vs 312) between semester I 2022 and semester I 2019, by 47% (203 vs 385) between semester II 2022 and semester II 2019 and by 22% (243 vs 312) between semester I 2023 and semester I 2019. Furthermore, the parameter total DOT normalised to *1000 PD decreased by 63% (DOT 270 vs 724) between semester I 2022 and semester I 2019, by 55% (DOT 370 vs 830) between semester II 2022 and semester II 2019 and by 50% (DOT 359 vs 724) between semester I 2023 and semester I 2019. Mean LOT *1000 PD (LOT 232 vs 450) decreased by 48% between semester I 2022 and semester I 2019, by 32% (LOT 319 vs 472) between semester II 2022 and semester II 2019 and by 30% (LOT 313 vs 450) between semester I 2023 and semester I 2019. The ITS analysis showed statistical significance (p<0.01) for the pre- versus post-intervention differences for all 3 consumption assessment parameters (DDD, DOT, LOT). There was a clear change in prescription habits with greater use of “Access” class antibiotics over “Watch” class antibiotics in the post-intervention period for the period 2022-2023. The “Access to Watch” ratio for mean DDD *1000 PD per observation semester was seen to increase progressively from semester I 2019 (ratio: 0.6) to semester II 2022 (ratio: 1.8), with a decrease in semester I 2023 (ratio: 0.8), nevertheless maintaining higher than pre-intervention values. LOS and in-hospital mortality remained constant in the pre- and post-intervention phase. The prevalence of MDR micro-organism infections remained constant and very low in the pre- and post-intervention phases (2019: 9%; 2022 and 2023: 7%). However, there was an increase in Escherichia coli micro-organisms isolated from urine cultures that were resistant to the therapy provided for in the guidelines (2019: 18%; 2022: 34%; semester I 2023: 40%), with an absolute preponderance of amoxicillin-clavulanic acid-resistant micro-organisms. During the post-intervention follow-up phase, 42 audits were carried out to assess 713 patients, 214 of whom were receiving antibiotic therapy (mean proportion: semester I 2022 - 29%; semester II 2022 - 32%; semester I 2023 - 29%). In the post-intervention phase, prescriptions were found to be appropriate according to the guidelines in a high proportion of subjects, with a consistently upward trend during the follow-up period (semester I 2022: 84%; semester II 2022: 89%; semester I 2023: 93%). Limitations of the study: The inclusion in the study of a control group and a “non-intervention arm” could have provided support for the assessment of any confounders (e.g. patient mix changes, nonavailability of certain active substances, etc.). However, they were not foreseen in the study design because all areas of the Paediatric Medical Area of Verona University Hospital were simultaneously involved in the study, and no other departments with similar characteristics were available at the same location for use as a control group. Conclusions: In this study, the AS intervention appeared to be associated with an improvement in the appropriateness of antibiotic prescriptions and a significant reduction in total antibiotic consumption, as well as with the consolidation of a prescriptive attitude that favoured, whenever possible, the choice of antibiotics in the “Access” class. The electronic tools specifically designed to support prescribers played an important role in promoting compliance with the guidelines and ensuring the long-term sustainability of objectives achieved. Regular monitoring of micro-organism resistance profiles at a local level is essential for appropriately adapting the guidelines for empirical antimicrobial treatment
Assessing Response Rates and Sleep Disorder Prevalence: Insights from a Propranolol Treatment Study for Infantile Haemangiomas
Full text linkBackground: Infantile haemangiomas (IHs) sometimes require treatment with propranolol. Sleep disturbances are the most frequently reported side effects. Monitoring adverse drug events necessitates repeated hospital visits, which can be challenging during a pandemic.
Objectives: To explore the effectiveness of a new electronic questionnaire in identifying sleep disturbances related to treatment with propranolol and potential confounding factors. To evaluate the response rate to the questionnaire. To report the proportion of patients on propranolol with sleep disturbances.
Methods: In an observational, prospective cohort study, caregivers provided clinical information during ambulatory visits and via an electronic questionnaire after an 8-week treatment course with propranolol and at the time of treatment interruption. Adverse drug reaction reporting forms were assessed for causality.
Results: The questionnaire response rate was 91%, and the completion rate was 100%. A total of 59% of patients experienced sleep disturbances during propranolol treatment, which were considered adverse reactions. Sleep disorders were frequent during sleep regression phases and in subjects who fell asleep during physical contact with caregivers or bed-sharing with parents.
Conclusion: The application of this questionnaire allows for identifying adverse sleep events associated with propranolol in IHs and potential confounders. Counselling on sleep hygiene is recommended before treatment onset
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Enforcing surveillance of antimicrobial resistance and antibiotic use to drive stewardship: experience in a paediatric setting
No full textBackground: Antibiotic Stewardship (AS) interventions in paediatrics are still not standardized regarding methodology, metrics, and outcomes. We report the results of an AS intervention in the paediatric area based on education and guideline provision via an electronic App. Materials and methods: The AS intervention was conducted in 2021 through observation, education, audit and feedback and provision of an electronic App (Firstline.org) to support antibiotic prescription based on local susceptibility data. The primary outcome was the antibiotic consumption in the 12-months following the intervention (year 2022) compared to a historical 12-month control (year 2019) via an interrupted time series analysis. Secondary outcomes were appropriateness of therapy, length-of-stay, 30-day readmission, transfers to the paediatric intensive care unit, in-hospital mortality, and prevalence of antimicrobial resistance (AMR). Results: During the post-intervention phase, 29 cross-sectional audits and feedback were conducted including 467 patients. Prescriptions were appropriate according to the guidelines in 85.7% of cases, with a stable trend over time. A significant decrease of antibiotic consumption was measured in terms of Defined Daily Doses per 1000 Patient Days (-222.13; p<0.001) and Days of Therapy per 1000 Patient Days (-452.49; p <0.001) in the post-intervention period with a clear inversion of the Access to Watch ratio (from 0.7 to 1.7). Length of stay, in-hospital mortality, ICU transfers, and incidence of AMR infections remained stable, while 30-day readmission decreased from 4.9 per 100 admissions to 2.8 per 100 admissions (p <0.001). Conclusions: The intervention was associated with a significant reduction in antimicrobial consumption and an increase in the appropriateness of prescriptions. Electronic tools can be of value in promoting adherence to guidelines and ensuring the sustainability of results
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Enforcing surveillance of antimicrobial resistance and antibiotic use to drive stewardship: a quality improvement intervention in the paediatric area of the Verona University Hospital
No full textBackground:
Antibiotic Stewardship (AS) interventions in paediatric settings are still poorly
standardised in terms of methodology, assessment parameters and the clinical
outcomes to be considered. Below are the results of the ENSURE (ENforcing
SUrveillance of antimicrobial Resistance and Antibiotic UsE to Drive Stewardship)
study, a quasi-experimental study aimed at improving the appropriateness of
antimicrobial prescriptions in the paediatric setting by providing treatment
guidelines specifically designed in accordance with locally-collected
microbiological surveillance data.
Materials and methods:
The AS intervention was carried out in the Paediatric medical area of a tertiary
referral hospital between March 2021 and June 2023. The key elements of the
intervention were: 1) an initial intensive phase (March 2021 - May 2021) conducted
by an infectious diseases specialist working full time in the unit in question, in order
to observe and identify the training needs regarding antibiotic therapy; 2)
processing of customised therapy guidelines drawn up in accordance with local
microbiological susceptibility data, provided to prescribing personnel in January
2022 and that were also available for consultation using a customised app
(Firstline.org); 3) 18-month follow-up phase (February 2022 - June 2023) utilising
the <audit and feedback= method. The primary endpoint assessed was consumption
of systemic antibiotics (class ATC J01), as calculated using the parameters
<Defined daily doses= (DDD), <Days of therapy= (DOT) and <Length of therapy=
(LOT), normalised to 1000 patient-days (*1000 PD), for the 18 months following
the intervention (period 2022-2023) compared with historical control data for a 12-
month period prior to the SARS-COV2 pandemic (2019), using a descriptive
method and statistical analysis by means of <Interrupted Time Series Analysis=
(ITSA). The secondary endpoints of the study were: 1) distribution of the
consumption of antibiotics by WHO AWaRe class; 2) therapeutic appropriateness
assessment (using the audit and feedback method); 3) length of stay (LOS); 4) in-
hospital mortality; and 5) prevalence of multi-drug resistant (MDR) microorganisms.
Results:
A consistent reduction in the consumption of antibiotics was recorded, in terms of
both DDD *1000 PD, and DOT and LOT *1000 PD. Comparing the data by
semesters in order to also take into consideration the expected seasonal fluctuations,
the parameter total DDD normalised to *1000 PD decreased by 55% (140 vs 312)
between semester I 2022 and semester I 2019, by 47% (203 vs 385) between
semester II 2022 and semester II 2019 and by 22% (243 vs 312) between semester
I 2023 and semester I 2019. Furthermore, the parameter total DOT normalised to
*1000 PD decreased by 63% (DOT 270 vs 724) between semester I 2022 and
semester I 2019, by 55% (DOT 370 vs 830) between semester II 2022 and semester
II 2019 and by 50% (DOT 359 vs 724) between semester I 2023 and semester I
2019. Mean LOT *1000 PD (LOT 232 vs 450) decreased by 48% between semester
I 2022 and semester I 2019, by 32% (LOT 319 vs 472) between semester II 2022
and semester II 2019 and by 30% (LOT 313 vs 450) between semester I 2023 and
semester I 2019. The ITS analysis showed statistical significance (p<0.01) for the
pre- versus post-intervention differences for all 3 consumption assessment
parameters (DDD, DOT, LOT).
There was a clear change in prescription habits with greater use of <Access= class
antibiotics over <Watch= class antibiotics in the post-intervention period for the
period 2022-2023. The <Access to Watch= ratio for mean DDD *1000 PD per
observation semester was seen to increase progressively from semester I 2019
(ratio: 0.6) to semester II 2022 (ratio: 1.8), with a decrease in semester I 2023 (ratio:
0.8), nevertheless maintaining higher than pre-intervention values.
LOS and in-hospital mortality remained constant in the pre- and post-intervention
phase.
The prevalence of MDR micro-organism infections remained constant and very low
in the pre- and post-intervention phases (2019: 9%; 2022 and 2023: 7%). However,
there was an increase in Escherichia coli micro-organisms isolated from urine
cultures that were resistant to the therapy provided for in the guidelines (2019: 18%;
2022: 34%; semester I 2023: 40%), with an absolute preponderance of amoxicillinclavulanic acid-resistant micro-organisms.
During the post-intervention follow-up phase, 42 audits were carried out to assess
713 patients, 214 of whom were receiving antibiotic therapy (mean proportion:
semester I 2022 - 29%; semester II 2022 - 32%; semester I 2023 - 29%). In the postintervention phase, prescriptions were found to be appropriate according to the
guidelines in a high proportion of subjects, with a consistently upward trend during
the follow-up period (semester I 2022: 84%; semester II 2022: 89%; semester I
2023: 93%).
Limitations of the study:
The inclusion in the study of a control group and a <non-intervention arm= could
have provided support for the assessment of any confounders (e.g. patient mix
changes, nonavailability of certain active substances, etc.). However, they were not
foreseen in the study design because all areas of the Paediatric Medical Area of
Verona University Hospital were simultaneously involved in the study, and no other
departments with similar characteristics were available at the same location for use
as a control group.
Conclusions:
In this study, the AS intervention appeared to be associated with an improvement
in the appropriateness of antibiotic prescriptions and a significant reduction in total
antibiotic consumption, as well as with the consolidation of a prescriptive attitude
that favoured, whenever possible, the choice of antibiotics in the <Access= class.
The electronic tools specifically designed to support prescribers played an
important role in promoting compliance with the guidelines and ensuring the longterm sustainability of objectives achieved.
Regular monitoring of micro-organism resistance profiles at a local level is essential
for appropriately adapting the guidelines for empirical antimicrobial treatment
Dispelling the Myths Behind First-author Citation Counts
Full text linkWe conducted a full-scale evaluative citation analysis study of scholars in the XML research field to explore just how different from each other author rankings resulting from different citation counting methods actually are, and to demonstrate the capability of emerging data and tools on the Web in supporting more realistic citation counting methods. Our results contest some common arguments for the continued
use of first-author citation counts in the evaluation of scholars, such as high correlations between author rankings by first-author citation counts and other citation
counting methods, and high costs of using more realistic citation counting methods that are not well-supported by the ISI databases. It is argued that increasingly available digital full text research papers make it possible for citation analysis studies to go beyond what the ISI databases have directly supported and to employ more
sophisticated methods
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