|PHARMACOLOGY - ORIGINAL ARTICLES
|Year : 2021 | Volume
| Issue : 3 | Page : 211-219
To Evaluate the Implementation and Impact of an Antimicrobial Stewardship at a Tertiary Care Teaching Hospital in India
Sweta Kumari1, Kavita Dhar Bagati2, Bala Krishnan Sadasivam3, Gudise Chitti Babu4
1 Department of Pharmacology, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
2 Department of Pharmacology, School of Medical Sciences and Research, Sharda Hospital, Sharda University, Greater Noida, Uttar Pradesh, India
3 Department of Pharmacology, All Institute of Medical Sciences, Bhopal, India
4 JNU Hospital and Medical College, Jagatpura, Jaipur, Rajasthan, India
|Date of Submission||12-Feb-2021|
|Date of Decision||21-Feb-2021|
|Date of Acceptance||06-Apr-2021|
|Date of Web Publication||28-Jul-2021|
Kavita Dhar Bagati
Department of Pharmacology, School of Medical Sciences and Research, Sharda Hospital, Sharda University, Greater Noida, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Antimicrobial stewardship programs refer to antibiotic policies, antibiotic management programs, and antibiotic control programs. According to the Centers for Disease Control and Prevention (CDC) Project ICARE, all hospitals reported having an antibiotic formulary, and 91% used at least one other antimicrobial control strategy. Materials and Methods: The present study is a retrospective and observational study. All information was noted and surveyed sporadically. Any deviations from the agreed criteria were communicated, discussed, and documented. Antibiotic stewardship started from an inpatient setting. In the first phase, the patient pool from inpatient was addressed. For the prospective audit, two components had been recognized to have an evidence level 1. These were multidisciplinary rounds of infectious diseases patients and the use of antimicrobials. Result: In Medicine ward, the most common class of drugs was beta-lactam; in beta-lactam, a combination of piperacillin/tazobactam, amoxicillin/clavulanic acid, and macrolides was used with a mean dose of 1408.18 g. While in orthopedics, most common drugs for prophylaxis use were found to be cephalosporins (cefazolin first generation) with a mean dose of 937.07 ± 741.81 g to reduce surgical site infections. Prophylactic use of beta-lactam (amoxicillin/clavulanic acid) was prescribed for the most of the cases of Ears, Nose and Throat (ENT) surgery with mean dose of 1019.63 g as well as in pediatrics with mean dose of 579.47 g. Conclusions: Antimicrobial stewardships have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in inpatient settings.
Keywords: Antimicrobial resistance, antimicrobial stewardship, rational antibiotic use
|How to cite this article:|
Kumari S, Bagati KD, Sadasivam BK, Babu GC. To Evaluate the Implementation and Impact of an Antimicrobial Stewardship at a Tertiary Care Teaching Hospital in India. Int J Nutr Pharmacol Neurol Dis 2021;11:211-9
|How to cite this URL:|
Kumari S, Bagati KD, Sadasivam BK, Babu GC. To Evaluate the Implementation and Impact of an Antimicrobial Stewardship at a Tertiary Care Teaching Hospital in India. Int J Nutr Pharmacol Neurol Dis [serial online] 2021 [cited 2021 Oct 19];11:211-9. Available from: https://www.ijnpnd.com/text.asp?2021/11/3/211/322485
| Introduction|| |
Antimicrobial stewardship has been defined as “the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.”
During an outbreak of infections due to antimicrobial-resistant organisms, temporary restrictions on antimicrobial use may be applied along with enhanced infection control measures to terminate the outbreak. In general, unless these interventions are part of an ongoing program to optimize antimicrobial use, we will not focus on these temporary interventions. Several surveys have attempted to determine what proportions of health care institutions have implemented antimicrobial stewardship programs. In the United States, hospitals found that two-thirds had an antimicrobial formulary. Twenty-eight percent of hospitals required prior approval of an infectious diseases clinician before dispensing certain antimicrobials, while in 21% approval by a clinical pharmacist was required. Larger hospitals tended to be more likely to have antimicrobial restriction programs. Of 502 physician members of the Infectious Diseases Society of America’s Emerging Infections Network responding to a survey, 50% reported that their hospital of practice had an antimicrobial restriction program in place, with teaching hospitals significantly more likely to have such a program than nonteaching hospitals (60% versus 17%).
Essential to a successful antimicrobial stewardship program is the presence of at least one infectious diseases-trained physician who dedicates a portion of their time to the design, implementation, and function of the program. Supervision by an infectious diseases physician is necessary to ensure that therapeutic guidelines, antimicrobial restriction policies, or other measures are based on the best evidence and practice and will not put patients at risk. Having the program led by an infectious diseases specialist may also lend the program legitimacy among physicians practicing at the hospital, and reduce the chance of the program simply being seen as a pharmacy-driven cost-savings scheme.
Thus, we can implement an antimicrobial stewardship program as an ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients to improve patient outcomes, ensure cost-effective therapy, and reduce adverse sequelae of antimicrobial use (including antimicrobial resistance). In reality, many early programs were designed to control the rising acquisition cost of antimicrobial drugs. Reduction in total or targeted antimicrobial use, increase in appropriate drug use, improvement in susceptibility profiles of hospital pathogens, and improvement in clinical markers are now being increasingly targeted as outcomes by antimicrobial stewardship programs.
Antimicrobial management or stewardship programs aim to ensure the proper use of antimicrobial agents to provide the best treatment outcomes, to lessen the risk of adverse effects (including antimicrobial resistance), and to promote cost-effectiveness. Increasingly, long-term sustainability is found to be the major focus of antimicrobial stewardship. Implementing structural measures in health care institutions is, therefore, a major, but not the sole, focus of attention in promoting prudent use of antibiotics. The problem of antimicrobial resistance requires common strategies at all levels − for the prescribers and at the ward, departmental, hospital, national, and international levels.
| Materials and Methods|| |
The present study is a retrospective and observational study conducted over a period of 1 year and included 341 patients. Patients of either sex and of any age who had been admitted in ward and on antibiotic therapy were included. Outdoor patients were excluded in our study.
This study was conducted at Santosh Medical College in collaboration with All India Institute of Medical Sciences (AIIMS) Bhopal from various clinical departments such as medicine wards, surgical wards, pediatric wards, and orthopedics wards.
All data were documented and reviewed periodically. Any deviations from the agreed criteria were communicated, discussed, and documented.
Antibiotic stewardship started from an inpatient setting. In the first phase, the patient pool from inpatient was addressed. For the prospective audit, two components had been recognized to have an evidence level 1. These were multidisciplinary rounds of infectious diseases patients and the use of antimicrobials. The tertiary care teaching hospital of AIIMS Bhopal caters to a large number of patients. A schedule was drawn up for the following groups of patients: (1) medical wards, (2) surgical wards, (3) pediatrics ward, and (4) orthopedics ward in AIIMS Bhopal.
The information recorded in the pre-designed proforma was translated to statistical variables by coding. After the coding of data, the descriptive statistics of discrete variables i.e. frequency distributions and percentages of demographic profile was calculated. Continuous variables were reviewed as mean ± standard deviation. We further analyzed their diagnosis of current illness and various antibiotics administered to the patients, its dosage, frequency, duration and route of administration from their prescription. Percentage of individuals on the basis of antibiotic administration and their hospital stay were also assessed. Chi-square (χ2) test was used for categorical variables. The result was considered significant at 5% level of significance. All analysis was done in the SPSS (ver.22. IBM Corp.) software.
| Results|| |
The association of sociodemographic factors, clinical presentation, and insights into the antibiotic prescription practices in a large tertiary care teaching hospital. Observations of the present study are described under the following headings:
- Sociodemographic parameters.
- Clinical presentation.
A total of 341 patients enrolled for this study at Santosh Medical College, Ghaziabad and AIIMS, Bhopal from Departments of Medicine, Orthopedics, Surgery, and Pediatrics.
The male:female ratio was more or less the same even under the ward but this difference is not significant [Table 1].
|Table 1 Gender-wise frequency distribution of the population according to wards|
Click here to view
The mean age of patients was 35.55 ± 21.68 years with an age range of 1 to 90 years. The majority of subjects belonged to 1 to 20 years (30.20%) followed by 21 to 40 years (29.90%) of the age range [Figure 1].
When it is categorized according to the ward, the mean age of patients in the medicine ward was recorded 46.97 ± 20.96 years, and for orthopedics it was 33.43 ± 18.34 years, while mean age was documented to be 32.61 ± 16.89 years and 7.11 ± 6.23 years for surgery and pediatrics wards, respectively [Table 2]. A highly significant difference was observed between the age groups according to the wards. Most of our patients are of age <20 years.
Antibiotic administration pattern
For this study, subjects were categorized into 18 groups based on their diagnosis. Out of which, the majority of the population (20.50%) were found with a diagnosis of carcinoma followed by orthopedic diseases (19.90%), while the least number of patients (0.9%) were diagnosed with ophthalmological as well as thyroid diseases [Figure 2].
|Figure 2 Frequency distribution of the population under study in respect of diagnosis|
Click here to view
Out of our 341 study subjects, only 169 patients received any one of the survey antibiotics before their surgery. Out of all the antibiotics, beta-lactam (24.6%) and cephalosporin (23.2%) were administered to the majority of patients, while fluoroquinolones were prescribed to <1% (i.e., 0.6%) of the patients [Figure 3].
|Figure 3 Prophylaxis use of antibiotics among study subjects before surgery|
Click here to view
A significantly high number (nearly half) of patients received no antibiotics during the first time of the survey. All these patients belong to medicine and pediatrics ward. While those who were enrolled in either orthopedics or surgery wards, were necessarily prescribed antibiotics [Table 3].
|Table 3 Prophylaxis use of antibiotics among study subjects before surgery according to each ward they were enrolled|
Click here to view
No antibiotic was prescribed to a significant number of patients (50.4%) before surgery. Out of the remaining cases, 32 (9.4%) were administered orally and 137 (40.2%) were administered via injectable route. Whatever the route of drug administration chosen, the preferred drug was still beta-lactam followed by cephalosporin [Table 4].
|Table 4 Various antibiotics prescribed to the patients before surgery and their route of administration|
Click here to view
The frequency of the first antibiotic was prescribed two times a day to the majority of the patients (70.7%), while 20.8% of patients were administered three times a day after the surgery. The result is highly significant [Table 5].
|Table 5 Frequency of the first antibiotic prescribed to the patients after surgery|
Click here to view
Ten antibiotics accounted for prescriptions of the second antibiotic after the surgery. Out of these, macrolides (24.68%) were prescribed most commonly. Cephalosporins and beta-lactam were administered on an equal population (17.72%) [Figure 4].
When a record of study subjects was analyzed for antibiotic administration according to all the four wards they were enrolled in, most prescribed second antibiotics after the surgery was found to be macrolides antibiotic, which was significantly higher than other antibiotics [Table 6].
|Table 6 Distribution of study subjects administered second antibiotics according to each ward they were enrolled|
Click here to view
The mean hospital stay of the study population was recorded at 9.33 ± 6.168 days. The majority of patients (45.5%) were discharged in 6 to 10 days after staying in the hospital with a mean stay of 7.68 ± 1.440 days, followed by 26.1% of study subjects who were discharged within 5 days (4.06 ± 1.125 days). The least population, that is, 12.9% stayed in the hospital even after 15 days and their mean stay was recorded 22.09 ± 6.401 days [Table 7].
|Table 7 Distribution of the study subjects according to the hospital stay|
Click here to view
Most of the patients (45.5%) were discharged 6 to 10 days after first antibiotic administration but it did not show any significant difference [Table 8]. No difference was found according to the first and second antibiotics prescription in-hospital stay pattern, as it was found almost the same.
|Table 8 Distribution of cases according to the first antibiotic prescribed after surgery and total stay in hospital|
Click here to view
In medicine ward, the most common class of drugs was beta-lactam; in beta-lactam, a combination of piperacillin/tazobactam, amoxicillin/clavulanic acid, and macrolides was used with a mean dose of 1408.18 g. While in orthopedics, the most common drugs for prophylaxis use were found to be cephalosporins (cefazolin first generation) with a mean dose of 937.07 ± 741.81 g to reduce surgical site infections. Prophylactic use of beta-lactam (amoxicillin/clavulanic acid) was prescribed for most of the cases of Ears, Nose and Throat (ENT) surgery with mean dose of 1019.63 g as well as in pediatrics with mean dose of 579.47 g [Table 9].
|Table 9 Postsurgery antibiotic doses, duration, and frequency in an individual ward|
Click here to view
| Discussion|| |
In our study, a total of 341 patients enrolled for this study from Departments of Medicine, Orthopedics, Surgery, and Pediatrics. The amount of antibiotics prescribed to male (57.1%) and female (42.8%) were statistically not significant. In a similar study conducted by Ravi et al., of the 519 patients, 280 were male (54%) and 239 (46%) were female. Contrast to our study the amount of antibiotics prescribed to women (40%) was higher than the prescribed for men. The gender difference in antibiotic prescription was estimated and found to be statistically significant. The reason for gender differences in bacterial infections might be related to genetic background. The X chromosome’s encoding for genes involved in regulation of immunity − such as Toll-like-receptors 7 and 8 (sensing viral pathogens), Forkhead box P3 (FOXP3) (transcription factor for regulatory T cells), CD40L (immunoglobulin class switching), and CD132 (X-linked severe combined immunodeficiency) − is differently represented in men and women.
In our study, the amount of antibiotics prescribed to women according to the age group was: 1 to 20 years age group 30.20%, 21 to 40 years age group 29.90%, 41 to 60 years age group 24.90%, and the least <60 years of age group 15%. Foolad et al. revealed that the amount of antibiotics prescribed to patients in the 35 to 54 years age group was 40% followed by 36% among 16 to 34 years age group which was significant than that in the older or younger groups (P < 0.001). These data were confirmed by an American study showing that older patients consult their general practitioners more frequently than younger patients, although well-known risk factors for bacterial infections (such as regular and heavy alcohol drinking, smoking, nonmedical drug use, and obesity) were more prevalent in younger patients.
For this study, subjects were categorized into 18 groups based on their diagnosis. Out of which, the majority of the population (20.50%) were found with a diagnosis of carcinoma followed by orthopedic diseases (19.90%), while the least number of patients (0.9%) were diagnosed with ophthalmological as well as thyroid diseases. Upper respiratory tract infection (5%). In a study by Çakmakçi, the identified infection sites were: respiratory tract (34%), intra-abdomen (14%), urinary tract (10%), bloodstream (8%), and skin and soft tissue (7%).
Out of our 341 study subjects, only 169 patients received any one of the survey antibiotics before their surgery. Out of all the antibiotics, beta-lactam (24.6%) and cephalosporin (23.2%) were administered to the majority of patients, while fluoroquinolones were prescribed to <1% (i.e., 0.6%) of the patients. Rupali et al. stated that the number of cephalosporins prescribed to the patients were 44% followed by 32% macrolides and the least were quinolones. In relation to antibiotic use, a few studies demonstrated a significant increase in the use of at least one antibiotic class. This could be due to many reasons including an inappropriate metric for measuring antimicrobial use. For example, an increase in the use of narrow-spectrum antibiotic offsets a decrease in broad-spectrum antibiotic yielding lower antimicrobial resistance. Additionally, if the consumption of only certain antibiotics is restricted, a global decrease in resistance cannot be expected. It is possible that resistant strains are unrelated to changes made in hospitals, as there may be an inability to differentiate between community- or hospital-acquired isolates.
In our study, 32 subjects (9.4%) were administered orally and 137 (40.2%) were administered via injectable route. Whatever the route of drug administration chosen, the preferred drug was still beta-lactam followed by cephalosporin. According to Li et al., most of the drugs were given by the injectable route. Reason for injectable route is i.v. has 100% : It goes directly into systemic circulation. In injectable route, drug action is faster and surer (valuable in emergencies), while gastric irritation and vomiting are not provoked. Injectable routes can be employed even in unconscious, uncooperative, or vomiting patients. There are no chances of interference by food or digestive juices. Liver is also bypassed from i.v. route. But antimicrobial stewardships should also include the reduction due to the shift from intravenous to oral administration, the reduction in length of hospital stays, and reduced rates of infections due to multidrug-resistant bacteria.
In our study, the frequency of the first antibiotic was prescribed two times a day to the majority of the patients (70.7%), while 20.8% of patients were administered three times a day after the surgery. The result is highly significant. Ten antibiotics accounted for prescriptions of the second antibiotic after the surgery. Out of these, macrolides (24.68%) were prescribed most commonly. Cephalosporins and beta-lactam were administered on an equal population (17.72%). According to Kumar et al., 15 different groups of antibiotics were prescribed. The most frequently prescribed antibiotic group was third- and fourth-generation cephalosporins (18%), followed by ampicillin–sulbactam (13%), piperacillin–tazobactam (12%), carbapenems (10%), quinolones (8%), first-generation cephalosporins (6%), glycopeptides (5%), aminoglycosides (4%), and colistin (1%). The indications for antibiotic use were preemptive (42%), documented infection (26%), empirical (17%), surgical prophylaxis (12%), and medical prophylaxis (2%).
The mean hospital stay of the study population was recorded at 9.33 ± 6.168 days. The majority of patients (45.5%) were discharged in 6 to 10 days after staying in the hospital with a mean stay of 7.68 ± 1.440 days, followed by 26.1% of study subjects who were discharged within 5 days (4.06 ± 1.125 days). The least population, that is, 12.9% stayed in the hospital even after 15 days and their mean stay was recorded 22.09 ± 6.401 days. Hamblin et al. stated that decrease in length of stay from 20.3 days to 17.4 days was demonstrated with the intervention, but this was not statistically significant (P = 0.095), probably due to the sample size. In a meta-analysis, it was shown that interventions reduced length of stay by 1.12 days. In another study, it was demonstrated that a prospective audit and feedback intervention reduced median length of stay in patients with community-acquired pneumonia by nearly 0.5 days. The overall reduction in length of stay was 19.4%. Length of stay can be influenced by factors beyond antibiotic use, including comorbidities and disease severity, yielding nonstatistically significant increases in patients’ hospital stays. Targeted interventions (e.g., focus on reducing particular antibiotics) may lead to overall changes in length of stay.
Limitation of the study
The present study highlights an area of pharmacy practice where literature is scarce. However, the present study has some limitations that should be considered while interpreting the results. The study was a cross-sectional survey conducted in hospitals and the results cannot be generalized to other cities in India. The high response rate reported in this study could be because some of the respondents may provide extreme responses as compared to others and might be subjected to recall bias as the self-administered questionnaire depends on the honesty and faith of the respondents. Furthermore, it would have been more helpful to explore for which conditions antibiotics were dispensed and a disease-specific approach was taken. Despite the above limitations, our findings have significant implications for improving the use of antibiotics in community settings.
| Conclusions|| |
The present study revealed positive perceptions and practices of community pharmacists toward antimicrobial stewardship. Yet, some weak areas like an integration of the antimicrobial stewardship program in community pharmacies, the significance of interprofessional involvement, and dispensing of antimicrobials without a valid prescription still need improvement. Interventions to further improve the perception and practices of community pharmacists toward antimicrobial stewardship must be tailored to target the gaps underlined in this study. Further large-scale studies are necessary to validate the findings of the present study by including a greater number of community pharmacists in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Davey P, Marwick CA, Scott CL et al.
Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017;2:CD003543.
Lee CF, Cowling BJ, Feng S et al.
Impact of antibiotic stewardship programs in Asia: a systematic review and meta-analysis. J Antimicrob Chemother 2018;73:844-51.
Kakkar M, Walia K, Vong S, Chatterjee P, Sharma A. Antibiotic resistance and its containment in India. BMJ 2017;358:j2687.
Barlam TF, Cosgrove SE, Abbo LM et al.
Executive summary: 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;62:1197-202.
Nation RL, Garonzik SM, Thamlikitkul V et al.
Dosing guidance for intravenous colistin in critically ill patients. Clin Infect Dis 2017;65:565-71.
Patterson TF, Thompson GR 3rd, Denning DW et al.
Executive summary: practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis 2016;63:433-42.
Baddour LM, Wilson WR, Bayer AS et al.
Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation 2015;132:1435-86.
Alawi MM, Darwesh BM. A stepwise introduction of a successful antimicrobial stewardship program. Experience from a tertiary care university hospital in Western, Saudi Arabia. Saudi Med J 2016;37:1350-8.
Luther VP, Shnekendorf R, Abbo LM et al.
Antimicrobial stewardship training for infectious diseases fellows: program directors identify a curriculum need. Clin Infect Dis 2018;67:1285-7.
Ravi N, Laha A, Hmar L et al.
Exploring the prescribing behaviors and the mind of antibiotic prescribers is critical for a successful antibiotic stewardship program: results of a survey from Eastern India. Indian J Med Microbiol 2017;35:299-301.
] [Full text]
Singh S, Charani E, Wattal C, Arora A, Jenkins A, Nathwani D. The state of education and training for antimicrobial stewardship programs in Indian hospitals − a qualitative and quantitative assessment. Antibiotics (Basel) 2019;8:11.
Foolad F, Huang AM, Nguyen CT et al.
A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy for the treatment of community-acquired pneumonia. J Antimicrob Chemother 2018;73:1402-7.
Sartelli M, Duane TM, Catena F et al.
Antimicrobial stewardship: a call to action for surgeons. Surg Infect (Larchmt) 2016;17:625-31.
Waters CD. Pharmacist-driven antimicrobial stewardship program in an institution without infectious diseases physician support. Am J Health Syst Pharm 2015;72:466-8.
Çakmakçi M. Antibiotic stewardship programs and the surgeon’s role. J Hosp Infect 2015;89:264-6.
Rupali P, Palanikumar P, Shanthamurthy D et al.
Impact of an antimicrobial stewardship intervention in India: evaluation of post-prescription review and feedback as a method of promoting optimal antimicrobial use in the intensive care units of a tertiary-care hospital. Infect Control Hosp Epidemiol 2019;40:512-9.
Walia K, Ohri VC, Mathai D; Antimicrobial Stewardship Programme of ICMR. Antimicrobial stewardship program (AMSP) practices in India. Indian J Med Res 2015;142:130-8.
] [Full text]
Nain VK, Khurana GS, Singh S et al.
Antibiotic resistance pattern in bacterial isolates obtained from different water samples of Delhi region. DU J Undergrad Res Innov 2015;1:219-27.
Sikkens JJ, Gerritse SL, Peters EJ, Kramer MH, Van Agtmael MA. The “morning dip” in antimicrobial appropriateness: circumstances determining appropriateness of antimicrobial prescribing. J Antimicrob Chemother 2018;73:1714-20.
Afzal M, Tenali J, Burri RR. Antibiotic stewardship program in a tertiary private hospital in India − a case study. Infect Dis Health 2017;22:S3.
Li Z, Cheng B, Zhang K et al.
Pharmacist-driven antimicrobial stewardship in intensive care units in East China: a multicenter prospective cohort study. Am J Infect Control 2017;45:983-9.
Baubie K, Shaughnessy C, Kostiuk L et al.
Evaluating antibiotic stewardship in a tertiary care hospital in Kerala, India: a qualitative interview study. BMJ Open 2019;9:e026193.
Singh S, Menon V, Kumar A et al.
Implementation of antibiotic stewardship: a South Indian experience. Open Forum Infect Dis 2017;4(Suppl 1):S267-8.
Kumar A, Sahu M, Sahoo PR, Wig N. Under-explored dimensions of anti-microbial stewardship in India. J Assoc Physicians India 2018;66:69-71.
Laxminarayan R, Chaudhury RR. Antibiotic resistance in India: drivers and opportunities for action. PLoS Med 2016;13:e1001974.
Hamblin S, Rumbaugh K, Miller R. Prevention of adverse drug events and cost savings associated with PharmD interventions in an academic level I trauma center: an evidence-based approach. J Trauma Acute Care Surg 2012;73:1484-90.
Rimawi RH, Cook PP, Gooch M et al.
The impact of penicillin skin testing on clinical practice and antimicrobial stewardship. J Hosp Med 2013;8:341-5.
Sutherland T, Beloff J, Lightowler M et al.
Description of a multidisciplinary initiative to improve SCIP measures related to pre-operative antibiotic prophylaxis compliance: a single-center success story. Patient Saf Surg 2014;8:37.
Seah XFV, Ong YLR, Tan SW et al.
Impact of an antimicrobial stewardship program on the use of carbapenems in a tertiary women’s and children’s hospital, Singapore. Pharmacotherapy 2014;34:1141-50.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]