br Acknowledgments We thank all the
Acknowledgments We thank all the ultramarathon runners who participated in this study and all the doctors, nurses, and emergency medical technicians who provided professional care at the ultramarathon race. We also thank our colleagues at Soochow University, Taipei, Taiwan and the Chinese Taipei Association of Ultra Runners, Taipei, Taiwan, who all assisted at the event. Finally, this study was supported by Taipei Veterans General Hospital, Taipei, Taiwan (V100C-202 and V106C-130).
Introduction Misuse of cyclooxygenase inhibitors is a common occurrence in hospitals. It was estimated that up to 40–50% of antibiotic use did not abide by local and national antibiotic guidelines or was discordant with microbiological results. Patients are placed at additional risk for adverse effects when exposed to unnecessary antibiotics, including Clostridium difficile infection, a potentially life-threatening infection associated with antibiotic therapy. Another major problem of antibiotic use is the selection of drug-resistant bacteria, particularly multidrug-resistant organisms. Overuse of antimicrobial agents exerts excessive selection pressures on the targeted as well as the bystander microbes that are exposed to the drugs. Alteration of the expression of genes regulating drug resistance is observed when microbes are exposed to antibiotics, and antimicrobial agents play complex roles in that they inhibit microbes while inducing resistance, and even help in dissemination of resistance at the same time. Multidrug-resistant organisms are increasingly being recognized as a global public health issue. Healthcare-associated infection and antimicrobial resistance that significantly increase morbidity, mortality, and medical costs are current challenges to the treatment of infectious diseases in Taiwan. Implementation of antibiotic stewardship programs (ASPs) has been shown to effectively reduce unnecessary antibiotic use and optimize the treatment of infectious diseases. The World Health Organization strongly recommends that governments implement ASPs for the containment of antimicrobial resistance. Following the reduction of antibiotic consumption, a decrease in the rate of drug-resistant bacteria is expected. To be successful, multiple aspects should be considered in an ASP. Several “core elements” have been suggested by the Center of Disease Control of the United States, including leadership commitment to dedicate necessary resources, appointing an accountable leader responsible for program outcomes, drug expertise to improve antibiotic use, actions to support optimal antibiotic use, tracking and monitoring antibiotic use and resistance, and reporting information to staff on improving antibiotic use and resistance. A systemic education program is one of the essential components that comprise an ASP, although education alone is only marginally effective unless it is incorporated with other control measures. Regular education and training furnish prescribers with fundamental knowledge on drug resistance bacteria, principles of antibiotic use, and infectious disease management, whereas a theme-based educational program provides a platform for stressing facility-specific issues and influencing prescribers’ behavior. Recently, implementation of an education-based ASP was shown to improve antimicrobial prescriptions and consumption, even when restrictive measures were not implemented. Here, we demonstrate the effectiveness of an educational program targeting primary prescribers to control the consumption of specific antibiotic classes in the early phase of a multidisciplinary ASP.
Discussion Based on the national database of antimicrobial resistance from the Taiwan Nosocomial Infection Surveillance System during the period 2003–2012, the proportion of A. baumannii isolates resistant to imipenem or meropenem increased from 17.2% to 72.8%. In YMUH, an increase in the use of carbapenems was observed in recent years. The increasing consumption of carbapenems was clearly associated with a steady rise in the rate of CRAB (up to 70.8% in January 2014), of which the majority was resistant to imipenem and meropenem. Although infection control measures including isolation of colonized patients, environmental cleaning, and hand hygiene promotion had been reinforced in the past decade, the effect was only marginal and the rate of CRAB continued to rise. Theoretically, clinicians are supposed to treat patients according to guidelines that have taken into account both the antibiotics effectiveness and the development of resistance of antimicrobials. However, in clinical practice, prescribers are generally more concerned about the effects, but not the resistance of, antimicrobial therapy. The usual scenario is that broad-spectrum antibiotics such as imipenem or meropenem are selected when the patient is unstable and continue to be used unless microbiological studies show clear evidence for de-escalation.