Sara Al Balushi

Antimicrobial Stewardship Programs (ASP) were introduced in healthcare as a public health priority to promote appropriate prescribing of antimicrobials, to reduce adverse events related to antimicrobials, as well as to control the escalating challenges of antimicrobial resistance. To deliver aimed outcome objectives, ASPs involve multiple connected implementation process measures. A systematic review was conducted to evaluate both concepts of ASPs. Guided by PRISMA frames, published systematic reviews (SR) focusing on ASPs restricted to secondary and tertiary healthcare were evaluated over the past 10 years involving all age groups. Out of 265 identified SR studies, 63 met the inclusion criteria. The majority were conducted in Europe and North America, with limited studies from other regions. In the reviewed studies, all age groups were examined, although they were conducted mainly on adults when compared to children and infants. Both process and outcomes measures of ASPs were examined equally and simultaneously through 25 different concepts, dominated by efficacy, antimicrobial resistance, and economic impact, while information technology as well as role of pharmacy and behavioral factors were equally examined. The main broad conclusions from the review were that, across the globe, ASPs demonstrated effectiveness, proved efficacy, and confirmed efficiency, while focused evaluation advocated that developed countries should target medium- and small-sized hospitals while developing countries should continue rolling ASPs across healthcare facilities. Additionally, the future of ASPs should focus on embracing evolving information technology to bridge the gaps in knowledge, skills, and attitude, as well as to enhance appropriate decision making.

Background: Antimicrobial Stewardship Programs (ASP) were introduced in healthcare as a public health priority to promote appropriate prescribing of antimicrobials, reduce antimicrobials adverse events as well as control challenges of antimicrobial resistance. To deliver aimed outcome objectives, ASPs involve multiple implementation measures. A review of systematic review was conducted to evaluate ASPs process and outcome measures. Guided by PRISMA frames, published systematic reviews (SR) focusing on ASPs restricted to secondary healthcare were evaluated over the past 10 years by examining major and primary databases involving all age groups. Out of 265 identified SR studies, 63 met inclusion criteria, the majority were conducted in European and North American regions. All age groups were examined in the studies but mainly conducted in adults when compared to children and infants . Both ASPs process and outcomes measures were examined equally and simultaneously through 25 different concepts, dominated by efficacy , antimicrobial resistance , and economic impact while information technology as well as role of pharmacy and behavioural factors were equally examined . The main broad conclusions from the review , that across the globe, ASPs demonstrated effectiveness, proved efficacy, and confirmed efficiency while focused evaluation advocate that developed countries should target medium and small sized hospitals while developing countries should continue rolling ASPs in their healthcare facilities . Additionally , the future of ASPs should focus on embracing evolving information technology to bridge gaps in knowledge, alter attitude and enhance decision making .

Background: Ivabradine is recommended in heart failure (HF) patients to reduce cardiovascular death and hospitalization due to worsening of HF symptoms. Aims and Objectives: To study the effect of Ivabradine in addition to guideline-directed medical therapy (GDMT) in a group of HF patients with HR more than 70 bpm, HF with reduced ejection fraction (HFrEF) left ventricular ejection fraction (LVEF ≤ 40%), and New York Heart Association class II-IV. Methods: The study was conducted at Heart Hospital, Hamad Medical Corporation, Qatar. HF patients with age > 18 years, LVEF ≤40%, on GDMT, and HR of ≥70 bpm were included. The study population was divided into two groups: ivabradine group and non-ivabradine group. The primary outcomes were risk, number and length of hospitalizations due to worsening HF, and cardiovascular mortality. The secondary outcome was all-cause mortality. Baseline characteristics were collected at enrollment. Study outcomes were compared in the two groups by applying Chi-square and Fisher's exact tests. Logistic regression model was applied to assess both hospitalizations and cardiovascular mortality. Results: A total of 111 patients were studied, 37 (33.94%) ivabradine group and 74 (66.67%) non-ivabradine group. Risk of hospitalization was lower in Ivabradine group compared to non-Ivabradine group (odds ratio: 0.43, 95% confidence interval [CI]: 0.16–1.015, P = 0.094). Average length of hospitalization in ivabradine and non-ivabradine groups was 12.54 and 8.91 days, respectively (incidence rate ratio [IRR]: 1.63, 95% CI: 0.79–3.38, P = 0.187). Compared to non-ivabradine, ivabradine patients had lower number of hospitalizations (IRR: 1.13, 95% CI: 0.61–2.11, P = 0.694). Death rate in both ivabradine and non-ivabradine groups was 3. Conclusions: Ivabradine along with GDMT reduces the risk of hospitalization due to worsening HF symptoms. Ivabradine had no significant effect on cardiovascular mortality and all-cause mortality. HFrEF non-Arabs patients have lower risk, number and length of hospitalization, and mortality compared to Arabs.

Background: Diuretics, ACE inhibitors or ARB, beta-blockers, and aldosterone antagonists are well established guideline directed medical therapies (GDMT) used in patients with left ventricular reduced ejection fraction (LVrEF) heart failure (HF). Hospitalization is an important marker of poor heart failure prognosis. Scientific reports have shown that ivabradine reduces cardiovascular outcomes (cardiovascular death and hospitalization due to worsening heart failure symptoms) in HF patients. However, in the SHIFT trial 8% of the ivabradine study group were from Asia, with 3% from other races and Caucasians making up the majority of the sample (89%). No previous studies have investigated the effect of ivabradine on cardiovascular outcomes among Arabs and non-Arabs from Asia and Africa or Middle Eastern countries in general. The aim of this single-center retrospective study was to assess the effect of ivabradine in addition to GDMT in a group of HF patients with a heart rate (HR) of more than 70 bpm, LVrEF (EF < 40%) and New York Heart Association (NYHA) class II-IV, compared with another group of patients not taking ivabradine with HR of more than 70 bpm, LVrEF and NYHA class II-IV on GDMT. Methods: The study was a retrospective cohort study. It was conducted in the Heart Hospital (HH) at Hamad Medical Corporation (HMC) in Qatar. All patients registered in the HF clinic from April 2015 to September 2016 were enrolled in the study. They were either exposed or not to ivabradine (). The primary outcomes studied were the associated risk, number and length of hospitalizations due to worsening HF, and cardiovascular mortality. The secondary outcome was mortality due to all causes. Patients’ follow up records for 18 months after recruitment were observed. Baseline characteristics were collected at enrollment. Logistic regression model was applied to assess both hospitalizations and cardiovascular mortality. The number of hospitalizations due to worsening HF was modeled using a Poisson regression model. Length of hospitalization (in days) was estimated and assessed between groups by a negative binomial regression. Results: The study included 111 patients (): 37 (33.94%) ivabradine patients and 74 (66.67%) non-ivabradine patients. The number of ivabradine patients hospitalized were 23 (62.16%) vs 54 hospitalized non-ivabradine patients (72.97%) (OR 0.43, 95% CI 0.16-1.015, p = 0.094) (). Days of hospitalization for the ivabradine group were 464 (41.28%) vs 660 (58.72%) for non-ivabradine (IRR 1.63, 95% CI 0.79-3.38, p = 0.187). The death rate in ivabradine patients was three (two patients died due to CVD and one due to other causes) and it was also three in non-ivabradine patients (one due to CVD and two due to other causes). Testing the outcome by the factor of ethnicity instead of treatment group had different results. The number of Arabs admitted was 55 (78.57%) compared to 22 non-Arabs (53.66%) (chi-square, p = 0.006). The number of Arabs admitted in the ivabradine group 19 (76%) was significantly higher than for non-Arabs 4(33.33%) (Pearson chi-square, p = 0.012). Conclusion: The results of the study are not generalizable but showed that ivabradine patients with HFrEF along with GDMT had less risk of hospitalizations but lengthier stays and increased count of hospitalization compared to non-ivabradine patients. Though the study did not aim to explore the differences between Arab and non-Arab patients, significant differences were found in the statistical analysis highlighting the need for further research to investigate the reasons behind these differences.