2.3. Antimicrobial stewardship program:
The program consists of three main parts: (1) Interventional part including preauthorization of restricted antibiotics list by clinical pharmacy specialists and primary physician, antibiotic timeout to reassess empiric antibiotics use 48-72 hours after their initiation, dosing optimization (based on patient-specific drug clearance, the volume of distribution, infection site, and microbiological factors), and managing the antibiotics-related problems, (2) Designing and implementing hospital-specific guidelines and antimicrobial policies, (3) Educational part including education of health-care professionals regarding antibiotics administration and handling.
2.4. Bacterial isolates:
Blood samples were transferred into brain heart infusion broth, incubated at 35 Co for 5 days, and if any turbidity was observed, it was transferred into MacConkey agar and blood agar. Sputum samples were inoculated in MacConkey agar, blood agar, and chocolate agar. Swab samples were inoculated in MacConkey agar and blood agar.
2.5. Klebsiella identification:
The Klebsiella isolates obtained in MacConkey agar showed large, highly mucoid, and pink colonies. Microscopic examination with gram stain showed short gram-negative rods. Confirmation forKlebsiella was performed using biochemical reactions (Hansen, Aucken, Abiola, & Podschun, 2004). These include Kligler’s Iron Agar (KIA) test, Lysine iron agar (LIA) test, Motility indole ornithine (MIO) test, Citrate test, and Urease test.
2.6. Antibiotic susceptibility:
The antibiotic susceptibility using the disc diffusion method was performed with Mueller Hinton agar and discs from Oxoid®, United Kingdom and based on Kirby-Bauer technique (Bauer, 1966) and the cut-off values for clear zones set by The Clinical & Laboratory Standards Institute (CLSI) recommendations and standards 2018 (In, 2018). The test discs were ceftriaxone 30 ηg, cefotaxime 30 ηg, ceftazidime 30 ηg, meropenem 10 ηg, and imipenem 10 ηg.
Klebsiella isolates were classified into three grades according to antibiotics susceptibility: grade 1 which are sensitive to ceftriaxone and cefotaxime, grade 2 which resist ceftriaxone/cefotaxime, and grade 3 including strains resistant to meropenem/imipenem (carbapenem-resistant Klebsiella (CRK))