Executive Summary: Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Current Status of Antimicrobial Stewardship Programs in São Paulo Hospitals

OBJECTIVES

Antimicrobial stewardship programs (ASPs) comprise coordinated interventions designed to improve antimicrobial use. Understanding the current structure of ASP hospitals will support interventions for the improvement of these programs. This study aimed to describe the status of ASPs in hospitals in São Paulo, Brazil.

METHODS

A cross-sectional survey was conducted on the ASPs of hospitals in the state of São Paulo from March to July 2018. Through interviews by telephone or e-mail, we queried which components of the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and Centers for Disease Control and Prevention guidelines were implemented.

RESULTS

The response rate was 30% (28/93 hospitals), and 26 hospitals (85%) reported having a formal ASP. The most frequently implemented strategies were antimicrobial surgical prophylaxis guidelines (100%), empiric sepsis guidelines (93%), and the presence of ASP team members during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring, and an adjustment program for patients on IV aminoglycosides (3%). Regarding the metrics of the ASP, the most common indicator was the rate of antimicrobial resistance (77%). Eighteen hospitals evaluated antimicrobial consumption using defined daily dose, and only 29% evaluated the days of therapy; 61% of hospitals reported their results to the hospital administration and 39% to the prescribers.

CONCLUSIONS

Most hospitals have a formal and active ASP, but with timely actions. We observed inconsistencies between what program leaders understand as the main objective of ASP and the metrics used to evaluate it. Part of the effort for the next few years should be to improve program evaluation metrics and to provide feedback to physicians and hospital leadership.

Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health

Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.

Review of antimicrobial resistance control strategies: low impact of prospective audit with feedback on bacterial antibiotic resistance within hospital settings

BACKGROUND

Antimicrobial stewardship constitutes an essential element of any concerted effort to tackle bacterial resistance, a rising public health threat both in community as well as hospital settings. The term comprises variable strategies which aim to optimise prescribing practices through either antibiotic restrictions or prospective audits of prescriptions with subsequent feedback to clinicians. Although highly debated, the actual effects of the latter on the antimicrobial susceptibility patterns of hospital flora are uncertain. The present study aims to review and evaluate the literature concerning the impact of persuasive stewardship strategies on antimicrobial resistance within hospitals.

MATERIALS AND METHODS

A literature review covering the period to 1st April 2020 was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases.

RESULTS

Fifteen studies were retrieved, including twelve simple before-and-after, and three interrupted time-series studies. Audit frequency and compliance rates varied broadly. The rationale of treatment optimisation is not clear in most cases. Overall, surveillance of sentinel microorganisms through antibiograms indicates ambiguous results, with uncertainty as to whether the few successes are due to a causal effect, random incidence fluctuations, or confounding. The most informative approach targeted solely fluoroquinolones, reporting improvements in relevant Pseudomonas susceptibilities and MRSA, but without sufficient data on other effects of the strategy to assess its overall utility in clinical practice.

CONCLUSION

Higher standard research is needed to address the actual effects of persuasive stewardship strategies on antimicrobial susceptibility patterns. At present, they seem inadequate to play a decisive role in bacterial resistance control within hospitals.

Metrics of neonatal antibiotic use

Responsible use of antibiotics is critical to preserve their effectiveness and to minimize adverse outcomes associated with overuse and misuse. Newborn infants are a unique population with high rates of antibiotic exposure. In order to improve neonatal antibiotic use, accurate and meaningful metrics are required. In this review, we highlight and compare existing antibiotic use metrics in detail, including definitions, current applications, advantages, and limitations of each metric, with a focus on applicability to neonatal populations. We explore future directions for identification of accurate and meaningful metrics that will allow hospitals and stakeholders to pinpoint antibiotic utilization practices that should be emulated or avoided, and ultimately improve the safety and quality of neonatal care.

Penicillin Allergy Assessment in Pregnancy: Safety and Impact on Antibiotic Use

BACKGROUND

Penicillin and other beta-lactam antibiotics are recommended for group B Streptococcus and cesarean section prophylaxis, but approximately 10% of pregnant patients report a penicillin allergy.

OBJECTIVE

To assess the safety and impact of penicillin allergy evaluation in pregnant patients.

METHODS

In this retrospective study of obstetrician-ordered Allergy/Immunology (AI) electronic consultations (e-consults) from September 20, 2017 through December 31, 2019, we reviewed the electronic health record for e-consult recommendation; patient demographic, obstetric, and allergy histories; and peripartum antibiotic utilization with indication. For patients whose electronic consultation recommended an in-person AI evaluation, testing outcomes were determined, and multivariable logistic regression models were used to compare antibiotic use between patients who did and did not receive an in-person AI evaluation.

RESULTS

Of 389 obstetrician-ordered e-consults, 363 (93%) recommended an in-person AI evaluation; of these, 222 (61%) patients received an in-person AI evaluation. Of 220 (99%) patients skin tested, 209 (95%) had their penicillin allergy label safely removed. Compared with patients who did not receive an in-person AI evaluation despite it being recommended (n = 141), patients with in-person AI evaluation (n = 222) had reduced peripartum vancomycin (adjusted odds ratio [aOR], 0.07; 95% CI, 0.01-0.33), clindamycin (aOR, 0.17; 95% CI, 0.08-0.34), and gentamicin (aOR, 0.39; 95% CI, 0.19-0.78) use and increased penicillin (aOR, 18.0; 95% CI, 6.30-51.2) use. The fully AI evaluated patients had increased first-line antibiotic prophylaxis for group B Streptococcus (aOR, 26.9; 95% CI, 6.32-114) and cesarean section (aOR, 1.94; 95% CI, 1.06-3.52).

CONCLUSIONS

In a sample of 220 pregnant patients with penicillin allergy histories and in-person AI evaluation, penicillin allergy testing was safe and associated with significantly reduced broad-spectrum antibiotic use and increased first-line beta-lactam antibiotic use.

A Narrative Review of Antimicrobial Stewardship Interventions within In-patient Settings and Resultant Patient Outcomes

The overuse of antibiotics has led to various healthcare problems such as the emergence of resistance in infectious microbes and mortality due to antibiotic resistant healthcare associated infections (HAIs). An antimicrobial stewardship (AMS) program is the set of interventions used worldwide to enhance the rational use of antibiotics especially for the hospitalized patients. This review aimed to describe the characteristics of the implemented AMS programs in various hospitals of the world mainly focusing on the interventions and patients outcomes. The literature about AMS program was searched through various databases such as PubMed, Google Scholar, Science Direct, Cochran Library, Ovid (Medline), Web of Science and Scopus. In this review the literature pertaining to the AMS programs for hospitalized patients is sorted on the basis of various interventions that are categorized as formulary restriction (pre-authorization), guideline development, clinical pathway development, educative interventions and prospective audit. Moreover a clear emphasis is laid on the patient outcomes obtained as a result of these interventions namely the infection control, drop in readmission rate, mortality control, resistance control and the control of an overall cost of antibiotic treatment obtained mainly by curbing the overuse of antibiotics within the hospital wards. AMS program is an efficient strategy of pharmacovigilance to rationalize the antimicrobial practice for hospitalized patients as it prevents the misuse of antibiotics, which ultimately retards the health threatening effects of various antibiotics.

The Association Between the Frequency of Interruptions in Antibiotic Exposure and the Risk of Health Care-Associated Clostridiodes difficile Infection

Background

Although antibiotic use is an established risk factor for health care-associated Clostridiodes difficile infection, estimates of the association between infection and antibiotic use vary, depending upon how antibiotic exposure is measured.

Objectives

The purpose of this study was to explore the association between the frequency of interruptions in antibiotic exposure and the risk of health care-associated C difficile infection.

Methods

A retrospective chart review cohort study was conducted of all inpatients between 2011and 2016 from a single academic health center who received at least 1 dose of a systemic antibacterial for a cumulative duration of >3 days and ≤30 days. The measures of antibiotic exposure examined were duration—cumulative total calendar days of antibiotics therapy—and continuity—the frequency of interruptions in antibiotic exposure that was defined as the number of antibiotic treatment courses.

Results

A total of 52,445/227,967 (23%) patients received antibacterial therapy for >3 days and ≤30 days during their hospitalization. Of these, 1161 out of 52,445 (2.21%) were patients with health care-associated C difficile infection. An adjusted multivariable logistic regression analysis revealed that the risk of C difficile increased with longer cumulative days (odds ratio = 2.7; comparison of >12 days to ≤5 days) and fewer interruptions of antibiotic treatment (odds ratio = 0.78; comparison of >3 discrete antibiotic treatment courses to 1 course or continuous antibiotic treatment course; all P values < 0.05).

Conclusions

For patients who received the same number of cumulative days of therapy, the patients who had more frequently interrupted courses of antibiotic therapy were less likely to experience health care-associated C difficile infection. (Curr Ther Res Clin Exp. 2020; 81:XXX–XXX)

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2019

Staying current on literature related to antimicrobial stewardship can be challenging given the ever-increasing number of published articles. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship–related peer-reviewed literature that detailed an actionable intervention for 2019. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the actionable intervention used by antimicrobial stewardship programs to provide key stewardship literature for teaching and training and to identify potential intervention opportunities within one’s institution.

Prescribing Pattern of Antibiotics Using WHO Prescribing Indicators Among Inpatients in Ethiopia: A Need for Antibiotic Stewardship Program

Background

Irrational prescribing of antibiotics is a universal public health problem, leading to antibiotic resistance. Understanding the prescribing pattern of antibiotics is crucial to tackling irrational prescription. Yet, comprehensive studies regarding the prescribing pattern of antibiotics among inpatients and the need for an Antibiotic Stewardship Program (ASP) are lacking in Ethiopia. This study aimed to evaluate prescribing patterns of antibiotics and the need for an ASP.

Methods

A hospital-based prospective observational study was carried out from February 2019 to December 2019. This study was conducted among patients admitted to Aksum University Comprehensive Specialized Hospital, Ethiopia. Data were collected using a data abstraction format generated by World Health Organization (WHO) prescribing indicators. Data analysis was carried out using SPSS version 25.0.

Results

A total of 1653 antibiotics were prescribed for 822 inpatients. Overall, 52.3% of patients had at least one oral and/or injectable antibiotic prescribed, for a mean duration of 4.2 (SD=2.3) days. The average number of prescribed antibiotics per patient was 2.01 (SD=1.9). The majority (97.6%) of antibiotics were prescribed by their generic name, and all prescribed antibiotics were from the national Essential Medicine List (EML). Frequently prescribed injectable and oral antibiotics were ceftriaxone (24.5%) and azithromycin (12.9%), respectively. Culture and sensitivity testing were not performed in any of the cases. During the study period, 65.2% of key antibiotics were available in stock.

Conclusion

In this study, more than half of patients were on at least one antibiotic, and all antibiotics were prescribed from the national EML. However, all antibiotics were prescribed empirically. This result shows that the prescribing pattern of antibiotics in the hospital deviates from and is non-compliant with the standard endorsed by WHO. This study provides evidence for the necessity and a way forward for the establishment of an ASP in the hospital that may help to introduce the prescribing of antibiotics with the aid of culture and sensitivity tests, and to develop institutional guidelines.

Tackling Antimicrobial Resistance by promoting Antimicrobial stewardship in Medical and Allied Health Professional Curricula

INTRODUCTION

Antimicrobial resistance poses a serious threat to global health with significantly higher morbidity, mortality, and economic burden. This review aims to discuss the importance of the promotion of antimicrobial stewardship in medical and allied health professional curricula and training/educating tomorrow's doctors in combatting antimicrobial resistance. A narrative literature review was conducted to retrieve relevant information related to antimicrobial resistance and stewardship and their implications on medical and allied health professional education and training from searches of computerized databases, hand searches, and authoritative texts.

AREAS COVERED

Antimicrobial stewardship programs improve rational antibiotic use, reduce antimicrobial resistance, decrease complications of antibiotic use, and improve patient outcomes. Though health professional students recognize the importance and impact of antibiotic prescribing knowledge, many studies have consistently demonstrated low levels of confidence and competencies amongst students, highlighting that health professional schools failed to prepare them to prescribe antibiotics accurately.

EXPERT OPINION

There is an urgent call for the integration of antimicrobial stewardship teaching at the undergraduate level of medical education to train future prescribers on this critical aspect of public health. Proper undergraduate education on rational antibiotics use would enable health professional graduates to enter clinical practice with adequate competencies to become rational prescribers.

The Infectious Diseases Society of America's 10 × '20 Initiative (10 New Systemic Antibacterial Agents US Food and Drug Administration Approved by 2020): Is 20 × '20 a Possibility?

BACKGROUND

Infections caused by antibiotic-resistant bacteria, including carbapenem-resistant Enterobacteriaceae, have increased in frequency, resulting in significant patient morbidity and mortality. The Infectious Diseases Society of America continues to propose legislative, regulatory, and funding solutions to address this escalating crisis. This report updates the status of development and approval of systemic antibiotics in the United States as of late 2018.

METHODS

We performed a review of the published literature and on-line clinical trials registry at www.clinicaltrials.gov to identify new systemically acting orally and/or intravenously administered antibiotic drug candidates in the development pipeline, as well as agents approved by the US Food and Drug Administration since 2012.

RESULTS

Since our 2013 pipeline status report, the number of new antibiotics annually approved for marketing in the United States has reversed its previous decline, likely influenced by new financial incentives and increased regulatory flexibility. Although our survey demonstrates progress in development of new antibacterial drugs that target infections caused by resistant bacterial pathogens, the majority of recently approved agents have been modifications of existing chemical classes of antibiotics, rather than new chemical classes. Furthermore, larger pharmaceutical companies continue to abandon the field, and smaller companies face financial difficulties as a consequence.

CONCLUSIONS

Unfortunately, if 20 × '20 is achieved due to efforts embarked upon in decades past, it could mark the apex of antibiotic drug development for years to come. Without increased regulatory, governmental, industry, and scientific support and collaboration, durable solutions to the clinical, regulatory, and economic problems posed by bacterial multidrug resistance will not be found.

Prospective evaluation of a rapid antimicrobial susceptibility test (QMAC-dRAST) for selecting optimal targeted antibiotics in positive blood culture

OBJECTIVES

MALDI-TOF MS has been successfully used for empirical antibiotic selection. However, limited data are available regarding the usefulness of MALDI-TOF MS in common resistant organisms compared with rapid antimicrobial susceptibility testing (AST). We prospectively evaluated the usefulness of rapid AST, compared with MALDI-TOF MS, for optimal antibiotic selection by infectious disease (ID) physicians in patients with bacteraemia including polymicrobial infection.

METHODS

Three hundred and fifty-nine patients with positive blood culture were included for analysis. ID physicians prospectively decided on antibiotic regimens with consensus at each timepoint of receiving results of Gram stain, MALDI-TOF MS and rapid AST, the last of which was performed using QMAC-dRAST.

RESULTS

ID physicians with MALDI-TOF MS results chose optimal targeted antibiotics in 255 (71.0%) cases, with appropriate antibiotic selection in 303 (84.4%) cases. The proportion of optimal targeted antibiotic selection and appropriate antibiotic selection was significantly lower for resistant strains than for susceptible strains [62.5% versus 79.2% (P < 0.001) and 68.2% versus 100% (P < 0.001), respectively]. QMAC-dRAST results led to optimal antibiotic treatment in 95 (91.3%) of the 104 cases receiving non-optimal targeted antibiotics. Optimal targeted treatments based on QMAC-dRAST results were possible in 322 (98.2%) of the 328 cases with monobacterial infection and in 345 (96.1%) of the 359 cases with monobacterial and polymicrobial infection.

CONCLUSIONS

MALDI-TOF MS has a high chance of failure in guiding ID physicians to optimal antibiotics, especially against resistant organisms. With increasingly common resistant organisms, rapid AST is needed to identify optimal targeted antibiotics early in bacteraemia.

General treatment principles for fracture-related infection: recommendations from an international expert group

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.

Association Between Penicillin Allergy Documentation and Antibiotic Use

This cohort study assesses the prevalence and association of documented penicillin allergy with inpatient antibiotic use in the US.

Current trends in the real-life use of dalbavancin: report of a study panel

Dalbavancin is a novel lipoglycopeptide antibiotic with a chemical structure similar to teicoplanin. Dalbavancin has been approved and marketed since 2014 in the USA and 2015 in the European Union for the treatment of acute bacterial skin and skin-structure infections (ABSSSIs) caused by Gram-positive cocci. ABSSSIs include infectious syndromes such as erysipelas, cellulitis, major cutaneous abscesses that require incision and drainage, and both surgical and traumatic wound infections. In current clinical practice, dalbavancin is also used for cardiac implantable electronic device-related soft tissue infection and other prosthetic infections, and therefore when the presence of biofilm is a concern. In this review, we aimed to highlight our experience with the use of dalbavancin for some of the most hard-to-treat Gram-positive infections, as well as a promising strategy in terms of pharmacoeconomic effectiveness. We describe our current real-life clinical practice with the use of dalbavancin, depicting a few representative clinical cases in order to share our own practice in the hospital setting.

Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention

BACKGROUND

Antibiotic allergy labels (AALs), reported by up to 25% of hospitalized patients, are a significant barrier to appropriate prescribing and a focus of antimicrobial stewardship (AMS) programmes.

METHODS

A prospective audit of a pharmacist-led AMS penicillin allergy de-labelling ward round at Austin Health (Melbourne, Australia) was evaluated. Eligible inpatients with a documented penicillin allergy receiving an antibiotic were identified via an electronic medical report and then reviewed by a pharmacist-led AMS team. The audit outcomes evaluated were: (i) AMS post-prescription review recommendations; (ii) direct de-labelling; (iii) inpatient oral rechallenge referral; (iv) skin prick testing/intradermal testing referral; and (v) outpatient antibiotic allergy clinic assessment.

RESULTS

Across a 5 month period, 106 patients were identified from a real-time electronic prescribing antibiotic allergy report. The highest rate of penicillin allergy de-labelling was demonstrated in patients who were referred for an inpatient oral rechallenge with 95.2% (n = 21) successfully having their penicillin AAL removed. From the 22 patients with Type A reactions, 63.6% had their penicillin AAL removed. We demonstrated a significant decrease in the prescribing of restricted antibiotics (defined as third- or fourth-generation cephalosporins, fluoroquinolones, glycopeptides, carbapenems, piperacillin/tazobactam, lincosamides, linezolid or daptomycin) in patients reviewed (pre 42.5% versus post 17.9%, P = 0.0002).

CONCLUSIONS

A pharmacist-led AMS penicillin allergy de-labelling ward round reduced penicillin AALs and the prescribing of restricted antibiotics. This model could be implemented at other hospitals with existing AMS programmes.

Antibiotic treatment in patients with sepsis: a narrative review

Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.

Factors determining the adherence to antimicrobial guidelines and the adoption of computerised decision support systems by physicians: A qualitative study in three European hospitals

BACKGROUND AND OBJECTIVES

Antimicrobial stewardship (AMS) programs aim to optimize antibiotic use and reduce inappropriate prescriptions through a panel of interventions. The implementation of clinical guidelines is a core strategy of AMS programs. Nevertheless, their dissemination and application remain low. Computerised decision support systems (CDSSs) offer new opportunities for semi-automated dissemination of guidelines. This qualitative study aimed at gaining an in-depth understanding of the determinants of adherence to antimicrobial prescribing guidelines and CDSSs adoption and is part of a larger project, the COMPASS trial, which aims to assess a CDSS for antimicrobial prescription. The final objective of this qualitative study is to 1) provide insights from end-users to assist in the design of the COMPASS CDSS, and to 2) help with the interpretation of the quantitative findings of the randomised controlled trial assessing the COMPASS CDSS, once data will be analysed.

METHODS

We conducted semi-structured individual interviews among in-hospital physicians in two hospitals in Switzerland and one hospital in France. Physicians were recruited by convenience sampling and snowballing until data saturation was achieved.

RESULTS

Twenty-nine physicians were interviewed. We identified three themes related to the potential barriers to guideline adherence: 1) insufficient clarity, accessibility and applicability of guidelines, 2) need of critical thinking skills to adhere to guidelines and 3) impact of the team prescribing process and peers on physicians in training. As to the perception of CDSSs, we identified four themes that could affect their adoption: 1) CDSSs are perceived as time-consuming, 2) CDSSs could reduce physicians' critical thinking and professional autonomy and raise new medico-legal issues, 3) effective CDSSs would require specific features, such as ease of use and speed, which affect usability and 4) CDSSs could improve physicians' adherence to guidelines and patient care.

DISCUSSION

CDSSs have the potential to overcome several barriers for adherence to guidelines by improving accessibility and providing individualised recommendations backed by patient data. When designing CDSSs, mixed clinical and information technology teams should focus on user-friendliness, ergonomics, workflow integration and transparency of the decision-making process.

A Critical Review of Cephalexin and Cefadroxil for the Treatment of Acute Uncomplicated Lower Urinary Tract Infection in the Era of "Bad Bugs, Few Drugs"

First-generation oral cephalosporins (cephalexin and cefadroxil) have traditionally been considered second-line treatment options for uncomplicated lower urinary tract infections (uLUTIs).  However, in the current age of "bad bugs, few drugs", where there are increasingly limited oral options against resistant Enterobacteriaceae, there is an urgent need to rethink how best to utilize the available antibiotic armamentarium.  This review examines the historical clinical trials and experimental studies of cephalexin and cefadroxil, particularly through the modern lens of pharmacokinetics/pharmacodynamics (PK/PD), to better appreciate the efficacy of these drugs in uLUTIs.  Furthermore, newer cefazolin-cephalexin surrogate testing, as recommended by the Clinical and Laboratory Standards Institute (CLSI) and the United States Committee on Antimicrobial Susceptibility Testing (USCAST), has recategorized cephalexin in many instances from resistant to susceptible.  We conclude that cephalexin and cefadroxil have very good early bacteriological and clinical cures in uLUTIs due to non-extended-spectrum beta-lactamase-producing (ESBL) Enterobacteriaceae comparable to many traditionally first-line agents.  Cephalexin can be conveniently administered as 500 mg twice or thrice daily, similar to cefadroxil (500 mg twice daily); therefore, either agent may be used as a fluoroquinolone-sparing alternative. Cephalexin may be the more practical choice for many clinicians because reliable antimicrobial susceptibility test interpretative criteria (STIC) are provided by CLSI, USCAST, and the European Committee on Antimicrobial Susceptibility Testing (EUCAST), whereas direct cefadroxil STIC is offered only by EUCAST.

Incidence of Acute Kidney Injury Among Critically Ill Patients With Brief Empiric Use of Antipseudomonal β-Lactams With Vancomycin

BACKGROUND

Nephrotoxins contribute to 20%-40% of acute kidney injury (AKI) cases in the intensive care unit (ICU). The combination of piperacillin-tazobactam (PTZ) and vancomycin (VAN) has been identified as nephrotoxic, but existing studies focus on extended durations of therapy rather than the brief empiric courses often used in the ICU. The current study was performed to compare the risk of AKI with a short course of PTZ/VAN to with the risk associated with other antipseudomonal β-lactam/VAN combinations.

METHODS

The study included a retrospective cohort of 3299 ICU patients who received ≥24 but ≤72 hours of an antipseudomonal β-lactam/VAN combination: PTZ/VAN, cefepime (CEF)/VAN, or meropenem (MER)/VAN. The risk of developing stage 2 or 3 AKI was compared between antibiotic groups with multivariable logistic regression adjusted for relevant confounders. We also compared the risk of persistent kidney dysfunction, dialysis dependence, or death at 60 days between groups.

RESULTS

The overall incidence of stage 2 or 3 AKI was 9%. Brief exposure to PTZ/VAN did not confer a greater risk of stage 2 or 3 AKI after adjustment for relevant confounders (adjusted odds ratio [95% confidence interval] for PTZ/VAN vs CEF/VAN, 1.11 [.85-1.45]; PTZ/VAN vs MER/VAN, 1.04 [.71-1.42]). No significant differences were noted between groups at 60-day follow-up in the outcomes of persistent kidney dysfunction (P = .08), new dialysis dependence (P = .15), or death (P = .09).

CONCLUSION

Short courses of PTZ/VAN were not associated with a greater risk of short- or 60-day adverse renal outcomes than other empiric broad-spectrum combinations.

Epidemiology, prevalence and risk factors for infections in burn patients: results from a regional burn centre's analysis

Burn patients are at high risk of infections due to severe impairment of immunity and loss of skin barrier function. We aimed to describe the epidemiology, incidence and risk factors for infection in a cohort of burns patients. Two hundred patients were retrospectively enrolled and subdivided into infected (N = 81) and uninfected groups (N = 119). The cumulative prevalence of infections was 27% on day 7 and 43.8% on day 28. Skin and soft tissue infections (32%) were the most frequent. Carbapenem-resistant Acinetobacter baumannii (28%), Pseudomonas aeruginosa (26%) and methicillin-resistant Staphylococcus aureus (25%) infections were most prevalent. An indwelling central venous catheter (CVC; sub-hazard ratio [SHR] 7.41, 95% confidence interval [CI] 3.78-14.62) and revised Baux score (RBS; SHR 2.08, 95% CI 0.98-4.42) were associated with higher incremental infection rate while surgical treatment resulted in a protective factor (SHR 0.45, 95% CI 0.29-0.75). RBS may be useful to stratify the infection risk: a strict collaboration between surgeons and infectious disease specialists is needed to implement source control and antimicrobial surveillance.

Oral vancomycin prophylaxis against recurrent Clostridioides difficile infection: Efficacy and side effects in two hospitals

OBJECTIVE

The data regarding the effectiveness of chemical prophylaxis against recurrent C. difficile infection (CDI) remain conflicting.

DESIGN

Retrospective cohort study on the effectiveness of oral vancomycin for prevention of recurrent CDI.

SETTING

Two academic centers in New York.

METHODS

Two participating hospitals implemented an automated alert recommending oral vancomycin 125 mg twice daily in patients with CDI history scheduled to receive systemic antimicrobials. Measured outcomes included breakthrough and recurrent CDI rates, defined as CDI during and 1 month after initiation of prophylaxis, respectively. A self-controlled, before-and-after study design was employed to examine the effect of vancomycin prophylaxis on the prevalence of vancomycin-resistant Enterococcus spp (VRE) colonization and infection.

RESULTS

We included 264 patients in the analysis. Breakthrough CDI was identified in 17 patients (6.4%; 95% confidence interval [CI], 3.8%-10.1%) and recurrent in 22 patients (8.3%; 95% CI, 5.3%-12.3%). Among the 102 patients with a history of CDI within the 3 months preceding prophylaxis, 4 patients (3.9%; 95% CIs, 1.1%-9.7%) had breakthrough CDI and 9 had recurrent disease (8.8%; 95% CIs, 4.1%-16.1%). In the 3-month period following vancomycin prophylaxis, we detected a statistically significant increase in both the absolute number of VRE (χ2, 0.003) and the ratio of VRE to VSE isolates (χ2, 0.003) compared to the combined period of 1.5 months preceding and the 3-4.5 months following prophylaxis. This effect persisted 6 months following prophylaxis.

CONCLUSIONS

Prophylactic vancomycin is an effective strategy to prevent CDI recurrence, but it increases the risk of VRE colonization. Thus, a careful selection of patients with high benefit-to-risk ratio is needed for the implementation of this preventive policy.

The clinical impact of implementing GenMark ePlex blood culture panels for around-the-clock blood culture identification; a prospective observational study

Background: Implementing rapid molecular blood culture diagnostics in the clinical management of sepsis is essential for early pathogen identification and resistance gene testing. The GenMark ePlex blood culture panels offer a broad microbial spectrum with minimal hands-on time and approximately 1.5 h to result. Therefore, ePlex can be utilized at times when the clinical microbiology laboratory is unavailable.Methods: From 23 October 2019 to 30 December 2019, consecutive non-duplicate positive blood cultures signalling microbial growth at the 24 h/7 days-a-week available clinical chemistry laboratory between 9 pm and 7 am were analysed with ePlex. All blood cultures were transported to the microbiology laboratory the following day for conventional identification and antibiotic susceptibility testing.Results: We used ePlex to test 91 blood cultures, of which 86 had confirmed microbial growth. Eighty-one were positive for ePlex target pathogens. The ePlex results were in complete agreement with conventional methods in 72/81 (88.9%) of cases and available within a median of 10.9 h earlier. Resistance gene targets (11 mecA and 1 CTX-M) were concordant with phenotypic susceptibility in all cases. In 18/86 (20.9%) of the patient cases, there was an opportunity to optimize antimicrobial therapy based on the ePlex result. The ePlex result affected clinical decision-making in 4/86 (4.7%) of the cases and reduced the average time to effective antimicrobial therapy by 8.9 h.Conclusions: Our implementation of ePlex is a feasible option to attain around-the-clock blood culture identification in many hospitals. It can significantly reduce time-to-pathogen identification and have an impact on clinical decision-making.

Procalcitonin-guided protocol decreased the antibiotic use in paediatric patients with severe bronchiolitis

AIM

Our aim was to determine the effectiveness and safety of a procalcitonin-guided protocol to decrease antibiotic use in infants with severe bronchiolitis.

METHODS

This prospective, observational study was conducted at the Hospital Sant Joan de Déu from 2010 to 2017. Patients under the age of one were included if they were diagnosed with bronchiolitis, had a suspected bacterial infection and were admitted to the paediatric intensive care unit. A procalcitonin-guided protocol was established in 2014, and two cohorts were compared before and after implementation: 340 in 2010-2014 and 366 in 2015-2017.

RESULTS

We recruited 706 patients (58.6% male) with a median age of 47 days and an interquartile range of 25.0-100.2. The rate for antibiotic use was 79.9%, and this differed before and after implementation (88.2% vs 72.1%, P = .003). Antibiotic stewardship and withdrawal decisions were higher after implementation (22.3% vs 36.4%, P = .005). The length of antibiotic treatment was also different between the two periods (8.65 ± 4.8 days vs 5.05 ± 3.18 days, P = .023). No adverse outcomes were observed due to the implementation of the protocol.

CONCLUSION

The implementation of a procalcitonin-guided protocol seems to lead to a safe and general decrease in antibiotic use in paediatric patients with severe bronchiolitis.

Primary Resistance Pattern of Helicobacter pylori to Antibiotics in Adult Population: A Systematic Review

Background

Helicobacter pylori is a spiral-shaped gram-negative bacteria associated with peptic ulcer, gastritis and gastric cancer. The global burden and occurrence of H. pylori infection remains prevalent and worldwide. Despite this, the trend of the bacterial resistance is not recently studied which can help in the adoption of global, regional and local prevention strategies.

Objective

The aim of the study was to systematically review the existing published literature that presents the estimate of H. pylori antibiotic resistance.

Methods

A protocol was primarily registered in PROSPERO International prospective register of systematic reviews and has given a registration number CRD42017068710. It was registered after checking whether there was similar study being conducted. A database search (PubMed/Medline and Google scholar) was used to collect relevant articles. A standardized form was prepared for the extraction of relevant data from studies which fulfilled the eligibility criteria. A National Institute for Health research (NIH)-based quality assessment tool was utilized to assess the quality of studies included in the study.

Results

Our searching process has retrieved a total of 288 publications which later resulted in 38 articles for full-text review. Among the 38 articles reviewed in full text, 14 studies were included which fulfilled the inclusion criteria. H.pylori-pooled overall prevalence rate of antibiotic resistance was found to be 4.55% (95% confidence interval (CI): 3.96–5.22%) to amoxicillin, 27.22% (95% CI: 25.89–28.58%) to clarithromycin, 39.66% (95% CI: 38.20–41.15%) to metronidazole, and 22.48% (95% CI: 21.24–23.76%) to levofloxacin.

Conclusion

The primary antibiotic resistance pattern of H. pylori is increasing worldwide. Thus, implementation of local drug susceptibility surveillance program, rational prescribing and use of antibiotics are necessary.

Chimeric Phage Nanoparticles for Rapid Characterization of Bacterial Pathogens: Detection in Complex Biological Samples and Determination of Antibiotic Sensitivity

Rapid, specific, and sensitive detection of pathogenic bacteria in drink, food, and clinical samples is an important goal for public health. In addition, rapid characterization of antibiotic susceptibility could inform clinical choices and improve antibiotic stewardship. We previously reported a straightforward, inexpensive strategy to detect Gram-negative bacterial pathogens, including Pseudomonas aeruginosa, Vibrio cholerae, and Escherichia coli, taking advantage of the high affinity and specificity of phages for their bacterial hosts. Chimeric phages targeted different bacterial pathogens, and thiolation of the phages induced aggregation of gold nanoparticles (AuNPs), leading to a visible colorimetric response in the presence of at least ∼100 cells of the target bacteria. Here, we apply this strategy to complex biological samples (milk, urine, and swabs from a porcine ex vivo model of P. aeruginosa infection). We also show that this assay can be used to identify the antibiotic susceptibility profile based on detection of bacterial growth in the presence of different antibiotics. The prospect for using phage-conjugated AuNPs to detect bacterial pathogens in clinical samples and guide antibiotic choice is discussed.

The effect of intervention by an antimicrobial stewardship team on anaerobic bacteremia

The effect of antimicrobial stewardship (AS) on anaerobic bacteremia is uncertain. This study aimed to assess the effect of interventions by the AS team (AST) on clinical and microbiological outcomes and antimicrobial use. An AS program was introduced at Osaka City University Hospital in January 2014; an interdisciplinary AST was established. We enrolled patients with anaerobic bacteremia between January 2009 and December 2018. Patients were classified into the pre-intervention group (from January 2009 to December 2013) and the post-intervention group (from January 2014 to December 2018). A significant decrease in definitive carbapenem use (P = 0.0242) and an increase in empiric tazobactam/piperacillin use (P = 0.0262) were observed in the post-intervention group. The de-escalation rate increased significantly from 9.38% to 32.7% (P = 0.0316) in the post-intervention group. The susceptibility of Bacteroides species and 30-day mortality did not worsen in the post-intervention group. These results showed that interventions by an AST can reduce carbapenem use and increase the de-escalation rate without worsening patient outcomes.

Improving the Quality of Hospital Antibiotic Use: Impact on Multidrug-Resistant Bacterial Infections in Children

Antimicrobial resistance (AMR) is considered a rapidly growing global public health emergency. Neonates and children are among patients for whom antibiotics are largely prescribed and for whom the risk of AMR development is high. The phenomenon of increasing AMR has led to the need to develop measures aimed at the rational and effective use of the available drugs also in children and antimicrobial stewardship (AS), which is one of the measures that in adults has showed the highest efficacy in reducing antibiotic abuse and misuse, appears as an attractive approach. The aim of this manuscript is to analyze the basic principles and strategies of pediatric AS. To this end, we searched in PubMed articles published in years 2000 to 2019 containing "antimicrobial resistance," "antibiotic use," "antimicrobial stewardship," and "children" or "pediatric" as keywords. Our review showed that the balance between multi-resistant organisms and new antimicrobials is extremely precarious. The AS tools are the most important weapon at our disposal to stem the phenomenon. Careful monitoring of prescriptions, continuous training of prescribing physicians and collaboration with highly qualified multidisciplinary staff, creation of local and national guidelines, use of rapid diagnostic tests, technological means of support, and research activities by testing new broad-spectrum antibiotics are mandatory. However, all of these measures must be supported by adequate investment by national and international health organizations. Only by making AS daily practice, through the use of financial resources and dedicated staff, we can fight AMR to ensure safe and effective care for our young patients.

Assessing an intervention to improve the safety of automatic stop orders for inpatient antimicrobials

Background

Automatic stop orders (ASOs) for antimicrobials have been recommended as a component of antimicrobial stewardship programs, but may result in unintentional treatment interruption due to failure of providers to re-order an antimicrobial medication. We examined the impact of a multifaceted intervention designed to reduce the potential harms of interrupting antimicrobial treatment due to ASOs.

Methods

An intervention was implemented that included pharmacist review of expiring antimicrobials as well as provider education to encourage use of a long-term antimicrobial order set for commonly used prophylactic antimicrobials. Pharmacist interventions and antimicrobial re-ordering was recorded. Percent of missed doses of a commonly used prophylactic antimicrobial, single strength co-trimoxazole, was compared pre- and post-intervention using a chi-squared test.

Results

From November 1, 2015 to November 30, 2016, there were 401 individual pharmacist interventions for antimicrobial ASOs, resulting in 295 instances of antimicrobial re-ordering. The total percent of presumed missed single strength co-trimoxazole doses was reduced from 8.4% to 6.2% post-intervention (P<0.001).

Conclusions

This study found that a targeted intervention was associated with a reduction in unintended antimicrobial treatment interruption related to ASOs.

Persuasive antimicrobial stewardship intervention in the context of a KPC outbreak: a controlled interrupted time series analysis

INTRODUCTION

Antimicrobial resistance is a major public health threat. Antimicrobial stewardship (AMS) is one of the key strategies to overcome resistance, but robust evidence on the effect of specific interventions is lacking. We report an interrupted time series (ITS) analysis of a persuasive AMS intervention implemented during a KPC producing Klebsiella pneumoniae outbreak.

METHODS

A controlled ITS for carbapenem consumption, total antibiotic consumption and antibiotic-free days, between January 2012 and May 2018 was performed, using segmented regression analysis. The AMS intervention was implemented in the Vascular Surgery ward starting on April 2016 in the context of a KPC outbreak. The General Surgery ward was taken as a control group. Data were aggregated by month for both wards, including 51 pre-intervention and 26 intervention points.

RESULTS

The AMS intervention produced a level change in carbapenem consumption of - 11.14 DDDs/100 patient-days accompanied by a decreasing trend of total antibiotic consumption and stable rate of antibiotic-free days in Vascular Surgery ward. These differences were not apparent in the control group. No differences in mortality or readmission rates between pre-intervention and intervention periods were noticed in any of the groups.

CONCLUSION

Persuasive AMS interventions on top of previously implemented restrictive interventions can reduce carbapenem consumption without increasing total antibiotic consumption. Starting persuasive AMS interventions in an outbreak setting does not compromise the sustainability of the intervention.

Enhanced antimicrobial stewardship based on rapid phenotypic antimicrobial susceptibility testing for bacteraemia in patients with haematological malignancies: a randomized controlled trial

OBJECTIVES

Recently, rapid phenotypic antimicrobial susceptibility testing (AST) based on microscopic imaging analysis has been developed. The aim of this study was to determine whether implementation of antimicrobial stewardship programmes (ASP) based on rapid phenotypic AST can increase the proportion of patients with haematological malignancies who receive optimal targeted antibiotics during early periods of bacteraemia.

METHODS

This randomized controlled trial enrolled patients with haematological malignancies and at least one positive blood culture. Patients were randomly assigned 1:1 to conventional (n = 60) or rapid phenotypic (n = 56) AST. The primary outcome was the proportion of patients receiving optimal targeted antibiotics 72 hr after blood collection for culture.

RESULTS

The percentage receiving optimal targeted antibiotics at 72 hr was significantly higher in the rapid phenotypic AST group (45/56, 80.4%) than in conventional AST group (34/60, 56.7%) (relative risk (RR) 1.42, 95% confidence interval (CI) 1.09-1.83). The percentage receiving unnecessary broad-spectrum antibiotics at 72 hr was significantly lower (7/26, 12.5% vs 18/60, 30.0%; RR 0.42, 95% CI 0.19-0.92) and the mean time to optimal targeted antibiotic treatment was significantly shorter (38.1, standard deviation (SD) 38.2 vs 72.8, SD 93.0 hr; p < 0.001) in the rapid phenotypic AST group. The mean time from blood collection to the AST result was significantly shorter in the rapid phenotypic AST group (48.3, SD 17.6 vs 83.1, SD 22.2 hr).

DISCUSSION

ASP based on rapid phenotypic AST can rapidly optimize antibiotic treatment for bacteraemia in patients with haematological malignancy. Rapid phenotypic AST can improve antimicrobial stewardship in immunocompromised patients.

Prevalence, impact, and management strategies for asymptomatic bacteriuria in the acute care elderly patient: a review of the current literature

Introduction: It is unclear how to prevent the negative impact of inappropriate urine cultures in older acute care patients who have a high rate of asymptomatic bacteriuria.Areas covered: A nonsystematic literature review of the definition, impact, and management of elderly acute care patients with asymptomatic bacteriuria (ASB).Expert opinion: In the elderly, patients with ASB include those with extra-urinary tract diseases (e.g. pneumonia) and those with symptoms/signs that resolve without antibiotic therapy, but the diagnosis of ASB is unclear in febrile patients responding to antibiotics. We consider four management strategies that could decrease the negative impact of culturing the urine including unnecessary antibiotic therapy in those with ASB: (1) Prevent urine testing in patients with extra-urinary tract reasons for their acute care (2) Cancel urine cultures if the urine dipstick is negative. (3) Avoid catheterization in stable patients who cannot provide a urine specimen on demand and (4) Withhold antibiotics in stable non-febrile elderly patients who do not have new local urinary tract symptoms or decompensation on follow-up, and pursue further investigations for another etiology/diagnosis.

Guidelines for Clostridium difficile infection in adults

Clostridium difficile infection (CDI) has become a serious medical and epidemiological problem, especially in well developed countries. There has been evident increase in incidence and severity of CDI. Prevention, proper diagnosis and effective treatment are necessary to reduce the risk for the patients, deplete the spreading of infection and diminish the probability of recurrent infection. Antibiotics are the fundamental treatment of CDI. In patients who had recurrent CDI fecal microbiota transplantation seems to be promising and efficient strategy. These guidelines systematize existing data and include recent changes implemented in the management of CDI.

An approach to antibiotic treatment in patients with sepsis

Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, which is time-dependent and associated with unacceptably high mortality. Thus, when treating suspicious or confirmed cases of sepsis, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Optimizing antibiotic use is essential to ensure successful outcomes and to reduce adverse antibiotic effects, as well as preventing drug resistance. All likely pathogens involved should be considered to provide an appropriate antibiotic coverage. Clinicians must investigate on the previous risk of multidrug-resistant (MDR) pathogens, and the principle of individualized dosing should replace the principle of standard dosing. The loading dose is an initial higher dose of an antibiotic for all patients, yet an individualized treatment approach for further doses should be implemented according to pharmacokinetics (PK)/pharmacodynamics (PD) and the presence of renal/liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring (TDM) can help to achieve therapeutic levels of antimicrobials. Reevaluation of duration and appropriateness of treatment at regular intervals are also necessary. De-escalation and shortened courses of antimicrobials must be considered for most patients, except in some justified circumstances. Leadership, teamwork, antimicrobial stewardship (AS) frameworks, guideline’s recommendations on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients’ quality of care.

Differentiating Epidemic from Endemic or Sporadic Infectious Disease Occurrence

One important scope of work of epidemiology is the investigation of infectious diseases that cluster in time and place. Clusters of infectious disease may represent outbreaks or epidemics in which the cases share in common a point source exposure or an infectious agent in a chain of transmission pathways. Investigations of outbreaks of an illness can facilitate identification of a source, risk, or cause of the illness. However, most infectious disease episodes occur not as part of any apparent outbreaks but as sporadic infections. Multiple sporadic infections that occur steadily in time and place are referred to as endemic disease. How does one investigate sources and risk factors for sporadic or endemic infections? As part of the Microbiology Spectrum Curated Collection: Advances in Molecular Epidemiology of Infectious Diseases, this review discusses limitations of traditional approaches and advantages of molecular epidemiology approaches to investigate sporadic and endemic infections. Using specific examples, the discussions show that most sporadic infections are actually part of unrecognized outbreaks and that what appears to be endemic disease occurrence is actually comprised of multiple small outbreaks. These molecular epidemiologic investigations have unmasked modes of transmission of infectious agents not known to cause outbreaks. They have also raised questions about the traditional ways to measure incidence and assess sources of drug-resistant infections in community settings. The discoveries made by the application of molecular microbiology methods in epidemiologic investigations have led to creation of new public health intervention strategies that have not been previously considered. *This article is part of a curated collection.

Development of an algorithm to facilitate the clinical management of syphilis

BACKGROUND

Syphilis staging is important to determine treatment, post-treatment monitoring, and sexual partner follow-up. Many prescribers find syphilis staging to be challenging. Current guidelines for the management of patients diagnosed with syphilis provide little direction aside from an overview of some common symptoms and directing providers to stage cases in conjunction with experienced colleagues.

LOCAL PROBLEM

In Canada and the United States, the rate of infectious syphilis has increased noticeably since 2000. Given the increase in rates of syphilis, it is important for all clinicians to understand how to appropriately manage patient care to reduce rates of infection.

METHODS AND INTERVENTIONS

A clinical algorithm was developed to stage infectious syphilis. This was tested among nurse practitioners and physicians in a sexually transmitted infection clinic. The algorithm was developed based on a review of the available United States, Canadian, and British practice guidelines.

RESULTS

Project results demonstrated that this resource could be a relevant practice tool for providers in multiple clinical settings to ensure that patients receive appropriate diagnosis, staging, and treatment of syphilis infection. A case study of a patient who presented to the clinic as a contact is used to review the algorithm and demonstrate the appropriate clinical management of patients.

CONCLUSIONS

The algorithm appropriately guided practice and was useful to clinicians.

Evaluation of two rapid molecular test systems to establish an algorithm for fast identification of bacterial pathogens from positive blood cultures

Fast identification of pathogens directly from positive blood cultures is of highest importance to supply an adequate therapy of bloodstream infections (BSI). There are several platforms providing molecular-based identification, detection of antimicrobial resistance genes, or even a full antimicrobial susceptibility testing (AST). Two of such test systems allowing rapid diagnostics were assessed in this study: The Biofire FilmArray® and the Genmark ePlex®, both fully automated test system with a minimum of hands-on time. Overall 137 BSI episodes were included in our study and compared to conventional culture–based reference methods. The FilmArray® is using one catridge including a panel for the most common bacterial and fungal BSI pathogens as well as selected resistance markers. The ePlex® offers three different cartridges for detection of Gram-positives, Gram-negatives, and fungi resulting in a broader panel including also rare pathogens, putative contaminants, and more genetic resistance markers. The FilmArray® and ePlex® were evaluated for all 137 BSI episodes with FilmArray® detecting 119 and ePlex® detecting 128 of these. For targets on the respective panel of the system, the FilmArray® generated a sensitivity of 98.9% with 100% specificity on Gram-positive isolates. The ePlex® system generated a sensitivity of 94.7% and a specificity of 90.7% on Gram-positive isolates. In each case, the two systems performed with 100% sensitivity and specificity for the detection of Gram-negative specimens covered by each panel. In summary, both evaluated test systems showed a satisfying overall performance for fast pathogen identification and are beneficial tools for accelerating blood culture diagnostics of sepsis patients.

Time to clinical response in sepsis associated with an algorithm for blood-culture pathogen identification using matrix-assisted laser desorption ionization time-of-flight mass spectroscopy

PURPOSE

Antimicrobial stewardship programs (ASPs) can be aided by using rapid diagnostics (RDT). However, there are limited data evaluating the impact of ASPs and RDT on sepsis outcomes in the setting of the new Sepsis-3 guidelines. This study evaluates the impact of a low-resource method for ASPs with RDT on sepsis outcomes.

METHODS

This was a prospective, quasi-experimental study with a retrospective double pretest. Patients ≥ 18 years old with sepsis and concurrent bacteremia or fungemia were included; patients who were pregnant, had polymicrobial septicemia or who were transferred from an outside hospital were excluded. In the first pretest (O1), polymerase chain reaction was used to identify Staphylococcal species from positive blood cultures, and traditional laboratory techniques were used to identify other species. Matrix-assisted laser desorption ionization time-of-flight mass spectroscopy and FilmArray were implemented in the second pretest (O2), and twice daily blood culture review was implemented in the posttest (O3).

RESULTS

A total of 394 patients (157 in O1, 176 in O2, 61 in O3) were enrolled. Clinical response was 73.2%, 83.5%, and 88.5% in O1, O2, and O3, respectively, p = 0.013. By Cox regression, the O3 was associated with improved time to clinical response (hazard ratio, 1.388; 95% confidence interval, 1.004-1.919) as compared with O1. Mortality, hospital length of stay, and intensive care unit length of stay were unchanged between groups.

CONCLUSION

Twice-daily blood culture review may be useful for implementing rapid diagnostics within low-resource ASPs. Further research is needed to identify the optimal method of blood culture follow-up within low-resource settings.

Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey

BACKGROUND

Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs.

METHODS

A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models.

RESULTS

Of 861 NHs, 33.2% (6-7) had "comprehensive" ASP policies, 41.1% (4-5) had "moderately comprehensive" ASP policies, and 25.6% (≤ 3) had "not comprehensive" ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy.

DISCUSSION

Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies.

CONCLUSIONS

NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.

Association between statewide adoption of the CDC's Core Elements of Hospital Antimicrobial Stewardship Programs and rates of methicillin-resistant Staphylococcus aureus bacteremia and Clostridioides difficile infection in the United States

OBJECTIVE

To measure the association between statewide adoption of the Centers for Disease Control and Prevention's (CDC's) Core Elements for Hospital Antimicrobial Stewardship Programs (Core Elements) and hospital-associated methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridioides difficile infection (CDI) rates in the United States. We hypothesized that states with a higher percentage of reported compliance with the Core Elements have significantly lower MRSA and CDI rates.

PARTICIPANTS

All US states.

DESIGN

Observational longitudinal study.

METHODS

We used 2014-2016 data from Hospital Compare, Provider of Service files, Medicare cost reports, and the CDC's Patient Safety Atlas website. Outcomes were MRSA standardized infection ratio (SIR) and CDI SIR. The key explanatory variable was the percentage of hospitals that meet the Core Elements in each state. We estimated state and time fixed-effects models with time-variant controls, and we weighted our analyses for the number of hospitals in the state.

RESULTS

The percentage of hospitals reporting compliance with the Core Elements between 2014 and 2016 increased in all states. A 1% increase in reported ASP compliance was associated with a 0.3% decrease (P < .01) in CDIs in 2016 relative to 2014. We did not find an association for MRSA infections.

CONCLUSIONS

Increasing documentation of the Core Elements may be associated with decreases in the CDI SIR. We did not find evidence of such an association for the MRSA SIR, probably due to the short length of the study and variety of stewardship strategies that ASPs may encompass.

Attitudes and Perceptions amongst Critical Care Physicians towards Handshake Antimicrobial Stewardship Rounds

Rationale In an era of antimicrobial resistance, antimicrobial stewardship programs are tasked with reducing inappropriate use of antimicrobials in community and hospital settings. Intensive care units are unique, high-stakes environments where high usage of broad-spectrum antimicrobials is often seen. Handshake stewardship has emerged as an effective mode of prospective audit and feedback to help optimize antimicrobial usage, emphasizing an in-person approach to providing feedback. Objectives Six months following the implementation of handshake stewardship rounds in our intensive care unit, we performed a cross-sectional survey of critical care physicians to assess their attitudes and perceptions towards handshake stewardship rounds and preferred mode of delivery of antimicrobial stewardship prospective audit and feedback strategies. Methods A web-based survey was distributed to 22 critical care physicians working in our hospital and responses were collected over a two-week period. Measurements and Main Results Most critical care physicians believe that handshake stewardship rounds improve the quality of patient care (85.7%) and few believe that handshake stewardship rounds are an ineffective use of their time (14.3%). The majority of critical care physicians believe formal, scheduled rounds with face-to-face verbal interaction are very useful compared to providing written suggestions in the absence of face-to-face interaction (71.4% vs 0%). Conclusions Based upon our survey results, handshake stewardship is valued amongst the majority of critical care physicians. Antimicrobial stewardship prospective audit and feedback strategies emphasizing face-to-face interaction are favored amongst critical care physicians.

Implementation of a Health-System Wide Antimicrobial Stewardship Program in Omaha, NE

The Centers for Medicare and Medicaid Services (CMS) have mandated that acute care and critical access hospitals implement an Antimicrobial Stewardship (AMS) Program. This manuscript describes the process that was implemented to ensure CMS compliance for AMS, across a 14-member health system (eight community hospitals, five critical access hospitals, and an academic medical center) in the Omaha metro area, and surrounding cities. The addition of the AMS program to the 14-member health system increased personnel, with a 0.5 full-time equivalent (FTE) infectious diseases (ID) physician, and 2.5 FTE infectious diseases trained clinical pharmacists to support daily AMS activities. Clinical decision support software had previously been implemented across the health system, which was also key to the success of the program. Overall, in its first year, the AMS program demonstrated a $1.2 million normalized reduction (21% total reduction in antimicrobial purchases) in antimicrobial expenses. The ability to review charts daily for antimicrobial optimization with ID pharmacist and physician support, identify facility specific needs and opportunities, and to collect available data endpoints to determine program effectiveness helped to ensure the success of the program.

Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis

BACKGROUND

There is little evidence on the ecological effect and sustainability of antimicrobial stewardship programmes (ASPs) in primary-care settings. We aimed to determine whether a multimodal, educational ASP would be sustainable in the long-term and reduce the incidence of infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community by optimising antibiotic use.

METHODS

We did this quasi-experimental intervention study in 214 primary health centres of four primary health-care districts in Andalusia, Spain. Local multidisciplinary teams, comprised of general practitioners, paediatricians, primary-care pharmacists, and epidemiologists, were created in each district and implemented a multimodal, education-based ASP. The core activity of the programme consisted of regular one-to-one educational interviews between a reference interviewing physician and prescribing physicians from each centre on the appropriateness of their most recent (same or preceding day) antibiotic prescriptions based on a structured questionnaire. Appropriate prescribing was defined as compliance of all checklist items with the reference guidelines. An average of five educational interviews were scheduled per prescriber per study year. We did an interrupted time-series analysis to assess the effect of the intervention on quarterly antibiotic use (prescription and collection by the patient) and quality of prescriptions (as defined daily doses per 1000 inhabitants per day) and incidence per 1000 inhabitants of E coli producing extended-spectrum β-lactamase (ESBL) isolated from urine samples.

FINDINGS

The study was done between January, 2012, and December, 2017, in a pre-intervention period of 2012-13 and an intervention period of 2014-17. Throughout the study period, there were 1387 physicians (1116 general practicioners and 271 paediatricians) in the included health centres serving a mean population of 1 937 512 people (299 331 children and 1 638 181 adults). 24 150 educational interviews were done over the 4 years. Inappropriate antibiotic prescribing was identified in 1794 (36·5%) of 4917 educational interviews in 2014 compared with 1793 (26·9%) of 6665 in 2017 (p<0·0001). The intervention was associated with a sustained reduction in the use of ciprofloxacin (relative effect -15·9%, 95% CI -23·9 to -8·0) and cephalosporins (-22·6%, -35·9 to -9·2), and a sustained increase in the use of amoxicillin (22·2%, 6·4 to 38·0) and fosfomycin trometamol (6·1%, 2·6 to 9·6). The incidence density of ESBL-producing E coli decreased by -0·028 cases per 1000 inhabitants (95% CI -0·034 to -0·021) after the start of the programme, reversing the pre-intervention increase and leading to a relative reduction of -65·6% (-68·2 to -63·0) 4 years later.

INTERPRETATION

Our data suggest that implementation of a multimodal ASP in primary care that is based on individual educational interviews improves the use of antibiotics and results in a sustained significant reduction of infections by ESBL-producing E coli in the community. This information should encourage the implementation of ASPs in primary care.

FUNDING

Instituto de Salud Carlos III, Spanish Government (PI14/01523).

Posters Have Limited Utility in Conveying a Message of Antimicrobial Stewardship to Pet Owners

Pet owners frequently administer antimicrobials to their pets and therefore have an important role to play in promoting antimicrobial stewardship in veterinary medicine. However, best methods of educating pet owners about antimicrobial stewardship have yet to be defined. While visual materials such as brochures and posters are often used in health promotion campaigns, their effectiveness in veterinary medicine is unknown. The objective of this study was to determine whether pet owners noticed and retained the message of a poster with an antimicrobial stewardship message placed in veterinary clinic exam rooms. A total of 111 pet owners from five veterinary clinics (three general practices, two low-cost clinics) in the greater Philadelphia area participated in the study. Participants completed a survey asking whether they noticed the poster and if they could paraphrase its message. In a follow-up survey, an antibiotic knowledge score was calculated from answers to questions assessing their knowledge of the poster message. Baseline knowledge was assessed by asking participants to define antibiotic resistance. At the end of the study, veterinarians at participating clinics were interviewed about their experiences with the poster. Only 51 (46.4%) participants noticed the poster, and only 11 (9.9%) could partially or completely reproduce its message. No demographic or clinic-level factors were significantly associated with noticing the poster or recalling its message. Antibiotic knowledge scores were highly correlated (ρ = 0.87, p < 0.001) with baseline knowledge and not affected by viewing the poster (p = 0.955). Veterinarians expressed skepticism that the poster was effective in conveying a message of judicious antibiotic use to clients and noted no difference in the frequency with which they discussed antibiotic resistance or felt pressured to prescribe antibiotics by their clients. Posters alone will likely have limited impact in conveying a message of judicious antibiotic use to pet owners. However, they might be useful as part of an active, multi-modal education strategy, especially if complemented by veterinarian actions.

Ventilator-Associated Pneumonia: Diagnostic Test Stewardship and Relevance of Culturing Practices

PURPOSE OF REVIEW

Ventilator-associated pneumonia (VAP) is one of the most common infections in the ICU. Prompt diagnosis is vital as mortality increases with delayed antibiotic therapy. However, accurate diagnosis is challenging due to non-specific clinical features in a complicated patient cohort. Microbiological culture data remains a crucial aspect in confirming diagnosis.

RECENT FINDINGS

Literature data comparing the benefit of invasive respiratory sampling to non-invasive is inconclusive. Differences in culturing practices translate in overidentification of organisms of unclear significance. Positive culture data in a low pre-test probability does not differentiate between true infection and colonization resulting in overtreatment. Furthermore, there are also opportunities for modifying the reporting of respiratory tract cultures that can better guide antimicrobial therapy. Under the umbrella of antimicrobial stewardship, diagnostic stewardship can be incorporated to create a systematic approach that would target culturing practices to match the right pre-test probability. Ideal outcome will be targeting cultures to the right patient population and minimizing unnecessary treatment.

The Benefit of Individualized Vancomycin Dosing Via Pharmacokinetic Tools: A Systematic Review and Meta-analysis

Background: Various pharmacokinetic (PK) equations and software have been developed to individualize vancomycin dosing. However, the benefit of using any PK information to guide vancomycin dosing has not been fully elucidated. Objective: To appraise available evidence on the effectiveness and safety of individualized vancomycin dosing via PK tools. Methods: PubMed, EMBASE, the Cochrane Library, and 2 Chinese literature databases were searched through August 1, 2019. Randomized controlled trials (RCTs) and cohort studies that reported the PK and clinical outcomes of individualized vancomycin dosing versus empirical dosing were included. Pooled risk ratios (RRs) and mean differences were calculated for dichotomous and continuous outcomes, respectively. Results: A total of 21 studies involving 4346 patients were finally included, of which 3 were RCTs and 18 were cohort studies. Meta-analysis revealed that PK-guided vancomycin dosing significantly increased the attainment of target trough concentration (RR = 1.59; 95% CI = 1.49-1.70) and decreased the incidence of nephrotoxicity (RR = 0.57; 95% CI = 0.46-0.71). Additionally, the available evidence showed that target area under the curve/minimum inhibitory concentration attainment rate and time to target concentration could improve. However, the evidence on clinical outcomes was scarce, and no significant differences were detected in clinical response rate, microbiological eradication rate, mortality, and length of hospital stay between PK-guided vancomycin dosing and empirical dosing strategies. Conclusion and Relevance: Individualized vancomycin dosing via PK tools significantly increases the attainment of target trough concentration and decreases the incidence of nephrotoxicity. Evidence on clinical effectiveness was limited and showed no significant benefit. Further well-designed studies are warranted to assess its clinical effectiveness and inform routine care.

The Standardized Antimicrobial Administration Ratio: A New Metric for Measuring and Comparing Antibiotic Use

Background

To provide a standardized, risk-adjusted method for summarizing antibiotic use (AU), enable hospitals to track their AU over time and compare their AU data to national benchmarks, the Centers for Disease Control and Prevention developed the Standardized Antimicrobial Administration Ratio (SAAR).

Methods

Hospitals reporting to the National Healthcare Safety Network (NHSN) AU Option collect and submit aggregated AU data electronically as antimicrobial days of therapy per patient days present. SAARs were developed for specific NHSN adult and pediatric patient care locations and cover five antimicrobial agent categories: (1) broad-spectrum agents predominantly used for hospital-onset/multi-drug resistant bacteria; (2) broad-spectrum agents predominantly used for community-acquired infections; (3) anti-methicillin-resistant Staphylococcus aureus agents; (4) agents predominantly used for surgical site infection prophylaxis; and (5) all antibiotic agents. The SAAR is an observed-to-predicted use ratio where predicted use is estimated from a statistical model; a SAAR of 1 indicates that observed use and predicted use are equal.

Results

Most location-level SAARs were statistically significantly different than 1: adult locations up to 52% lower than 1 and up to 41% higher than 1. Median SAARs in adult and pediatric ICUs had a range of 0.667-1.119. SAAR distributions serve as an external comparison to national SAARs.

Conclusions

This is the first aggregate AU metric that uses point-of-care, antimicrobial administration data electronically reported to a national surveillance system to enable risk-adjusted, AU comparisons across multiple hospitals. Endorsed by the National Quality Forum, SAARs provide AU benchmarks that stewardship programs can use to help drive improvements.

Pharmacist recommendations for carbapenem de-escalation in urinary tract infection within an antimicrobial stewardship program

BACKGROUND

Carbapenem antibiotics are considered the treatment of choice for serious extended-spectrum beta-lactamase-producing Gram-negative bacteria infections. Our objectives were to analyze the results of carbapenem de-escalation therapy in complicated urinary tract infections (UTIs) attended in a third-level Spanish hospital and to evaluate the impact of pharmacist recommendation in this practice, the outcomes obtained, and associated factors.

METHODS

This prospective observational study of carbapenem prescriptions and de-escalation performance was conducted in a third-level hospital between August 1 2013 and July 31, 2014. Data were gathered on carbapenem treatment duration, de-escalation, length of hospital stay, mortality rate, and associated re-admissions.

RESULTS

De-escalation, which was only ordered for patients with positive cultures, was conducted in 49.7% of the 163 patients with complicated UTI. More than half (69.1%) of pharmacist interventions were accepted. De-escalation reduced the median hospital stay by five days (p=0.030). Crude hospital mortality was lower in the de-escalation group (7.4% vs. 29.3%, p<0.001), although their exposure to carbapenems was lower (4 vs 6 days, p<0.001). Factors associated with de-escalation were ICU stay for at least 48h, pharmacist recommendation and ESBL or AmpC producing Enterobacteriaceae. Factors associated with in-hospital mortality were age, previous admission and duration of hospital stay, but not pharmacist recommendation. Otherwise, carbapenem de-escalation was associated as a protective factor against in-hospital mortality.

CONCLUSIONS

Carbapenem de-escalation in accordance with pharmacist recommendation proved to be a safe approach in complicated UTI, reducing the hospital stay of patients without affecting the re-admission rate.