Role of Education in Antimicrobial Stewardship

A mixed-methods needs assessment for an antimicrobial stewardship curriculum in pediatrics

Objective

Antimicrobial stewardship (AS) education initiatives for multidisciplinary teams are most successful when addressing psychosocial factors driving antimicrobial prescribing (AP) and when they address the needs of the team to allow for a tailored approach to their education.

Design

We conducted a mixed-methods embedded study as a needs assessment, involving quantitative analysis of AS concerns observed by pharmacists through an audit while attending clinical team rounds, as well as qualitative semi-structured interviews based on the Theoretical Domain Framework (TDF) to identify psychosocial barriers and facilitators for antimicrobial prescribing for an inpatient general pediatric service. We analyzed the data using deductive and inductive methods by mapping the TDF to a model for social determinants of antimicrobial prescribing (SDAP) in pediatric inpatient health care teams.

Setting

The Clinical Teaching Unit (CTU) and Pediatric Intensive Care Unit (PICU), at a tertiary care pediatric hospital in Canada.

Participants

Interviews (n = 23) with staff and resident physicians, nurse practitioners, and pharmacists.

Results

Psychosocial facilitators and barriers for AS practice in the PICU and CTU which were identified included: collaboration, shared decision-making, locally accessible guidelines, and an overarching goal of doing right by the patient and feeling empowered as a prescriber. Some of the barriers identified included the norm of noninterference, professional comparisons, limited resources, feeling inadequately trained in AS, emotional prescribing, and a pejorative monitoring system.

Conclusions

Our findings identified barriers and facilitators to AS decisions on pediatric inpatient teams as well as actionable needs in psychosocial-based AS education.

The COVID-19 Pandemic Enhanced the Decade-Long Trend of the Decreasing Utilization of Antibiotics

PURPOSE/INTRODUCTION

A decline in antibiotic (AB) prescriptions was reported during the coronavirus 2019 (COVID-19) pandemic. Therefore, we investigated AB utilization during the COVID-19 pandemic using data from a large database in Germany.

METHODS

AB prescriptions in the Disease Analyzer database (IQVIA) were analyzed for each year between 2011 and 2021. Descriptive statistics were used to assess developments in relation to age group, sex, and antibacterial substances. Infection incidence rates were also investigated.

RESULTS

In total, 1,165,642 patients received antibiotic prescriptions during the entire study period (mean age: 51.8; SD: 18.4 years; 55.3% females). AB prescriptions started to decline in 2015 (505 patients per practice), and this development persisted until 2021 (2020: 300 patients per practice and 2021: 266 patients per practice). The sharpest drop was observed in 2020 and occurred in both women and men (27.4% and 30.1%). In the youngest age group (≤30), the decrease was -56%, while in the age group >70, it was -38%. The number of patients with prescriptions for fluoroquinolones dropped the most, falling from 117 in 2015 to 35 in 2021 (-70%), followed by macrolides (-56%) and tetracyclines (-56%). In 2021, 46% fewer patients were diagnosed with acute lower respiratory infections, 19% fewer with chronic lower respiratory diseases, and just 10% fewer with diseases of the urinary system.

CONCLUSION

AB prescriptions decreased more in the first year (2020) of the COVID-19 pandemic than infectious diseases did. While the factor of older age influenced this trend negatively, it remained unaffected by the factor of sex and the selected antibacterial substance.

Interventions to Improve Antibiotic Use in Hospitals with Different Levels of Complexity in Colombia: Findings from a Before-and-After Study and Suggestions for the Future

BACKGROUND

In the collaborative efforts to control bacterial antimicrobial resistance (AMR), the challenge for many low- and middle-income countries currently lies in the adequate design and successful implementation and operation of different strategies aimed at improving antibiotic use during hospital care. This study aims to provide data on these different strategies in three hospitals with different levels of complexity and geographic locations in Colombia.

METHODS

This before-and-after study describes and analyzes the development and implementation of clinical practice guidelines (CPGs), continuing education courses, quick consultation tools, and antimicrobial stewardship programs (ASPs) with the use of telemedicine. This includes measuring indicators in the ASP framework such as adherence to CPGs and antibiotic consumption.

RESULTS

We used five CPGs developed in the Colombian context. We designed and developed a Massive Open Online Course (MOOC) and a mobile application (app) as strategies for dissemination and implementation. The ASP was designed and implemented according to each institution's level of complexity. In the three hospitals, a progressive increase in adherence to the antibiotic recommendations proposed in the CPGs was observed, and there was a lower use of antibiotics with the ASPs, both in the general wards and ICUs.

CONCLUSIONS

We concluded that in medium-complexity hospitals located in small rural cities, successful development of ASPs is possible when they are well-planned, implemented, and supported by the organization. It is necessary that Colombia and other Latin American countries continue activities that reduce AMR by designing, implementing, and improving these interventions throughout the national territory.

Building an antimicrobial stewardship program: A narrative of six years under the Donabedian perspective

Introduction: Antimicrobial resistance (AMR) is increasing and represents one of the world's major challenges. AMR increase morbimortality, length of hospital stay and costs. Antimicrobial Stewardship Programs (ASP) are one of the key strategies to promote the rational use of antimicrobials since AMR is mostly driven by antimicrobial consumption. Objective: To describe the ASP implementation in a teaching hospital from the perspective of Donabedian quality assessment and the Brazilian regulatory requirements. Method: This was a descriptive study with secondary data collection, including document review of the ASP. The study setting was a general public 392-bed hospital. The ASP activities were performed by the hospital infection control committee (HICC), hospital pharmacy (HP) and diagnostic support laboratory (DSL). The description of the three services mainly involved in the ASP was based on a quality assessment model involving the dimensions of "structure", "process" and "result" proposed by Donabedian. The distribution among dimensions was guided by the checklist of essential elements of the ASP that compose the Brazilian regulatory requirements. The checklist was applied in July, 2022, and the ASP results described from 2016 to 2021. Results: ASP actions have been gradually implemented since 2008 with the implementation of HICC and improved over the years. Regarding structure, the investments in technology were mapped, quantifying 26 computers and three software programs employed to computerize the ASP processes performed in specific physical areas by HICC, HP and DSL. Institutional guidelines used by HICC, HP and DSL guided clinical practices to operationalize ASP. The evaluation metrics improved for 10 indicators and worsened for four indicators. From the 60 items composing the checklist, the hospital met the requirements in 73.3% of the items (n = 44). Conclusion: This study described the implementation of ASP in a teaching hospital, applying the Donabedian perspective. Although the hospital still does not have a classic ASP model, there were investments to improve structure, processes and results, aiming to comply with international guidelines. A high proportion of key elements of ASP in the hospital were followed according to the Brazilian regulatory requirements. Aspects related to antimicrobial consumption and the emergence of microbial resistance deserve further investigations.

The Optimal Management of Neisseria gonorrhoeae Infections

Neisseria gonorrhoeae is one of the most frequent etiologic agents of STDs (sexually transmitted diseases). Untreated asymptomatic gonococcal infection in women can lead to spreading of the infection in the sexually active population and could lead to late consequences, such as sterility or ectopic pregnancies. One important issue about N. gonorrhoeae is its increasing resistance to antibiotics. This paper summarized the newest molecular antimicrobial resistance (AMR) detection assays for Neisseria gonorrhoeae connected with the latest therapeutic antimicrobials and gonococcal vaccine candidates. The assays used to detect AMR varied from the classical minimal inhibitory concentration (MIC) detection to whole-genome sequencing. New drugs against multi drug resistant (MDR) N. gonorrhoeae have been proposed and were evaluated in vivo and in vitro as being efficient in decreasing the N. gonorrhoeae burden. In addition, anti-N. gonorrhoeae vaccine candidates are being researched, which have been assessed by multiple techniques. With the efforts of many researchers who are studying the detection of antimicrobial resistance in this bacterium and identifying new drugs and new vaccine candidates against it, there is hope in reducing the gonorrhea burden worldwide.

Polish Medical Doctors’ Opinions on Available Resources and Information Campaigns concerning Antibiotics and Antibiotic Resistance, a Cross-Sectional Study

Background: Antibiotic resistance (ABR) is at the top of global health threats. This paper aims to assess Polish physicians’ readiness to impact ABR through prescribing routines. Methods: Surveying Polish physicians participating in specialization courses at the Center for Postgraduate Medical Education in Warsaw, Poland from October 2019 to March 2020. Results: Information was obtained from 504 physicians aged 25–59, mean 32.8 ± 5.9 years, mainly women (65%). Most doctors (78%) prescribed antibiotics at least once a week. Physicians indicated clinical practice guidelines as resources most often consulted in the management of infections (90%). However, clinical experience was also declared a powerful resource. In total, 54% of respondents recalled receiving information about the prudent use of antibiotics within 12 months, which partially translated into changing views (56%) and practice (42%). Physicians disagreed that national campaigns provide good promotion of prudent antibiotics use (75%) or that they are effective (61%). Only 40% of doctors were aware of the national campaign promoting responsible antibiotics use, 24% had heard about the European Antibiotic Awareness Day and 20% knew about the World Antimicrobial Awareness Week. Conclusions: Prescribers most often rely on clinical practice guidelines and their own experience as resources for antibiotics use. Doctors’ awareness of available resources and information campaigns concerning antibiotics and antibiotic resistance should be improved.

How Are We Educating Future Physicians and Pharmacists in Pakistan? A Survey of the Medical and Pharmacy Student's Perception on Learning and Preparedness to Assume Future Roles in Antibiotic Use and Resistance

Background: Medical and pharmacy students are future healthcare professionals who will be on the forefront in dealing with antibiotics in hospitals or community settings. Whether the current medical and pharmacy education in Pakistan prepares students to take future roles in antibiotic use remains an under-researched area. Aim: This study aims to compare medical and pharmacy students’ perceived preparedness, learning practices and usefulness of the education and training on antibiotic use and resistance imparted during undergraduate studies in Pakistan. Design and Setting: It was amulti-centre cross-sectional survey of medical and pharmacy colleges in Punjab, Pakistan. Method: A self-administered questionnaire was used to collect data from final year medical and pharmacy students. Descriptive statistics were used for categorical variables while independent t-test and One-way ANOVA computed group differences. Result: Nine hundred forty-eight respondents (526 medical and 422 pharmacy students) completed the survey from 26 medical and 19 pharmacy colleges. Majority (76.1%) of the pharmacy students had not completed a clinical rotation in infectious diseases. The top three most often used sources of learning antibiotic use and resistance were the same among the medical and the pharmacy students; included textbooks, Wikipedia, and smart phone apps. Overall self-perceived preparedness scores showed no significant difference between pharmacy and medical students. The least prepared areas by medical and pharmacy students included transition from intravenous to oral antibiotics and interpretation of antibiograms. Both medical and pharmacy students found problem solving sessions attended by a small group of students to be the most useful (very useful) teaching methodology to learn antibiotic use and resistance. Conclusions: Differences exist between medical and pharmacy students in educational resources used, topics covered during undergraduate degree. To curb the growing antibiotic misuse and resistance, the concerned authorities should undertake targeted educational reforms to ensure that future physicians and pharmacists can play a pivotal role in rationalizing the use of antibiotics.

Current Antimicrobial Stewardship Practice and Education in Russian Hospitals: Results of a Multicenter Survey

Proper antibiotic usage education and training of medical students and healthcare professionals is the cornerstone to implement antimicrobial stewardship (AMS) programs worldwide. We conducted this voluntary and anonymous survey on current and preferred educational provision of AMS in Russia. Among 1358 polled respondents from six participating Centers located in geographically remote Federal Districts of Russia, the majority were nurses (52.8%) and doctors (42.0%). Results of the survey demonstrated better coverage of education in AMS on an undergraduate level (57.1%). More than half of respondents in total (52.4%) stated they had not received any postgraduate training. Those 38.4% respondents who received postgraduate teaching in AMS stated that it had been provided substantially by an employing hospital (28.4%) or by a medical university/college (22.3%). According to the conducted survey, the methods of education in AMS in Russian Federation mainly include traditional face-to-face lectures, presentations and provision with clinical guidelines, recommendations and printed materials. The involvement of e-learning and web-based online approaches was lacking. The survey allowed us the identify the key problems associated with training of healthcare workers in this field, in particular the varying availability of under- and postgraduate education in different parts of Russia.

Development of the Three Antimicrobial Stewardship E's (TASE) framework and Association between Stewardship Interventions and intended Results (ASIR) analysis to identify key facility-specific interventions and strategies for successful antimicrobial stewardship

BACKGROUND

Successful antimicrobial stewardship (AS) interventions have been described previously. Currently, a uniform operational approach to planning and implementing successful AS interventions does not exist. From 2015 to 2019, concomitant vancomycin and piperacillin-tazobactam use (CVPTU) for >48 hours at Vanderbilt University Medical Center (VUMC) significantly decreased through AS efforts. We analyzed the interventions that led to this change and created a model to inform future intervention planning and development.

METHODS

VUMC adult admissions from January 2015 to August 2019 were evaluated for CVPTU. Percentage of admissions receiving CVPTU >48 hours, the primary outcome, was evaluated using statistical process control charts. We created the Three Antimicrobial Stewardship E's (TASE) framework and Association between Stewardship Interventions and intended Results (ASIR) analysis to assess potential intensity and impact of interventions associated with successful change during this time period and to identify guiding principles for development of future initiatives.

RESULTS

The mean percentage of admissions receiving CVPTU per month declined from 4.2% to 0.7%. Over 8 time periods, we identified 4 high, 3 moderate and 1 low intervention intensity periods. Continuous provider-level AS education was present throughout. Creation and dissemination of division and department algorithms and reinforcement via computerized provider order entry sets preceded the largest reduction in CVPTU and sustained prescribing practice changes.

CONCLUSIONS

The TASE framework and ASIR analysis successfully identified pivotal interventions and strategies needed to effect and sustain change at VUMC. Further research is needed to validate its effectiveness as a stewardship intervention planning tool at our institution and others.

Antimicrobial Stewardship: A Review for Internal Medicine Physicians

Antimicrobial stewardship is the need of the hour to prevent the collapse of our health care system at the hands of a pandemic of resistant pathogens. Inappropriate and indiscriminate abuse of antibiotics has left very few options for prescribing physicians as most of the pathogens, particularly gram-negative, are resistant to the major antibiotics. This article reviews the importance of Antimicrobial Stewardship Programs (ASP) for internal medicine physicians and residents. Commonly encountered clinical scenarios are discussed. Appropriate indications of antibiotics, pathogen-guided prescriptions, adverse effects of common antibiotics, and options to use newer antibiotics are reviewed. The role of a health care team is highlighted. The evidence-based steps taken to ensure ASPs implementation are reiterated to serve as an educational guide for medical residents and physicians.

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.

Metaphylactic Antibiotic Treatment to Prevent the Transmission of Corynebacterium bovis to Immunocompromised Mouse Offspring

Current methods for eradicating Corynebacterium bovis, such as depopulation, embryo transfer, and cesarean rederivation followed by cross fostering, are expensive, complex, and time-consuming. We investigated a novel method to produce immunocompromised offspring free of C. bovis from infected NOD. Cg-PrkdcscidIl2rgtm1Wgl/SzJ (NSG) breeding pairs. Adult NSG mice were infected with C. bovis, paired, and randomly assigned to either a no-antibiotic control group (NAB, n = 8) or a group that received amoxicillin-clavulanic acid (0.375 mg/mL) in their drinking water for a mean duration of 7 wk (AB group, n = 7), spanning the time from pairing of breeders to weaning of litters. The AB group also underwent weekly cage changes for 3 wk after pairing to decrease intracage C. bovis contamination, whereas the NAB mice received bi-weekly cage changes. Antibiotics were withdrawn at the time of weaning. All litters (n = 7) in the AB group were culture- and qPCR-negative for C. bovis and remained negative for the duration of the study, whereas all litters in the NAB group (n = 6) remained C. bovis positive. A single adult from each breeding pair was sampled at weaning and at 5 and 10 wk after weaning to confirm the maintenance of (NAB) or to diagnose the reemergence (AB) of C. bovis infection. By the end of the study, C. bovis infection had returned in 3 of the 7 (43%) tested AB adults. Our data suggest that metaphylactic antibiotic use can decrease viable C. bovis organisms from adult breeder mice and protect offspring from infection. However, using antibiotics with frequent cage changing negatively affected breeding performance. Nevertheless, this technique can be used to produce C. bovis-free NSG offspring from infected adults and may be an option for salvaging infected immunocompromised strains of mice that are not easily replaced.

FDA approved antibacterial drugs: 2018-2019

Bacterial resistance to existent antibiotherapy is a perpetual internationally-recognized problem. Year after year, there is a continuous need for novel antibacterial drugs and this research and development efforts recently resulted in few new drugs or combination of drugs proposed for the use into the clinic. This review focuses on the novel US FDA approved antibacterial agents in the last two years (2018-2019). Plazomicin, eravacycline, sarecycline, omadacycline, rifamycin (2018) and imipenem, cilastatin and relebactam combination, pretomanid, lefamulin, cefiderocol (2019) are new therapeutic options. Plazomicin aminoglycoside antibiotic targets Enterobacteriaceae infections, being mainly used for the complicated urinary tract infections. The fully synthetic fluorocycline eravacycline gained approval for the complicated intra-abdominal infections. The tetracycline-derived antibiotic sarecycline might be a useful strategy for the management of non-nodular moderate to severe acne, while the other tetracycline-derived antibiotic approved, omadacycline, may be used for the patients with acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. The already-known RNA-synthesis suppressor rifamycin is now also approved for noninvasive Escherichia Coli-caused travelers' diarrhea. Two combinatorial strategies were approved for complicated urinary tract infections, complicated intra-abdominal infections (imipenem, cilastatin and relebactam) and lung tuberculosis (pretomanid in combination with bedaquiline and linezolid). Lefamulin is a semisynthetic pleuromutilin antibiotic for community-acquired bacterial pneumonia, while cefiderocol, a cephalosporin antibiotic is the last antibacterial drug approved in 2019, for the use in complicated urinary tract infections. Despite of these new developments, there is an ongoing need and urgency to develop novel antibiotic strategies and drugs to overrun the bacterial resistance to antibiotics.

Is online case-based learning effective in helping undergraduate medical students choose the appropriate antibiotics to treat important infections?

Background

Medical students are frequently confused about indication for and choice of antibiotic. We developed an online learning resource that focused on antibiotic stewardship and important infections where medical students could practise their antibiotic decision-making skills safely.

Methods

The resource was made available to third-year undergraduate medical students via their virtual learning environment. It covered the theory and fundamentals of antibiotic stewardship and five clinical cases covering important infections. We assessed the number of attempts taken to achieve the required level of understanding to pass each activity and surveyed a selection of students for their feedback.

Results

Of 310 students, over 80% engaged with the theory-based components, with an average score exceeding 90% (range 93.4%–99.7%). Eighty-three percent (258/310) engaged with the first two cases (Clostridioides difficile infection and pyelonephritis) but only 61% (189/310) of students completed the fifth case on bacterial meningitis. Only 49.4% (153/310) of students completed all five cases, with 48% (73/153) of these achieving ≥90% on their first attempt of the associated quizzes. Fifty-nine percent (23/39) agreed or strongly agreed that the quality of the learning resource was excellent. Seventy-two percent (28/39) agreed or strongly agreed that the objectives of the resource were relevant to their needs as undergraduate medical students. Only 33% (13/39) reported the resource would change their practice.

Conclusions

Student feedback was positive but engagement with the cases needs improvement. Highlighting the utility of case-based technology-enhanced learning as a safe place to practise antibiotic decision-making skills among students may improve this.