A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs

OBJECTIVE

To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers.

DESIGN

Qualitative semistructured interviews.

SETTING

The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare.

PARTICIPANTS

We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders.

METHODS

Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR.

RESULTS

We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff.

CONCLUSION

Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.

Revitalizing the infection prevention workforce with a fellowship program for underrepresented groups

Infection preventionist (IP) positions are difficult to fill, and future workforce shortages are anticipated. The IP field has less racial and ethnic diversity than the general nursing workforce or patient population. A targeted fellowship program for underrepresented groups allowed the recruitment and training of IPs while avoiding staffing shortages.

Antibiotic therapy completion for injection drug use-associated infective endocarditis at a center with routine addiction medicine consultation: a retrospective cohort study

Background

Addiction medicine consultation and medications for opioid use disorder are shown to improve outcomes for patients hospitalized with infective endocarditis associated with injection drug use. Existing studies describe settings where addiction medicine consultation and initiation of medications for opioid use disorder are not commonplace, and rates of antibiotic therapy completion are infrequently reported. This retrospective study sought to quantify antibiotic completion outcomes in a setting where these interventions are routinely implemented.

Methods

Medical records of patients hospitalized with a diagnosis of bacteremia or infective endocarditis at an urban hospital between October 1, 2015 and December 31, 2017 were screened for active injection drug use within 6 months of hospitalization and infective endocarditis. Demographic and clinical parameters, receipt of antibiotics and medications for opioid use disorder, and details of re-hospitalizations within 1 year of discharge were recorded.

Results

Of 567 subjects screened for inclusion, 47 had infective endocarditis and active injection drug use. Addiction medicine consultation was completed for 41 patients (87.2%) and 23 (48.9%) received medications for opioid use disorder for the entire index admission. Forty-three patients (91.5%) survived to discharge, of which 28 (59.6%) completed antibiotic therapy. Twenty-nine survivors (67.4%) were re-hospitalized within 1 year due to infectious complications of injection drug use.

Conclusions

Among patients admitted to a center with routine addiction medicine consultation and initiation of medications for opioid use disorder, early truncation of antibiotic therapy and re-hospitalization were commonly observed.

145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach

Background

Hospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another.

Methods

We proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016.

Results

We identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096).

Conclusion

The developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development.

Disclosures

Matthew B. Goetz, MD, Nothing to disclose

103. Expansion of an Antimicrobial Stewardship Program Through Implementation of a Discharge Verification Queue

Background

Antimicrobial stewardship programs (ASPs) have traditionally focused interventions on inpatient care to improve antibiotic prescribing. Support of effective interventions for ASPs targeting antibiotic prescriptions at hospital discharge is emerging. Our objective was to expand stewardship services into the outpatient setting through implementation of a process by the antimicrobial stewardship team (AST) to verify antimicrobials prescribed at discharge.

Methods

This quality improvement initiative incorporated a discharge order verification queue managed by AST pharmacists to review electronically prescribed antimicrobials Monday through Friday, from 8:00 am to 4:00 pm. The queue was piloted Sep 2020 and expanded hospital-wide Feb 2021. Patients < 18 years old and those with observation or emergency department status were excluded. The AST pharmacist reviewed discharge prescriptions for appropriateness, intervened directly with prescribers, and either rejected or verified prescriptions prior to transmission to outpatient pharmacies. Complicated cases were reviewed with the AST physician to evaluate intervention appropriateness. Interventions were categorized as either dose adjustment, duration, escalation or de-escalation, discontinuation, or safety monitoring.

Results

A total of 602 prescriptions were reviewed between Sep 2020 and Apr 2021. An AST pharmacist intervened on 28% (171/602) of prescriptions. The most common intervention types were duration (41%, 70/171), discontinuation (18%, 31/171), and dose adjustment (17%, 30/171). The most common indications in which the duration was shortened was community acquired pneumonia (26%, 18/70), skin and soft tissue infection (21%, 15/70), and urinary tract infection (17%, 12/70). The most common antibiotics recommended for discontinuation were cephalexin (32%, 10/31) and trimethoprim-sulfamethoxazole (10%, 3/31). The overall intervention acceptance rate was 78%.

Conclusion

An AST pharmacist review of antimicrobial prescriptions at discharge improved appropriate prescribing. The discharge queue serves as an effective stewardship strategy for inpatient ASPs to expand into the outpatient setting.

Disclosures

All Authors: No reported disclosures

Provider views on rapid diagnostic tests and antibiotic prescribing for respiratory tract infections: A mixed methods study

BACKGROUND

Respiratory tract infections (RTIs) are often inappropriately treated with antibiotics. Rapid diagnostic tests (RDTs) have been developed with the aim of improving antibiotic prescribing but uptake remains low. The aim of this study was to examine provider knowledge, attitudes and behaviors regarding RDT use and their relationship to antibiotic prescribing decisions across multiple clinical departments in an urban safety-net hospital.

METHODS

We conducted a mixed methods sequential explanatory study. Providers with prescribing authority (attending physicians, nurse practitioners and physician assistants) who had at least 20 RTI encounters from January 1, 2016 to December 31, 2018. Eighty-five providers completed surveys and 16 participated in interviews. We conducted electronic surveys via RedCap from April to July 2019, followed by semi-structured individual interviews from October to December 2019, to ascertain knowledge, attitudes and behaviors related to RDT use and antibiotic prescribing.

RESULTS

Survey findings indicated that providers felt knowledgeable about antibiotic prescribing guidelines. They reported high familiarity with the rapid streptococcus and rapid influenza tests. Familiarity with comprehensive respiratory panel PCR (RPP-respiratory panel PCR) and procalcitonin differed by clinical department. Qualitative interviews identified four main themes: providers trust their clinical judgment more than rapid test results; patient-provider relationships play an important role in prescribing decisions; there is patient demand for antibiotics and providers employ different strategies to address the demand and providers do not believe RDTs are implemented with sufficient education or evidence for clinical practice.

CONCLUSION

Prescribers are knowledgeable about prescribing guidelines but often rely on clinical judgement to make final decisions. The utility of RDTs is specific to the type of RDT and the clinical department. Given the low familiarity and clinical utility of RPP and procalcitonin, providers may require additional education and these tests may need to be implemented differently based on clinical department.

Optimizing the Management of Uncomplicated Gram-Negative Bloodstream Infections: Consensus Guidance Using a Modified Delphi Process

Background

Guidance on the recommended durations of antibiotic therapy, the use of oral antibiotic therapy, and the need for repeat blood cultures remain incomplete for gram-negative bloodstream infections. We convened a panel of infectious diseases specialists to develop a consensus definition of uncomplicated gram-negative bloodstream infections to assist clinicians with management decisions.

Methods

Panelists, who were all blinded to the identity of other members of the panel, used a modified Delphi technique to develop a list of statements describing preferred management approaches for uncomplicated gram-negative bloodstream infections. Panelists provided level of agreement and feedback on consensus statements generated and refined them from the first round of open-ended questions through 3 subsequent rounds.

Results

Thirteen infectious diseases specialists (7 physicians and 6 pharmacists) from across the United States participated in the consensus process. A definition of uncomplicated gram-negative bloodstream infection was developed. Considerations cited by panelists in determining if a bloodstream infection was uncomplicated included host immune status, response to therapy, organism identified, source of the bacteremia, and source control measures. For patients meeting this definition, panelists largely agreed that a duration of therapy of ~7 days, transitioning to oral antibiotic therapy, and forgoing repeat blood cultures, was reasonable.

Conclusions

In the absence of professional guidelines for the management of uncomplicated gram-negative bloodstream infections, the consensus statements developed by a panel of infectious diseases specialists can provide guidance to practitioners for a common clinical scenario.

The state of antibiotic stewardship programs in 2021: The perspective of an experienced steward

Recognition of antibiotic stewardship programs (ASPs) as essential components of quality health care has dramatically increased in the past decade. The value of ASPs has been further reinforced during the coronavirus disease 2019 (COVID-19) pandemic because these programs were instrumental in monitoring antibiotic use, assessing emerging COVID-19 therapies, and coordinating implementation of monoclonal antibody infusions and vaccinations. ASPs are now required across hospital settings as a condition of participation for the Centers for Medicare and Medicaid Services and for accreditation by The Joint Commission. In the 2019 National Healthcare Safety Network annual survey, almost 89% of hospitals met the Seven Core Elements for ASPs defined by the Centers for Disease Control and Prevention. More than 61% of programs were co-led by physicians and pharmacists, evidence of the leadership role of both groups. ASPs employ many strategies to improve prescribing. Core interventions of preauthorization for targeted antibiotics, prospective audit and feedback, and development of local treatment guidelines have been supplemented with numerous emerging strategies. Diagnostic stewardship, optimizing duration of therapy, promoting appropriate conversion from intravenous to oral therapy, monitoring at transitions of care and hospital discharge, implementing stewardship initiatives in the outpatient setting, and increasing use of telemedicine are approaches being adopted across hospital settings. As a core function for medical facilities, ASP leaders must ensure that antibiotic use and ASP interventions promote optimal and equitable care. The urgency of success becomes progressively greater as complex patterns of antibiotic resistance continue to emerge, exacerbated by unpredictable factors such as a worldwide pandemic.

1558. Injection Drug Use-Related Skin and Soft Tissue Infections Serve as Sentinel Events for Healthcare Utilization in a Vulnerable Population

Background

Persons with injection drug use (IDU) can have frequent skin and soft tissue infections (SSTIs) and high healthcare utilization. We sought to examine whether IDU-related SSTIs are associated with an acceleration in disease course and increased healthcare utilization (a ‘sentinel event’) and may present an important opportunity for intervention.

Methods

We performed a retrospective chart review of patients with an emergency department (ED) visit or hospital admission due to an IDU-related SSTI between 10/1/2015 and 6/1/2019 to obtain information on demographics, microbiologic data, addiction service consultation, and treatment with medications for opioid use disorder (MOUD). We compared the number of healthcare encounters in the 12 months before and after the SSTI using the Wilcoxon signed rank test for data with non-normal distribution. We examined differences in the distribution of variables between patients who were admitted and those discharged from the ED using Chi Square and Fisher exact tests for categorical variables and t-tests and Wilcoxon tests for continuous variables.

Results

In all, 305 patients met inclusion criteria for an IDU-related SSTI. The patients were 66.5% male, had a median age of 41 years (range 23-70), 84% were experiencing homelessness and 87% had Medicaid. Most patients (55.7%) were admitted to the hospital and the remainder were discharged from the ED. There was a statistically significant change in healthcare utilization in the year prior to the SSTI compared to the year after (median change +16.7%, p < 0.0001). Compared to those who were admitted, it was rare for patients discharged from the ED to have microbiologic data sent (13% vs 87%, p < 0.0001), an addiction consult completed (4% vs 96%, p < 0.0001), or to be discharged on MOUD (8.0% vs 92%, p < 0.0001). Despite these differences, there were no significant predictors of high vs low utilization among all-comers based on demographic and clinical data.

Conclusion

IDU-related SSTIs serve as sentinel events with increased healthcare utilization after the episode. Addiction consultation and initiation of MOUD had no impact on the trajectory of healthcare utilization. Further work must be done to identify how best to improve outcomes for this vulnerable population.

Disclosures

All Authors: No reported disclosures

1562. Reduction in Healthcare Utilization and Overdose after Skin and Soft Tissue Infections for Injection Drug Users through Addiction Medicine Consultation

Background

Healthcare encounters for skin and soft tissue infections (SSTIs) due to injection drug use (IDU) may provide opportunities for interventions to improve outcomes. We explored factors that may impact reduction of healthcare utilization and modify other complications of substance use disorder after an IDU-related SSTI.

Methods

We conducted a retrospective cohort chart review for 305 patients with IDU-related SSTIs between 10/1/2015 and 6/1/2019 to examine demographic, clinical and healthcare utilization data one year before and after the SSTI encounter. Patients were categorized as a low utilizer if they had < 3 emergency department encounters and as a high utilizer if they had ≥3 encounters in the one-year period before or after the SSTI. For patients that changed utilization categories from the pre- to post-SSTI period, we analyzed demographic and clinical differences using Chi Square tests. We performed a secondary analysis using a Wilcoxon test to examine the relationship between receipt of an addiction consult and change in number of overdoses after SSTI.

Results

131 patients were low utilizers at baseline and 174 were high utilizers. Patients who transitioned from low to high utilization (64 patients) were significantly less likely to have received an addiction consult, 16 (25%), than patients who transitioned from high to low utilization, 15 (48%), p=0.03. However, high utilizers were significantly more likely to remain a high utilizer (p< 0.0001) with no variable predictive of transition to low utilization including addiction consultation, homelessness, insurance type, or treatment with medications for opioid use disorder. Patients who were low utilizers at baseline were more likely to remain low utilizers if they were not homeless, p=0.01. Of the entire sample, 96.2% (p< 0.0001) of those admitted obtained an addiction consult, which significantly reduced rates of overdose in the following year (p=0.0014) for 223 patients for which we had overdose data.

Conclusion

Patients with IDU-related SSTIs who do not receive an addiction consult are more likely to cross from low to high utilization after the event. Preferentially targeting this population for addiction consultation can significantly improve outcomes.

Disclosures

All Authors: No reported disclosures

Assessment of Oropharyngeal Specimens for Discontinuation of Transmission-Based COVID-19 Precautions

We compared oropharyngeal swab test performance with nasopharyngeal testing for discontinuation of transmission-based COVID-19 precautions. We performed a retrospective review of confirmed COVID-19-positive patients who received paired nasopharyngeal and oropharyngeal SARS-CoV-2 tests for clearance from isolation from May 4, 2020, to May 26, 2020. Using nasopharyngeal swabs as the reference standard, we calculated the sensitivity, specificity, and negative predictive value of oropharyngeal swabs. We also calculated the kappa between the 2 tests. A total of 189 paired samples were collected from 74 patients. Oropharyngeal swab sensitivity was 38%, specificity was 87%, and negative predictive value was 70%. The kappa was 0.25. Our study suggests that oropharyngeal swabs are inferior to nasopharyngeal swabs for test-based clearance from COVID-19 isolation.

How Do You Measure Up: Quality Measurement for Improving Patient Care and Establishing the Value of Infectious Diseases Specialists

The shift from volume-based to value-based reimbursement has created a need for quantifying clinical performance of infectious diseases (ID) physicians. Nationally recognized ID specialty-specific quality measures will allow stakeholders, such as patients and payers, to determine the value of care provided by ID physicians and will promote clinical quality improvement. Few ID-specific measures have been developed; herein, we provide an overview of the importance of quality measurement for ID, discuss issues in quality measurement specific to ID, and describe standards by which candidate quality measures can be evaluated. If ID specialists recognize the need for quality measurement, then ID specialists can direct ID-related quality improvement, quantify the impact of ID physicians on patient outcomes, compare their performance to that of peers, and convey to stakeholders the value of the specialty.

Early administration of interleukin-6 inhibitors for patients with severe COVID-19 disease is associated with decreased intubation, reduced mortality, and increased discharge

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Observational data on interleukin-6 receptor inhibitors (IL6ri) for COVID-19 disease are reported.

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IL6ri therapy was found to be associated with improved COVID-19 outcomes.

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The treatment benefit was greatest when therapy was initiated early during the disease course.

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IL6ri therapy appears to be superior to remdesivir and dexamethasone.

Objective

The aim of this observational study was to determine the optimal timing of interleukin-6 receptor inhibitor (IL6ri) administration for coronavirus disease 2019 (COVID-19).

Methods

Patients with COVID-19 were given an IL6ri (sarilumab or tocilizumab) based on iteratively reviewed guidelines. IL6ri were initially reserved for critically ill patients, but after review, treatment was liberalized to patients with lower oxygen requirements. Patients were divided into two groups: those requiring ≤45% fraction of inspired oxygen (FiO₂) (termed stage IIB) and those requiring >45% FiO₂ (termed stage III) at the time of IL6ri administration. The main outcomes were all-cause mortality, discharge alive from hospital, and extubation.

Results

A total of 255 COVID-19 patients were treated with IL6ri (149 stage IIB and 106 stage III). Patients treated in stage IIB had lower mortality than those treated in stage III (adjusted hazard ratio (aHR) 0.24, 95% confidence interval (CI) 0.08–0.74). Overall, 218 (85.5%) patients were discharged alive. Patients treated in stage IIB were more likely to be discharged (aHR 1.43, 95% CI 1.06–1.93) and were less likely to be intubated (aHR 0.43, 95% CI 0.24–0.79).

Conclusions

IL6ri administration prior to >45% FiO₂ requirement was associated with improved COVID-19 outcomes. This can guide clinical management pending results from randomized controlled trials.

Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study

Background

Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs.

Methods

Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems.

Results

We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success.

Conclusions

The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.

Low Uptake of Rapid Diagnostic Tests for Respiratory Tract Infections in an Urban Safety Net Hospital

Background

Rapid diagnostic tests (RDTs) have been developed with the aim of providing accurate results in a timely manner. Despite this, studies report that provider uptake remains low.

Methods

We conducted a retrospective analysis of ambulatory, urgent care, and emergency department (ED) encounters at an urban safety net hospital with a primary diagnosis of an upper or lower respiratory tract infection (eg, bronchitis, pharyngitis, acute sinusitis) from January 1, 2016, to December 31, 2018. We collected RDT type and results, antibiotics prescribed, demographic and clinical patient information, and provider demographics.

Results

RDT use was low; a test was performed at 29.5% of the 33494 visits. The RDT most often ordered was the rapid Group A Streptococcus (GAS) test (n = 7352), predominantly for visits with a discharge diagnosis of pharyngitis (n = 5818). Though antibiotic prescription was more likely if the test was positive (relative risk [RR], 1.68; 95% confidence interval [CI], 1.58–1.8), 92.46% of streptococcal pharyngitis cases with a negative test were prescribed an antibiotic. The Comprehensive Respiratory Panel (CRP) was ordered in 2498 visits; influenza was the most commonly detected pathogen. Physicians in the ED were most likely to order a CRP. Antibiotic prescription was lower if the CRP was not ordered compared with a negative CRP result (RR, 0.77; 95% CI, 0.7–0.84). There was no difference in prescribing by CRP result (negative vs positive).

Conclusions

RDTs are used infrequently in the outpatient setting, and impact on prescribing was inconsistent. Further work is needed to determine barriers to RDT use and to address potential solutions.

Disproportionate Exposure to Antibiotics in Children at Risk for Invasive Pneumococcal Disease: Potential for Emerging Resistance and Opportunity for Antibiotic Stewardship

We compared antibiotic prescribing for children with and those without an underlying chronic condition associated with increased risk for invasive pneumococcal disease. Children with a chronic condition had significantly greater cumulative exposure to antibiotics and higher rates of prescriptions per person-year than those without a chronic condition; this population is at increased risk for the emergence of multidrug-resistant pathogens.

Retrospective analysis of long-term gastrointestinal symptoms after Clostridium difficile infection in a nonelderly cohort

Elderly patients and those with comorbid conditions are at high risk for poor outcomes after Clostridium difficile infection (CDI) but outcomes in a healthier, nonelderly population are not well described. We sought to investigate gastrointestinal diagnoses and CDI during hospitalizations in the 24 to 36 months after an initial episode of CDI in nonelderly patients in a cohort with an overall low prevalence of comorbid conditions. We performed a retrospective analysis of hospital admissions from 2010–2013 using the Truven MarketScan database of employment-based private insurance claims. Subjects <65 years of age and their adult dependents (> = 18 years old); a CDI diagnosis in 2011 (index date); at least 12 months of pre-index continuous enrollment; and 24–36 months of continuous post-index enrollment were included. The 12 months of each subject’s enrollment prior to the index date for a CDI served as the reference period for the analyses of that subject’s post-CDI time periods. Hospital claims during the follow-up period were evaluated for gastrointestinal diagnoses and/or CDI ICD-9 codes. The risk of gastrointestinal diagnoses was assessed using Cox proportional hazards models adjusted for a pre-specified set of baseline demographic and clinical factors. During 2011, 5,632 subjects with CDI met the inclusion criteria for our study. The risk of gastrointestinal diagnoses in patients with a CDI diagnostic code for the same admission was almost 8-fold higher 3 months post-CDI (hazard ratio (HR) = 7.56; 95% confidence interval (CI): 2.97–19.19) than for subjects without CDI and remained statistically significant until month 24 (HR = 1.47; 95% CI = 1.04–2.08). After CDI, patients remained at risk for gastrointestinal symptoms with CDI for up to two years. There is an important, long-term healthcare burden after CDI in this population.

A Qualitative Study of the Real-world Experiences of Infectious Diseases Fellows Regarding Antibiotic Stewardship

Background

Antibiotic-resistant bacterial infections are a major threat to public health, yet improper use of antibiotics remains high. Infectious Diseases (ID) fellows play a major role in antibiotic stewardship efforts, but there is little research on how they view stewardship activities. We performed a qualitative study to explore ID fellows’ experiences and perspectives regarding their antibiotic stewardship training and their role as future antibiotic stewards.

Methods

We conducted 17 in-depth interviews with ID fellows across the country. The interviews were transcribed verbatim by the study team, and we used grounded theory to generate themes from these interviews

Results

Fellows focused on concrete tasks of stewardship such as performing antibiotic approvals, didactic and case-based education, and interactions with other physicians and pharmacists. There was little focus on the broader public health relevance of antibiotic stewardship. Pharmacists, not ID physician leaders, were identified as fellows’ primary resource for antibiotic teaching. Several fellows suggested that stewardship programs should be led by pharmacists.

Conclusions

ID fellowship training is not successfully conveying the public health importance of antibiotic stewardship or the role of ID physicians as leaders of antibiotic stewardship programs. Fellows are more focused on concrete tasks related to stewardship. ID training programs and societies should consider developing robust curricula involving fellows in the operation of the stewardship program itself, not solely in antibiotic approvals, emphasizing aspects of the program such as complex problem solving that fellows find most compelling, and emphasizing the important role these programs serve in improving public health.

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

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Ten-year review of Clostridium difficile infection in acute care hospitals in the USA, 2005-2014

Clostridium difficile infection (CDI) is a major health concern for acute care hospitals because of the increase in the number and severity of cases. Using the Nationwide Inpatient Sample database, a 10-year review was performed on the trends in incidence, mortality, and hospital charges for CDI patients in acute care hospitals during 2005-2014. The review found increased CDI incidence and hospital charges, but decreased mortality during the 10-year study period.

Antibiotic-Stewardship Practices at Top Academic Centers Throughout the United States and at Hospitals Throughout Massachusetts

Objective.

Improvements in antibiotic prescribing to reduce bacterial resistance and control hospital costs is a growing priority, but the way to accomplish this is poorly defined. Our goal was to determine whether certain antibiotic stewardship interventions were universally instituted and accepted at top US academic centers and to document what interventions, if any, are used at both teaching and community hospitals within a geographic area.

Design.

Two surveys were conducted. In survey 1, detailed phone interviews were performed with the directors of antibiotic stewardship programs at 22 academic medical centers that are considered among the best for overall medical care in the United States or as leaders in antibiotic stewardship programs. In survey 2, teaching and community hospitals throughout Massachusetts were surveyed to ascertain what antibiotic oversight program components were present.

Results.

In survey 1, each of the 22 participating hospitals had instituted interventions to improve antibiotic prescribing, but none of the interventions were universally accepted as essential or effective. In survey 2, of 97 surveys that were mailed to prospective participants, a total of 54 surveys from 19 teaching hospitals and 35 community hospitals were returned. Ninety-five percent of the teaching hospitals had a restricted formulary, compared with 49% of the community hospitals, and 89% of teaching hospitals had an antibiotic approval process, compared with 29% of community hospitals.

Conclusion.

There was great variability among the approaches to the oversight of antibiotic prescribing at major academic hospitals. Antibiotic management interventions were lacking in more than half of the Massachusetts community hospitals surveyed. More research is needed to define the best antibiotic stewardship interventions for different hospital settings.

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

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Unnecessary Antibiotics for Acute Respiratory Tract Infections: Association With Care Setting and Patient Demographics

Background.  Up to 40% of antibiotics are prescribed unnecessarily for acute respiratory tract infections (ARTIs). We sought to define factors associated with antibiotic overprescribing of ARTIs to inform efforts to improve practice. Methods.  We conducted a retrospective analysis of ARTI visits between 2006 and 2010 from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Those surveys provide a representative sample of US visits to community-based physicians and to hospital-based emergency departments (EDs) and outpatient practices. Patient factors (age, sex, race, underlying lung disease, tobacco use, insurance), physician specialty, practice demographics (percentage poverty, median household income, percentage with a Bachelor's Degree, urban-rural status, geographic region), and care setting (ED, hospital, or community-based practice) were evaluated as predictors of antibiotic overprescribing for ARTIs. Results.  Hospital and community-practice visits had more antibiotic overprescribing than ED visits (odds ratio [OR] = 1.64 and 95% confidence interval [CI], 1.27-2.12 and OR = 1.59 and 95% CI, 1.26-2.01, respectively). Care setting had significant interactions with geographic region and urban and rural location. The quartile with the lowest percentage of college-educated residents had significantly greater overprescribing (adjusted OR = 1.41; 95% CI, 1.07-1.86) than the highest quartile. Current tobacco users were overprescribed more often than nonsmokers (OR = 1.71; 95% CI, 1.38-2.12). Patient age, insurance, and provider specialty were other significant predictors. Conclusions.  Tobacco use and a lower grouped rate of college education were associated with overprescribing and may reflect poor health literacy. A focus on educating the patient may be an effective approach to stewardship.

Guidance for the knowledge and skills required for antimicrobial stewardship leaders

Antimicrobial stewardship programs are increasingly recognized as critical in optimizing the use of antimicrobials. Consequently, more physicians, pharmacists, and other healthcare providers are developing and implementing such programs in a variety of healthcare settings. The purpose of this guidance document is to outline the knowledge and skills that are needed to lead an antimicrobial stewardship program. It was developed by antimicrobial stewardship experts from organizations that are engaged in advancing the field of antimicrobial stewardship.

Coagulase-negative staphylococcal bloodstream infections: Does vancomycin remain appropriate empiric therapy?

OBJECTIVES

It is unknown if vancomycin minimal inhibitory concentrations (MICs) have increased in coagulase-negative staphylococci (CoNS) or whether vancomycin remains appropriate empiric therapy.

METHODS

We performed a retrospective study at a single tertiary care center over 8 years. Adult inpatients with ≥2 positive blood cultures for CoNS within a 48-h period were eligible. Susceptibilities were performed by automated broth based-microdilution. Changes in antimicrobial susceptibility were analyzed using logistic regression. The clinical characteristics and outcomes of patients with bloodstream infections (BSI) were compared by MIC.

RESULTS

Of 308 episodes of possible CoNS bacteremia, the vancomycin MIC was ≤1 μg/mL in 80 (26%) isolates, 2 μg/mL in 223 (72.4%) isolates and 4 μg/mL in 5 (1.6%) isolates. No isolates were resistant. We observed an 11-fold increased chance of having an isolate with a vancomycin MIC ≤1 μg/mL in 2009-2011 compared with 2004-2008 (OR 10.8, 95% CI 6.0-19.5, p < 0.05). In 152 patients with BSI, the median days of bacteremia, hospital mortality and readmissions at 30 days were similar in BSI caused by isolates with high vancomycin MICs (2-4 μg/mL) and low vancomycin MICs (≤1 μg/mL).

CONCLUSIONS

We conclude vancomycin is still appropriate empiric therapy for CoNS BSIs. CoNS vancomycin MICs decreased over the study period despite widespread use of vancomycin.

Antibiotic Resistance Spreads Internationally Across Borders

Antibiotic-resistant (ABR) bacteria develop when bacteria are exposed to antibiotics either during treatments in humans or animals or through environmental sources contaminated with antibiotic residues. Resistant bacteria selected by medical, agricultural, and industrial use spread globally through international travel, the export of animals and retail products, and the environment. It is essential that nations work together to identify how to reduce emergence and amplification of resistant bacteria through sensible antibiotic treatment guidelines and restrictions, concerted efforts for surveillance, and infection control.

Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities

OBJECTIVES

To describe patterns of antimicrobial use for respiratory tract infections (RTIs) in older residents of long-term care facilities (LTCFs).

DESIGN

Data from a prospective, randomized, controlled study of the effect of vitamin E supplementation on RTIs conducted from April 1998 through August 2001 were analyzed.

SETTING

Thirty-three LTCFs in the greater Boston area.

PARTICIPANTS

Six hundred seventeen subjects aged 65 and older residing in LTCFs.

MEASUREMENTS

RTIs, categorized as acute bronchitis, pneumonia, common cold, influenza-like illness, pharyngitis, and sinusitis, were studied for appropriateness of antimicrobial use, type of antibiotics used, and factors associated with their use. For cases in which drug treatment was administered, antibiotic use was rated as appropriate (when an effective drug was used), inappropriate (when a more-effective drug was indicated), or unjustified (when use of any antimicrobial was not indicated).

RESULTS

Of 752 documented episodes of RTI, overall treatment was appropriate in 79% of episodes, inappropriate in 2%, and unjustified in 19%. For acute bronchitis, treatment was appropriate in 35% and unjustified in 65% of cases. For pneumonia, treatment was appropriate in 87% of episodes. Of the most commonly used antimicrobials, macrolide use was unjustified in 43% of cases. No statistically significant differences in the patterns of antibiotic use were observed when stratified according to age, sex, race, or comorbid conditions, including diabetes mellitus, dementia, and chronic kidney disease.

CONCLUSION

Antimicrobials were unjustifiably used for one-fifth of RTIs and more than two-thirds of cases of acute bronchitis, suggesting a need for programs to improve antibiotic prescribing at LTCFs.

Pulmonary aspergillosis and invasive disease in AIDS: review of 342 cases

Aspergillosis is an infrequent but commonly fatal infection among HIV-infected individuals. We review 342 cases of pulmonary Aspergillus infection that have been reported among HIV-infected patients, with a focus on invasive disease. Invasive pulmonary aspergillosis usually occurs among patients with <50 CD4 cells/mm3. Major predisposing conditions include neutropenia and steroid treatment. Fever, cough, and dyspnea are each present in >60% of the cases. BAL is often suggestive, but biopsy specimens are necessary for definite diagnosis. Amphotericin B is the mainstay of treatment and mortality is > 80%. Avoiding neutropenia and judicious use of steroids may be helpful in prevention. Aggressive diagnostic approach, early initiation of treatment, adequate dosing of antifungals, and close follow-up may improve the currently dismal prognosis.

Focal mycobacterial lymphadenitis following initiation of protease-inhibitor therapy in patients with advanced HIV-1 disease

BACKGROUND

Inhibitors of HIV-1 protease produce a rapid decrease in plasma HIV-1 RNA, with concomitant increases in CD4 T-helper lymphocyte counts. The main side-effects of the protease inhibitors currently in use include gastrointestinal disturbances, paraesthesias, hyperbilirubinaemia, and nephrolithiasis. The increasing use of these agents in patients with advanced HIV-1 infection and CD4 counts of less than 50 cells/microL may be associated with unforeseen adverse effects not observed in earlier studies of patients with higher CD4 counts.

METHODS

Five HIV-infected patients with baseline CD4 lymphocyte counts of less than 50 cells/mL were admitted to the Beth Israel Deaconess Medical Center (Boston, MA, USA) with high fever (> 39 degrees C), leucocytosis, and evidence of lymph-node enlargement within 1-3 weeks of starting indinavir therapy. Informed consent was obtained for studies that entailed CD4 lymphocyte counts, immunophenotyping, isolator blood cultures, and radiological scans. Biopsy samples of cervical, paratracheal, or mesenteric lymph nodes were taken for culture and pathology in four patients.

FINDINGS

Lymph-node biopsy samples showed that focal lymphadenitis after initiation of indinavir resulted from unsuspected local or disseminated Mycobacterium avium complex (MAC) infection. The prominent inflammatory response to previously subclinical MAC infection was associated with leucocytosis in all patients and with an increase in the absolute lymphocyte counts in four patients. Three patients with follow-up CD4 counts showed two-fold to 19-fold increases after 1-3 weeks of indinavir therapy. Immunophenotyping after therapy in two patients showed that more than 90% of the CD4 cells were of the memory phenotype.

INTERPRETATION

The initiation of indinavir therapy in patients with CD4 counts of less than 50 cells/mL and subclinical MAC infection may be associated with a severe illness, consisting of fever (> 39 degrees C), leucocytosis, and lymphadenitis (cervical, thoracic, or abdominal). The intense inflammatory reactions that make admission to hospital necessary may be secondary to significant numbers of functionally competent immune cells becoming available to respond to a heavy mycobacterial burden. Prophylaxis or screening for subclinical MAC infection, or both, should therefore be done before the beginning of protease-inhibitor therapy in patients with advanced HIV infection.

Two regions of the herpes simplex virus type 1 UL42 protein are required for its functional interaction with the viral DNA polymerase

Two essential gene products of herpes simplex virus type 1, the viral DNA polymerase (pol) and UL42, its accessory protein, physically and functionally interact to form the core of the viral DNA replication complex. Understanding this essential interaction would provide a basis from which to develop novel anti-herpesvirus agents. We previously have shown that when coexpressed in an in vitro transcription-translation system, UL42 stimulates pol activity (M. L. Gallo, D. I. Dorsky, C. S. Crumpacker, and D. S. Parris, J. Virol. 63:5023-5029, 1989). By analyzing various insertion, deletion, and frameshift mutations of UL42 in this system, we found the C-terminal 149 amino acids to be dispensable for the ability of the protein to stimulate pol activity. In addition, two distinct internal regions of UL42 were found to be required for pol stimulation. Regions I and II were defined to lie between amino acid residues 129 and 163 and between residues 202 and 337, respectively. When physical association was examined with antibody to UL42, pol was found to coimmunoprecipitate to the same level when expressed with a UL42 mutant protein lacking region I as that with wild-type UL42. Thus, mere physical association is insufficient for stimulation of pol activity. Deletion of region II reduced or eliminated coimmunoprecipitation with pol. Interestingly, an antibody to pol specific for residues 1216 to 1224 coimmunoprecipitated UL42 when both proteins were synthesized in a baculovirus expression system but not in rabbit reticulocyte lysates. These results indicate that (i) at least a portion of the region recognized by the pol antiserum may be accessible in the pol-UL42 heterodimer and (ii) immunoprecipitation results for products made in different expression systems may vary. Thus, at least two distinct regions of UL42 are essential for functional interaction with pol. Moreover, these results point to a UL42 region I function other than physical association with pol.

Invasive aspergillosis in patients with AIDS

Invasive aspergillosis is a rare complication of AIDS. We discuss the cases of 18 patients with AIDS and invasive aspergillosis who were identified at our institution and 19 patients who are described in the literature. Twenty-one patients were either homosexual or bisexual, eight were intravenous drug users, three were hemophiliacs, two attributed their disease to a heterosexual contact, and one was a transfusion recipient; risk factors for AIDS were unknown for two patients. Twenty-eight of the 37 patients had pulmonary aspergillosis; for 18 of these 28, the lung was the sole site of disease. Aspergillosis involved the brain in 12 cases, the heart in five cases, and the kidney, sinuses, or skin in six other cases. Eleven patients had multiple sites of disease, and eight patients had extrapulmonary disease alone. Possible risk factors for aspergillosis included leukopenia (7 patients, of whom 5 were also neutropenic) and use of corticosteroids (8 patients), alcohol (6 patients), broad-spectrum antibiotics (5 patients), and antineoplastic agents (4 patients); 14 patients had no identifiable risk. Death was the usual outcome, despite treatment of patients with amphotericin B. In cases of AIDS and invasive aspergillosis, early diagnosis may lead to improved outcome.