Rationale and development of a business case for antimicrobial stewardship programs in acute care hospital settings

Background

Antimicrobial stewardship programs (ASPs) have been shown to reduce inappropriate antimicrobial use and its consequences. However, these programs lack legislative requirements in many places and it can be difficult to determine what human resources are required for these programs and how to create a business case to present to hospital administrators for program funding. The objectives of the current paper were to review legislative requirements and outline human resource requirements for ASPs, and to create a base business case for ASPs.

Methods

A working group of antimicrobial stewardship experts from across Canada met to discuss the necessary components for creation of a business case for antimicrobial stewardship. A narrative review of the literature of the regulatory requirements and human resource recommendations for ASPs was conducted. Informed by the review and using a consensus decision-making process, the expert working group developed human resource recommendations based on a 1000 bed acute care health care facility in Canada. A spreadsheet based business case model for ASPs was also created.

Results

Legislative and /or regulatory requirements for ASPs were found in 2 countries and one state jurisdiction. The literature review and consensus development process recommended the following minimum human resources complement: 1 physician, 3 pharmacists, 0.5 program administrative and coordination support, and 0.4 data analyst support as full time equivalents (FTEs) per 1000 acute care beds. Necessary components for the business case model, including the human resource requirements, were determined to create a spreadsheet based model.

Conclusions

There is evidence to support the negative outcomes of inappropriate antimicrobial use as well as the benefits of ASPs. Legislative and /or regulatory requirements for ASPs are not common. The available evidence for human resource recommendations for ASPs using a narrative review process was examined and a base business case modelling scenario was created. As regulatory requirements for ASPs increase, it will be necessary to create accurate business cases for ASPs in order to obtain the necessary funding to render these programs successful.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0396-z) contains supplementary material, which is available to authorized users.

Feeding dicyandiamide (DCD) to cattle: An effective method to reduce N2O emissions from urine patches in a heavy-textured soil under temperate climatic conditions

Nitrate (NO₃^-) leaching and nitrous oxide (N₂O) emission from urine patches in grazed pastures are key sources of water and air pollution, respectively. Broadcast spraying of the nitrification inhibitor dicyandiamide (DCD) has been shown to reduce these losses, but it is expensive. As an alternative, it had been demonstrated that feeding DCD to cattle (after manual mixing with supplementary feeds) was a practical, effective and cheaper method to deliver high DCD rates within urine patches. This two-year study carried out on simulated urine patches in three application seasons (spring, summer, autumn) explored the efficacy of DCD feeding to cattle to reduce N losses from grazed pasture soil in a heavy-textured soil under temperate climatic conditions. In each application season, DCD fed to cows, then excreted with urine and applied at a rate of 30kgDCDha^-1 (treatment U+DCD³⁰-f) was as effective as powdered DCD mixed with normal urine and applied at the same rate (treatment U+DCD³⁰) at reducing cumulative N₂O-N emissions and the N₂O-N emission factor (EF3, expressed as % of N applied). Increasing DCD loading within urine patches from 10 to 30kgDCDha^-1 improved efficacy by significantly reducing the EF3 from 34% to 64%, which highlights that under local conditions, 10kgDCDha^-1 (the recommended rate for commercial use in New Zealand) was not the optimum DCD rate to curb N₂O emissions. The modelling of EF3 in this study also suggests that N mitigation should be given more attention when soil moisture is going to be high, which can be predicted with short-term weather forecasting. DCD feeding, for instance in autumn when cows are not lactating and the risk of N losses is high, could then be reduced by focusing mainly on those forecasted wet periods.

Sensitivity, specificity and predictive probability values of serum agglutination test titres for the diagnosis of Salmonella Dublin culture-positive bovine abortion and stillbirth

The objective of this study was to determine the diagnostic value of maternal serology for the diagnosis of Salmonella Dublin bovine abortion and stillbirth. A retrospective, unmatched, case-control study was carried out using twenty year's data (1989-2009) from bovine foetal submissions to an Irish government veterinary laboratory. Cases (n = 214) were defined as submissions with a S. Dublin culture-positive foetus from a S. Dublin unvaccinated dam where results of maternal S. Dublin serology were available. Controls (n = 415) were defined as submissions where an alternative diagnosis other than S. Dublin was made in a foetus from an S. Dublin unvaccinated dam where the results of maternal S. Dublin serology were available. A logistic regression model was fitted to the data: the dichotomous dependent variable was the S. Dublin foetal culture result, and the independent variables were the maternal serum agglutination test (SAT) titre results. Salmonella serology correctly classified 87% of S. Dublin culture-positive foetuses at a predicted probability threshold of 0.44 (cut-off at which sensitivity and specificity are at a maximum, J = 0.67). The sensitivity of the SAT at the same threshold was 73.8% (95% CI: 67.4%-79.5%), and the specificity was 93.2% (95% CI: 90.3%-95.4%). The positive and negative predictive values were 84.9% (95% CI: 79.3%-88.6%) and 87.3% (95% CI: 83.5%-91.3%), respectively. This study illustrates that the use of predicted probability values, rather than the traditional arbitrary breakpoints of negative, inconclusive and positive, increases the diagnostic value of the maternal SAT. Veterinary laboratory diagnosticians and veterinary practitioners can recover from the test results, information previously categorized, particularly from those results declared to be inconclusive.

Effect of an antimicrobial stewardship programme on antimicrobial utilisation and costs in patients with leukaemia: a retrospective controlled study

OBJECTIVES

To examine the effectiveness of an antimicrobial stewardship programme on utilization and cost of antimicrobials in leukaemia patients in Canada.

METHODS

We conducted a multisite retrospective observational time series study from 2005 to 2013. We implemented academic detailing as the intervention of an antimicrobial stewardship programme in leukaemia units at a hospital, piloted February-July 2010, then fully implemented December 2010-March 2013, with no intervention in August-November 2010. Internal control was the same hospital's allogeneic haematopoietic stem-cell transplantation unit. External control was the combined leukaemia-haematopoietic stem-cell transplantation unit at another hospital. Primary outcome was antimicrobial utilization (antibiotics and antifungals) in defined daily dose per 100 patient-days (PD). Secondary outcomes were antimicrobial cost (Canadian dollars per PD); cost and utilization by drug class; length of stay; 30-day inpatient mortality; and nosocomial Clostridium difficile infection. We used autoregressive integrated moving average models to evaluate the impact of the intervention on outcomes.

RESULTS

The intervention group included 1006 patients before implementation and 335 during full implementation. Correspondingly, internal control had 723 and 264 patients, external control 1395 and 864 patients. Antimicrobial utilization decreased significantly in the intervention group (p <0.01, 278 vs. 247 defined daily dose per 100 PD), increased in external control (p = 0.02, 237.4 vs. 268.9 defined daily dose per 100 PD) and remained stable in internal control (p = 0.66). Antimicrobial cost decreased in the intervention group (p = 0.03; $154.59 per PD vs. $128.93 per PD), increased in external control (p = 0.01; $109.4 per PD vs. $135.97 per PD) but was stable in internal control (p = 0.27). Mortality, length of stay and nosocomial C. difficile rate in intervention group remained stable.

CONCLUSIONS

The antimicrobial stewardship programme reduced antimicrobial use in leukaemia patients without affecting inpatient mortality and length of stay.

Factors controlling headspace pressure in a manual manometric BMP method can be used to produce a methane output comparable to AMPTS

The manual manometric biochemical methane potential (mBMP) test uses the increase in pressure to calculate the gas produced. This gas production may be affected by the headspace volume in the incubation bottle and by the overhead pressure measurement and release (OHPMR) frequency. The biogas and methane yields of cellulose, barley, silage and slurry were compared with three incubation bottle headspace volumes (50, 90 and 180ml; constant 70ml total medium) and four OHPMR frequencies (daily, each third day, weekly and solely at the end of experiment). The methane yields of barley, silage and slurry were compared with those from an automated volumetric method (AMPTS). Headspace volume and OHPMR frequency effects on biogas yield were mediated mainly through headspace pressure, with the latter having a negative effect on the biogas yield measured and relatively little effect on methane yield. Two mBMP treatments produced methane yields equivalent to AMPTS.

Obsessive-compulsive disorder in the elderly: A report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a highly disabling condition, with frequent early onset. Adult/adolescent OCD has been extensively investigated, but little is known about prevalence and clinical characterization of geriatric patients with OCD (G-OCD≥65years). The present study aimed to assess prevalence of G-OCD and associated socio-demographic and clinical correlates in a large international sample.

METHODS

Data from 416 outpatients, participating in the ICOCS network, were assessed and categorized into 2 groups, age<vs≥65years, and then divided on the basis of the median age of the sample (age<vs≥42years). Socio-demographic and clinical variables were compared between groups (Pearson Chi-squared and t tests).

RESULTS

G-OCD compared with younger patients represented a significant minority of the sample (6% vs 94%, P<.001), showing a significantly later age at onset (29.4±15.1 vs 18.7±9.2years, P<.001), a more frequent adult onset (75% vs 41.1%, P<.001) and a less frequent use of cognitive-behavioural therapy (CBT) (20.8% vs 41.8%, P<.05). Female gender was more represented in G-OCD patients, though not at a statistically significant level (75% vs 56.4%, P=.07). When the whole sample was divided on the basis of the median age, previous results were confirmed for older patients, including a significantly higher presence of women (52.1% vs 63.1%, P<.05).

CONCLUSIONS

G-OCD compared with younger patients represented a small minority of the sample and showed later age at onset, more frequent adult onset and lower CBT use. Age at onset may influence course and overall management of OCD, with additional investigation needed.

Determinación de anticuerpos contra patógenos virales y bacterianos seleccionados en la población de cerdos silvestres (Sus scrofa) de la Reserva Natural Bahía Samborombón, Argentina

Los cerdos silvestres (Sus scrofa) descienden de cruzamientos entre cerdos domésticos liberados durante la colonización con jabalíes salvajes euroasiáticos, liberados con propósitos cinegéticos. Son invasivos y su coexistencia con especies domésticas implica riesgos sanitarios. Argentina es considerada libre de fiebre aftosa (FA), peste porcina clásica (PPC) y africana (PPA) y síndrome reproductivo y respiratorio porcino (PRRS). La enfermedad de Aujeszky (EA) y la leptospirosis son endémicas en ciertas áreas del país. El objetivo fue evaluar la presencia de ciertas enfermedades zoonóticas y/o de importancia para la producción animal y la conservación de la biodiversidad en cerdos silvestres de la Bahía de Samborombón. Se capturaron 118 animales. Se tomaron muestras de suero, tonsilas, músculo, intestino delgado, linfonódulos, entre otras. Se estudió la presencia de anticuerpos contra Brucella spp., coronavirus respiratorio porcino, virus de la estomatitis vesicular, de la FA, de la gastroenteritis transmisible porcina (TGEV), de la PPC, PPA, EA, PRRS y Leptospira spp. Se realizaron análisis bacteriológicos para Mycobacterium spp. Los resultados ratificaron la ausencia de las enfermedades exóticas e indicaron que 36 % de los animales presentó anticuerpos contra Leptospira interrogans serovar pomona y 62,5 % contra el virus de la EA. Estos resultados remarcan la importancia del monitoreo de la interfase productiva/silvestre en función de la salud pública, producción animal y conservación de la biodiversidad.

Groundwater nitrate reduction versus dissolved gas production: A tale of two catchments

At the catchment scale, a complex mosaic of environmental, hydrogeological and physicochemical characteristics combine to regulate the distribution of groundwater and stream nitrate (NO₃^-). The efficiency of NO₃^- removal (via denitrification) versus the ratio of accumulated reaction products, dinitrogen (excess N₂) & nitrous oxide (N₂O), remains poorly understood. Groundwater was investigated in two well drained agricultural catchments (10km²) in Ireland with contrasting subsurface lithologies (sandstone vs. slate) and landuse. Denitrification capacity was assessed by measuring concentration and distribution patterns of nitrogen (N) species, aquifer hydrogeochemistry, stable isotope signatures and aquifer hydraulic properties. A hierarchy of scale whereby physical factors including agronomy, water table elevation and permeability determined the hydrogeochemical signature of the aquifers was observed. This hydrogeochemical signature acted as the dominant control on denitrification reaction progress. High permeability, aerobic conditions and a lack of bacterial energy sources in the slate catchment resulted in low denitrification reaction progress (0-32%), high NO₃^- and comparatively low N₂O emission factors (EF_5g1). In the sandstone catchment denitrification progress ranged from 4 to 94% and was highly dependent on permeability, water table elevation, dissolved oxygen concentration solid phase bacterial energy sources. Denitrification of NO₃- to N₂ occurred in anaerobic conditions, while at intermediate dissolved oxygen; N₂O was the dominant reaction product. EF_5g1 (mean: 0.0018) in the denitrifying sandstone catchment was 32% less than the IPCC default. The denitrification observations across catchments were supported by stable isotope signatures. Stream NO₃^- occurrence was 32% lower in the sandstone catchment even though N loading was substantially higher than the slate catchment.

The Mysterious Case of Dyspnea

INTRODUCTION

Dehiscence of a mitral valve annuloplasty ring is a rare occurrence that often manifests as mitral regurgitation and heart failure. We present a case of mitral ring dehiscence which was initially unrecognized by standard 2-dimensional transthoracic echocardiography (2D TTE); and 2-dimensional transesophageal echocardiography (2D TEE);.

CASE

A 65-year-old woman was referred to Cardiology clinic for evaluation of dyspnea. Her history included tobacco abuse, atrial fibrillation status post pulmonary vein isolation, nonischemic cardiomyopathy, and prior mitral valve repair with annuloplasty ring for rheumatic valvular disease. She had been asymptomatic post-surgery. Physical examination, cardiac rhythm and initial ischemic workup were unremarkable. Pulmonary function tests revealed moderate emphysematous type obstructive lung disease. A 2D TTE demonstrated moderate mitral regurgitation with normal left ventricular function. In right heart catheterization, large v waves were noted and 2D TEE also revealed severe mitral regurgitation. On 2D TEE, the mitral valve annuloplasty ring was visible above the native anterior mitral valve leaflet. Color Doppler flow estimated the effective regurgitation orifice area of 0.4cm2 using the proximal isovelocity surface area method and regurgitant volume of 58 cc, consistent with severe mitral regurgitation. A "floating mitral ring" and dehiscence measuring 1 cm in diameter were seen on high resolution three-dimensional reconstruction resulting from the detachment of the ring from the weakened posterior annulus. Based on these findings patient was referred to cardiothoracic surgeon for re-do mitral valve surgery.

DISCUSSION

This was a perplexing case as the patient's dyspnea could be explained by many disease processes including atrial fibrillation, mitral regurgitation and chronic obstructive lung disease. The standard imaging modalities did not help us to formulate a diagnosis. 3D TEE provided invaluable and unparalleled information of mitral valve pathology. Annuloplasty ring dehiscence is a well described complication of mitral valve repair and should always be considered in symptomatic patients.

Experiences and perceptions of the United States Ebola Active Monitoring Program: results from a survey of Former Persons Under Monitoring in Washington, DC

OBJECTIVES

To assess Former Persons Under Monitoring (FPUM)s' experiences and perceptions of the United States (US) Ebola Active Monitoring Program.

STUDY DESIGN

Retrospective assessment survey of FPUM.

METHODS

An electronic survey was distributed to FPUMs monitored in Washington, DC, during October 2014-September 2015 (n = 830).

RESULTS

Most FPUMs (>70%) had a favourable perception of the program. Less than 5% avoided future travel or participation in outbreak response activities as a result of their monitoring experience. Approximately 29% experienced a negative consequence in the US due to their travel history. Only 19.2% reported that the Check and Report Ebola (CARE) phone was their only means of communication and 56.5% never used it for daily reporting. Experiences and perceptions varied significantly by citizenship with citizens of Ebola-affected countries more likely to have a favourable perception of the program, use CARE phones and express concern about Ebola transmission and development.

CONCLUSIONS

FPUMs perceived the program as beneficial and undergoing monitoring was not a barrier to future travel. Negative consequences resulting from travel were frequent. Targeted distribution of resources (e.g. CARE phones) should be considered for future programs.

Preterm neonatal morbidity and mortality by gestational age: a contemporary cohort

BACKGROUND

Although preterm birth <37 weeks' gestation is the leading cause of neonatal morbidity and mortality in the United States, the majority of data regarding preterm neonatal outcomes come from older studies, and many reports have been limited to only very preterm neonates. Delineation of neonatal outcomes by delivery gestational age is needed to further clarify the continuum of mortality and morbidity frequencies among preterm neonates.

OBJECTIVE

We sought to describe the contemporary frequencies of neonatal death, neonatal morbidities, and neonatal length of stay across the spectrum of preterm gestational ages.

STUDY DESIGN

This was a secondary analysis of an obstetric cohort of 115,502 women and their neonates who were born in 25 hospitals nationwide, 2008 through 2011. All liveborn nonanomalous singleton preterm (23.0-36.9 weeks of gestation) neonates were included in this analysis. The frequency of neonatal death, major neonatal morbidity (intraventricular hemorrhage grade III/IV, seizures, hypoxic-ischemic encephalopathy, necrotizing enterocolitis stage II/III, bronchopulmonary dysplasia, persistent pulmonary hypertension), and minor neonatal morbidity (hypotension requiring treatment, intraventricular hemorrhage grade I/II, necrotizing enterocolitis stage I, respiratory distress syndrome, hyperbilirubinemia requiring treatment) were calculated by delivery gestational age; each neonate was classified once by the worst outcome for which criteria was met.

RESULTS

In all, 8334 deliveries met inclusion criteria. There were 119 (1.4%) neonatal deaths. In all, 657 (7.9%) neonates had major morbidity, 3136 (37.6%) had minor morbidity, and 4422 (53.1%) survived without any of the studied morbidities. Deaths declined rapidly with each advancing week of gestation. This decline in death was accompanied by an increase in major neonatal morbidity, which peaked at 54.8% at 25 weeks of gestation. As frequencies of death and major neonatal morbidity fell, minor neonatal morbidity increased, peaking at 81.7% at 31 weeks of gestation. The frequency of all morbidities fell >32 weeks. After 25 weeks, neonatal length of hospital stay decreased significantly with each additional completed week of pregnancy; among babies delivered from 26-32 weeks of gestation, each additional week in utero reduced the subsequent length of neonatal hospitalization by a minimum of 8 days. The median postmenstrual age at discharge nadired around 36 weeks' postmenstrual age for babies born at 31-35 weeks of gestation.

CONCLUSION

Our data show that there is a continuum of outcomes, with each additional week of gestation conferring survival benefit while reducing the length of initial hospitalization. These contemporary data can be useful for patient counseling regarding preterm outcomes.

Variation associated with sampling bale or pit silage for mycotoxins and conventional chemical characteristics

Mycotoxins are heterogeneously distributed analytes such that obtaining a representative sample of silage for analysis can be highly challenging. The objectives of this study were to: (1) identify the variability in mycotoxin concentrations, nutritional value characteristics and fermentation characteristics when 20 cores were taken from individual next-to-be-fed silage bales and five cores were taken from the next-to-be-fed section of the feed face of pit silages, (2) compare the values obtained from intensive sampling of the silage after simulated feed-out to values obtained by the above mentioned core sampling, and (3) describe the impact of reducing the number of core samples taken from the baled and pit silages. Round baled silages (n=10) or sections (2 m wide × 1 m height) of pit silages (n=10) were core sampled at twenty and five positions, respectively. After coring, baled silages were chopped, mixed and placed along a simulated feed trough. Silage in the simulated feed trough was then grab sampled (n=20) to produce an aggregate sample, and this was undertaken in triplicate. For pits, silage was mixed and placed along a simulated feed trough before being sampled, as per baled silage. Variation within or among either baled or pit silages, and for core or feed trough samples, was generally much higher for mycotoxins than for conventional chemical composition traits. Within silage (bale or pit) and among silages, variation was generally reduced when samples were collected from the feed trough, except for mycotoxins in pit silages which had higher variation in the feed trough compared with core samples. Increasing the number of core samples increased the likelihood of detecting a positive sample if present and precise estimates of the true chemical composition of the population. Representatively sampling a next-to-be-fed section or bale of silage for conventional chemical characteristics was achieved with 2-4 core samples or 1-2 feed trough samples. However, in contrast, when sampling silages for mycotoxins, collecting a representative sample using core or feed trough sampling methods sometimes required over 100 and over 20 samples, respectively.