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Sutton KF, Ashley LW. Antimicrobial resistance in the United States: Origins and future directions. Epidemiol Infect 2024; 152:e33. [PMID: 38343135 PMCID: PMC10894903 DOI: 10.1017/s0950268824000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 02/24/2024] Open
Abstract
Antimicrobial resistance (AMR) remains a critical public health problem that pervades hospitals and health systems worldwide. The ongoing AMR crisis is not only concerning for patient care but also healthcare delivery and quality. This article outlines key components of the origins of AMR in the United States and how it presents across the American healthcare system. Numerous factors contributed to the crisis, including agricultural antibiotic use, wasteful prescribing practices in health care, conflicting behaviours among patients and clinicians, patient demand and satisfaction, and payment and reimbursement models that incentivize inappropriate antibiotic use. To combat AMR, clinicians, healthcare professionals, and legislators must continue to promote and implement innovative solutions, including antibiotic stewardship programmes (ASPs), hand hygiene protocols, ample supply of personal protective equipment (PPE), standardized treatment guidelines for antibiotic prescribing, clinician and patient educational programmes, and health policy initiatives. With the rising prevalence of multi-drug resistant bacterial infections, AMR must become a greater priority to policymakers and healthcare stakeholders.
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Affiliation(s)
- Kent F. Sutton
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lucas W. Ashley
- Brody School of Medicine at East Carolina University, Greenville, NC, USA
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Hawes AM, Greene MT, Ratz D, Fowler KE, Kendall RE, Patel PK. Antimicrobial Stewardship Teams in Veterans Affairs and Nonfederal Hospitals in the United States: A National Survey of Antimicrobial Stewardship Practices. Open Forum Infect Dis 2024; 11:ofad620. [PMID: 38213633 PMCID: PMC10783152 DOI: 10.1093/ofid/ofad620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/16/2023] [Indexed: 01/13/2024] Open
Abstract
In a cross-sectional survey of US acute care hospitals, antimicrobial stewardship programs were present in most Veterans Affairs and nonfederal hospitals but varied in team composition, scope, and impact. Diagnostic stewardship was common across hospitals. Veterans Affairs hospitals had increased reach in outpatient settings. Telestewardship remains an opportunity in all hospital systems.
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Affiliation(s)
- Armani M Hawes
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Todd Greene
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - David Ratz
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - Karen E Fowler
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - Ronald E Kendall
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Payal K Patel
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
- Division of Infectious Diseases, Department of Internal Medicine, Intermountain Health, Salt Lake City, Utah, USA
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3
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Dumkow LE, Geyer AC, Davidson LE. Antimicrobial Stewardship at Transitions of Care. Infect Dis Clin North Am 2023; 37:769-791. [PMID: 37580244 DOI: 10.1016/j.idc.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Antimicrobial stewardship interventions have historically been siloed in different care settings; recently, a need for stewardship interventions at care transitions has arisen as inappropriate prescribing at care transitions may result in patient harm. There are several care areas that should be considered for optimizing antibiotic prescribing. Interventions can be difficult to implement as they often require the efforts of a multidisciplinary team and are resource intensive. Antimicrobial stewardship programs should prioritize interventions at transitions of care to improve prescribing and patient outcomes.
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Affiliation(s)
- Lisa E Dumkow
- Trinity Health Grand Rapids, 200 Jefferson Avenue, Grand Rapids, MI 49503, USA.
| | - Abigail C Geyer
- Trinity Health Grand Rapids, 200 Jefferson Avenue, Grand Rapids, MI 49503, USA
| | - Lisa E Davidson
- Atrium Health, 1540 Garden Terrace, Suite 211, Charlotte, NC 28203, USA; Wake Forest School of Medicine, 475 Vine Street, Winston-Salem, NC 27101, USA
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Tjilos M, Drainoni ML, Burrowes SAB, Butler JM, Damschroder LJ, Bidwell Goetz M, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem EA, Zhang Y, Barlam TF. A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1995-2001. [PMID: 36987859 PMCID: PMC10755145 DOI: 10.1017/ice.2023.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/30/2023]
Abstract
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.
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Affiliation(s)
- Maria Tjilos
- Department of Community Health Sciences, School of Public Health, Boston University, BostonMassachusetts
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jorie M. Butler
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans’ Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah
| | - Laura J. Damschroder
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Karl Madaras-Kelly
- Boise VA Medical Center, Boise, Idaho
- College of Pharmacy, Idaho State University, MeridianIdaho
| | - Caitlin M. Reardon
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew H. Samore
- IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Yue Zhang
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Hughes AM, Evans CT, Ray C, Kaur H, Fitzpatrick MA, Vivo A, Olagoke AA, Wilson GM, Suda KJ. Antimicrobial stewardship strategy implementation and impact in acute care spinal cord injury and disorder units. J Spinal Cord Med 2023:1-17. [PMID: 37982811 DOI: 10.1080/10790268.2023.2277963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023] Open
Abstract
CONTEXT Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D). OBJECTIVE The goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies. METHOD SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders). RESULTS AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation. CONCLUSION Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.
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Affiliation(s)
- Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois Chicago, Chicago, Illinois, USA
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines JR VA Medical Center, Hines, Illinois, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines JR VA Medical Center, Hines, Illinois, USA
- Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois, USA
| | - Cara Ray
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines JR VA Medical Center, Hines, Illinois, USA
| | - Harveen Kaur
- Department of Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Margaret A Fitzpatrick
- Center of Innovation for Veteran Centered and Value Driven Care, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines JR VA Medical Center, Hines, Illinois, USA
| | - Ayokunle A Olagoke
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska, USA
| | - Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines JR VA Medical Center, Hines, Illinois, USA
- Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Britt NS, Khader K, He T, Willson TM, Effiong A, Timbrook TT, Potter EM, Lodise TP. Examining the clinical impact of rapid multiplex polymerase chain reaction-based diagnostic testing for bloodstream infections in a national cohort of the Veterans Health Administration. Pharmacotherapy 2023; 43:24-34. [PMID: 36484553 DOI: 10.1002/phar.2747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE Bloodstream infections (BSIs) are a significant cause of mortality. Use of a rapid multiplex polymerase chain reaction-based blood culture identification panel (BCID) may improve antimicrobial utilization and clinical outcomes by shortening the time to appropriate therapy and de-escalating antibiotics among patients on overly broad-spectrum empiric therapy. The effect of BCID on clinical outcomes across varying institutional antimicrobial stewardship program (ASP) practices is unclear. This study evaluated clinical outcomes associated with the "real-world" implementation of BCID in a national health system with varying ASP practices. DESIGN National, multicenter, retrospective, pre-post quasi-experimental study of hospitalized patients admitted from 2015 to 2020 to VHA facilities, which introduced the BCID for ≥1 year. SETTING United States Veterans Health Administration (VHA) hospitals with BCID. PATIENTS Hospitalized VHA patients with ≥1 blood culture positive for bacteria featured on the BCID panel. INTERVENTION Comparison of outcomes between the pre- and post-BCID implementation groups. MEASUREMENTS Outcomes evaluated included early antimicrobial de-escalation within 48 h, defined as reduction in antimicrobial spectrum scores, time to appropriate therapy, and 30-day mortality. MAIN RESULTS A total of 4138 patients (pre-BCID, n = 2100; post-BCID, n = 2038) met the study criteria. Implementation of BCID was associated with significant improvements in early antimicrobial de-escalation (34.6%: pre-BCID vs. 38.1%: post-BCID; p = 0.022), which persisted after adjusting for other covariates (adjusted risk ratio [aRR], 1.11; 95% confidence interval [CI], 1.02-1.20; p = 0.011). Median time to appropriate therapy was shorter in the post-BCID implementation group relative to the pre-BCID group (9 h: pre-BCID vs. 8 h: post-BCID, respectively, p = 0.005), and a greater percentage of patients received early appropriate antimicrobial therapy within 48 h in the post-BCID implementation group (91.7%: pre-BCID vs. 93.8%: post-BCID; p = 0.008). In the multivariable regression analysis, BCID implementation was significantly associated with a higher likelihood of appropriate therapy within 48 h (aRR, 1.02; 95% CI, 1.01-1.08; p = 0.020). There was no difference in 30-day mortality between groups overall (12.6% pre-BCID vs. 11.2% post-BCID; p = 0.211). CONCLUSIONS In a "real-world" clinical setting, the implementation of BCID was associated with clinical improvements in antimicrobial utilization. The BCID platform may serve as a useful adjunct for BSI management in facilities with ASP.
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Affiliation(s)
- Nicholas S Britt
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, Lawrence, Kansas, USA.,Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA.,Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth, Kansas, USA
| | - Karim Khader
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Tao He
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Tina M Willson
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Atim Effiong
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | | | - Emily M Potter
- Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth, Kansas, USA
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA.,Samuel S. Stratton Veterans Affairs Medical Center, Albany, New York, USA
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7
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Antimicrobial stewardship for sepsis in the intensive care unit: Survey of critical care and infectious diseases physicians. Infect Control Hosp Epidemiol 2022; 43:1368-1374. [PMID: 35959529 PMCID: PMC9588438 DOI: 10.1017/ice.2021.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To evaluate the attitudes of infectious diseases (ID) and critical care physicians toward antimicrobial stewardship in the intensive care unit (ICU). Design: Anonymous, cross-sectional, web-based surveys. Setting: Surveys were completed in March–November 2017, and data were analyzed from December 2017 to December 2019. Participants: ID and critical care fellows and attending physicians. Methods: We included 10 demographic and 17 newly developed, 5-point, Likert-scaled items measuring attitudes toward ICU antimicrobial stewardship and transdisciplinary collaboration. Exploratory principal components analysis (PCA) was used for data reduction. Multivariable linear regression models explored demographic and attitudinal variables. Results: Of 372 respondents, 315 physicians had complete data (72% attendings, 28% fellows; 63% ID specialists, and 37% critical care specialists). Our PCA yielded a 3-item factor measuring which specialty should assume ICU antimicrobial stewardship (Cronbach standardized α = 0.71; higher scores indicate that ID physicians should be stewards), and a 4-item factor measuring value of ICU transdisciplinary collaborations (α = 0.62; higher scores indicate higher value). In regression models, ID physicians (vs critical care physicians), placed higher value on ICU collaborations and expressed discomfort with uncertain diagnoses. These factors were independently associated with stronger agreement that ID physicians should be ICU antimicrobial stewards. The following factors were independently associated with higher value of transdisciplinary collaboration: female sex, less discomfort with uncertain diagnoses, and stronger agreement with ID physicians as ICU antimicrobial stewards. Conclusions: ID and critical care physicians endorsed their own group for antimicrobial stewardship, but both groups placed high value on ICU transdisciplinary collaborations. Physicians who were more uncomfortable with uncertain diagnoses reported preference for ID physicians to coordinate ICU antimicrobial stewardship; however, physicians who were less uncomfortable with uncertain diagnoses placed greater value on ICU collaborations.
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Storey DF, Guastadisegni JM, Kouma MA, Arasaratnam RJ. Mind the OPAT Gap: Providing Home Intravenous Antibiotic Therapy for Veterans Hospitalized at Community Hospitals. Clin Infect Dis 2022; 75:1675-1676. [PMID: 35748634 DOI: 10.1093/cid/ciac513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Donald F Storey
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Marcus A Kouma
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Reuben J Arasaratnam
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
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9
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Pierce J, Stevens MP. The Emerging Role of Telehealth in Antimicrobial Stewardship: A Systematic Review and Perspective. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2021; 13:175-191. [PMID: 34975344 PMCID: PMC8713008 DOI: 10.1007/s40506-021-00256-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/16/2022]
Abstract
Purpose of Review The purpose of this article is to critically evaluate the available literature on telehealth and antimicrobial stewardship. Recent Findings There is limited evidence regarding the role of telehealth within the discipline of antimicrobial stewardship. A review of the available literature suggests remote antimicrobial stewardship programs conducted via telehealth can decrease antimicrobial consumption. A direct comparison between traditional antimicrobial stewardship programs and remote antimicrobial stewardship programs is lacking. Summary Telehealth is a promising tool for expanding antimicrobial stewardship, especially in small rural or community hospitals. Trust, team, and technology, the three Ts of remote antimicrobial stewardship derived from themes within the available literature, can serve as a framework for developing a remote antimicrobial stewardship program.
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Affiliation(s)
- Jacob Pierce
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University School of Medicine, 1000 E Marshall St., Richmond, VA 23298 USA
| | - Michael P Stevens
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University School of Medicine, 1000 E Marshall St., Richmond, VA 23298 USA
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Appaneal HJ, O'Neill E, Lopes VV, LaPlante KL, Caffrey AR. National trends in hospital, long-term care and outpatient Acinetobacter baumannii resistance rates. J Med Microbiol 2021; 70. [PMID: 34919041 DOI: 10.1099/jmm.0.001473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Acinetobacter baumannii is a top-priority pathogen of the World Health Organization (WHO) and the Centers for Disease Control (CDC) due to antibiotic resistance.Gap Statement. Trends in A. baumannii resistance rates that include community isolates are unknown.Aim. Identify trends in A. baumannii resistance rates across the Veterans Affairs (VA) Healthcare System, including isolates from patients treated in hospitals, long-term care facilities and outpatient clinics nationally.Methodology. We included A. baumannii clinical cultures collected from VA patients from 2010 to 2018. Cultures were categorized by location: VA medical centers (VAMCs), long-term care (LTC) units [community living centers (CLCs)], or outpatient. We assessed carbapenem resistance, multidrug resistance (MDR) and extensive drug resistance (XDR). Time trends were assessed with Joinpoint regression.Results. We identified 19 376 A. baumannii cultures (53% VAMCs, 4% CLCs, 43% outpatient). Respiratory cultures were the most common source of carbapenem-resistant (43 %), multidrug-resistant (49 %) and extensively drug-resistant (21 %) isolates. Over the study period, the number of A. baumannii cultures decreased significantly in VAMCs (11.9% per year). In 2018, carbapenem resistance was seen in 28% of VAMC isolates and 36% of CLC isolates, but only 6% of outpatient isolates, while MDR was found in 31% of VAMC isolates and 36% of CLC isolates, but only 8 % of outpatient isolates. Carbapenem-resistant, multidrug-resistant and extensively drug-resistant A. baumannii isolates decreased significantly in VAMCs and outpatient clinics over time (VAMCs: by 4.9, 7.2 and 6.9%; outpatient: by 11.3, 10.5 and 10.2% per year). Resistant phenotypes remained stable in CLCs.Conclusion. In the VA nationally, the prevalence of A. baumannii is decreasing, as is resistance. Carbapenem-resistant and multidrug-resistant A. baumannii remain common in VAMCs and CLCs. The focus of infection control and antimicrobial stewardship efforts to prevent transmission of resistant A. baumannii should be in hospital and LTC settings.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Brown University School of Public Health, Providence, RI, USA
| | - Emily O'Neill
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Brown University School of Public Health, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Brown University School of Public Health, Providence, RI, USA
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11
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Hines-Munson C, May S, Poon I, Holmes SA, Martin L, Trautner BW, Skelton F. Experiences of veterans with spinal cord injury related to annual urine screening and antibiotic use for urinary tract infections. PM R 2021; 13:1369-1375. [PMID: 33543579 PMCID: PMC8333194 DOI: 10.1002/pmrj.12568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Antimicrobial-resistant bacterial infections are an increasing public health threat and people with spinal cord injury (SCI) are disproportionally at higher risk. National guidelines concerning urine testing after SCI are conflicting. Unnecessary urine testing in the SCI population (with high asymptomatic bacteriuria prevalence) leads to unnecessary antimicrobial use, propagating resistant infections, especially urinary tract infections (UTIs). OBJECTIVES (a) Describe UTI antimicrobial adherence in patients with SCI. (b) Explore SCI patient knowledge and attitudes toward current urine testing and treatment practices. DESIGN Mixed methods. SETTING Veterans Health Administration (VHA) patients with SCI. PARTICIPANTS Veterans identified as having SCI seen at a VHA facility nationwide. INTERVENTIONS N/A. MAIN OUTCOME MEASURES Self-reported medication adherence, patient beliefs and behaviors toward UTIs and antimicrobial use. RESULTS A total of 105 Morisky Medication Adherence Scale-8 (MMAS-8) surveys were completed out of 369 distributed surveys (28% response rate). Overall, patients reported high medication adherence (mean score of 7.2/8, with 8 being a perfect adherence score). Ten qualitative interviews were completed. Themes identified include generally high adherence to prescribed antimicrobial courses and high levels of patient satisfaction with current outpatient VHA SCI bladder care. The quantitative findings converge with these themes observed in the qualitative interviews; patients were satisfied with current urine testing and treatment practices. CONCLUSIONS Veterans with SCI are generally satisfied with their current UTI management and self-report taking antimicrobials for UTIs as prescribed. Veterans with SCI typically report high trust in their SCI providers and value their advice on bladder care management. Therefore, it is imperative for clinicians to provide evidence-based education to patients, as well as ensure that each prescribed course of antibiotics for UTI is clinically necessary. Information from this study will guide an intervention promoting appropriate urine testing and antimicrobial prescription practices by SCI providers.
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Affiliation(s)
- Casey Hines-Munson
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Sarah May
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ivy Poon
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas, USA
| | - S Ann Holmes
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | | | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
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12
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Clarke D, Nguyen D, Overton K. Antimicrobial stewardship in spinal cord injury: A multidisciplinary approach. J Spinal Cord Med 2021; 44:770-774. [PMID: 32105194 PMCID: PMC8477917 DOI: 10.1080/10790268.2020.1731225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Context: In a global environment of escalating antimicrobial resistance and limited new antibiotic development, there is a desire to optimize antibiotic use across all settings to preserve options for the future. Despite this, antibiotics continue to be prescribed inappropriately in many settings. Patients with a spinal cord injury (SCI) are particularly vulnerable to receiving multiple courses of antibiotics, yet there is limited data reviewing antimicrobial stewardship (AMS) programs in this patient population.Hypothesis: Adopting AMS rounds will reduce days of antibiotic treatment.Intervention: We implemented a systematic bedside AMS multidisciplinary team (MDT) ward round within the SCI Unit at our hospital, where a collaborative inter-speciality and inter-professional approach was undertaken to address antibiotic prescriptions. A retrospective audit of antibiotic prescriptions was performed one month prior and one month during the intervention.Outcome measures: An infectious disease consultant led a multidisciplinary, multispecialty ward rounding team, looking at antibiotic appropriateness and guideline compliance. The effectiveness of this intervention was assessed by retrospectively looking at antibiotic days of usage per patient day of occupancy.Results: Antibiotic consumption significantly decreased following the AMS intervention, from 69.8 to 24.3 days on treatment per 100 patient days (P < 0.001). Following implementation of the ward round the proportion of therapeutic guideline compliant prescriptions significantly rose from 18% in April to 56% in August (P < 0.001).Conclusions: Utilizing a collaborative inter-speciality and inter-professional AMS approach and providing face to face feedback about the appropriateness of antibiotic prescribing can help optimize antibiotic usage within a SCI unit.
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Affiliation(s)
| | - Daniel Nguyen
- Department of Pharmacy, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Kristen Overton
- Department of Infectious Diseases, Prince of Wales Hospital, Randwick, NSW, Australia,Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia,Correspondence to: Kristen Overton, Infectious Diseases Department, Level 4 Dickinson Building, Prince of Wales Hospital, Barker St, Randwick, NSW2031, Australia; ph: +61-2-9382-3405.
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Implementation of Pharmacist-Driven Antifungal Stewardship Program in a Tertiary Care Hospital. Antimicrob Agents Chemother 2021; 65:e0062921. [PMID: 34152808 DOI: 10.1128/aac.00629-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antifungal stewardship (AFS) is recommended to reduce the inappropriate use of antifungal drugs. In this study, the role of AFS in providing appropriate antifungal therapy was evaluated. This study included three periods, consisting of observation, feedback/education, and daily AFS activities. In the observation period, the use of systemic antifungals was evaluated for a baseline measurement of appropriateness. In the second period, monthly meetings were organized to provide feedback and education to physicians regarding antifungal therapy and the rate of adherence to the clinical guidelines. In the final period, a clinical pharmacist participated in daily ward rounds to evaluate the appropriateness of the antifungal therapy. A scoring system for appropriateness was used for comparison between the three periods. Four hundred eighteen episodes of antifungal therapy were evaluated. Baseline demographics of patients were similar in all three periods for age, gender, and the number of comorbidities. The indications for antifungal use were for prophylaxis in 22.7%, Candida infections in 58.6%, and invasive mold infections in 18.7%. During the third period, 157 (78.9%) recommendations were made and 151 (96.2%) were accepted. The overall appropriateness of antifungal use increased significantly for prophylaxis (30.8%, 17.9%, and 46.3%; P = 0.046) and treatment of fungal diseases (27.8%, 32.4%, and 71.9%; P < 0.001) between the first, second, and third periods, respectively. The 30-day mortality was not significantly changed between the three periods (19%, 15.6%, and 27.5%; P = 0.050). Appropriateness in antifungal therapy can be augmented by the integration of an AFS program. A team-based evaluation of fungal infections and assessment of patients by a clinical pharmacist with a therapeutic perspective may help to increase the quality of antifungal therapy.
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14
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Johnson MC, Hulgan T, Cooke RG, Kleinpell R, Roumie C, Callaway-Lane C, Mitchell LD, Hathaway J, Dittus R, Staub M. Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis. BMJ Open Qual 2021; 10:bmjoq-2020-001275. [PMID: 34210668 PMCID: PMC8252871 DOI: 10.1136/bmjoq-2020-001275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/06/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Antibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to <32% by April 2020. METHODS From January to December 2018, community-based outpatient clinics' 6 months' average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan-do-study-act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ2 tests and statistical process control charts using Western Electric rules were used to analyse intervention data. RESULTS The AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward. CONCLUSIONS Operational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.
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Affiliation(s)
- Morgan Clouse Johnson
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Todd Hulgan
- Infectious Diseases, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robin G Cooke
- Pharmacy, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Ruth Kleinpell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Christianne Roumie
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carol Callaway-Lane
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Lauren D Mitchell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Jacob Hathaway
- Primary Care, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Robert Dittus
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Milner Staub
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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15
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection. Dis Colon Rectum 2021; 64:650-668. [PMID: 33769319 DOI: 10.1097/dcr.0000000000002047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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16
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Nelson GE. Another Key Moment for Antimicrobial Stewardship: Hospital Discharge. Clin Infect Dis 2021; 71:1240-1242. [PMID: 31562813 DOI: 10.1093/cid/ciz969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- George E Nelson
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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17
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Johnson SH, Waisbren SJ. Physician Responsiveness to Positive Blood Culture Results at the Minneapolis Veterans Affairs Hospital-Is Anyone Paying Attention? Fed Pract 2021; 38:128-135. [PMID: 33859464 DOI: 10.12788/fp.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Patients presenting with suspected infections are typically placed on empiric broad-spectrum antibiotics. With mounting evidence supporting the efficacy of using the narrowest spectrum of antimicrobial therapy to cover the suspected pathogen, current guidelines recommend decreasing the breadth of coverage in response to culture results both in relation to microbe identification and antibiotic sensitivity. Methods A retrospective chart review of electronic health records at the Minneapolis Veterans Affairs Medical Center (VAMC) in Minnesota was performed for 208 positive blood cultures with antibiotic spectrum analysis from July 1, 2015 to June 30, 2016. The time of reporting for pathogen identification and subsequent pathogen susceptibilities were compared to the time at which any alterations to antibiotic coverage were made. The breadth of antibiotic coverage was recorded using a nonlinear spectrum score. The use of this score allowed for the reliable classification of antibiotic adjustments as either deescalation, escalation, or no change. Results The percentage of cases deescalated was higher in response to physician (house staff or attending physician) notification of pathogen susceptibility information when compared with a response to pathogen identification alone (33.2% vs 22.6%). Empiric antibiotics were not altered within 24 hours in response to pathogen identification in 70.7% of cases and were not altered within 24 hours in response to pathogen sensitivity determination in 58.6% of cases. However, when considering the time frame from when empiric antibiotics were started to 24 hours after notification of susceptibility information, 49.5% of cases were deescalated and 41.5% of cases had no net change in the antibiotic spectrum score. The magnitude of deescalations were notably larger than escalations. The mean (SD) time to deescalation of antibiotic coverage was shorter (P =.049) in response to pathogen identification at 8 (7.4) hours compared with sensitivity information at 10.4 (7) hours, but may not be clinically relevant. Conclusion Health care providers at the Minneapolis VAMC appear to be using positive blood culture results in a timely fashion consistent with best practices. Because empirically initiated antibiotics typically are broad in spectrum, the magnitude of deescalations were notably larger than escalations. Adherence to these standards may be a reflection of the infectious disease staff oversight of antibiotic administration. Furthermore, the systems outlined in this quality improvement study may be replicated at other VAMCs across the country by either in-house infectious disease staff or through remote monitoring of the electronic health record by other infectious disease experts at a more centralized VAMC. Widespread adoption throughout the Veterans Health Administration may result in improved antibiotic resistance profiles and better clinical outcomes for our nation's veterans.
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Affiliation(s)
- Shaun Heimbichner Johnson
- is a Medical Student at Case Western Reserve University School of Medicine in Cleveland, Ohio. is a Surgeon and Assistant Service Chief at the Minneapolis Veterans Affairs Health Care System in Minnesota and an Assistant Professor of Surgery at the University of Minnesota
| | - Steven James Waisbren
- is a Medical Student at Case Western Reserve University School of Medicine in Cleveland, Ohio. is a Surgeon and Assistant Service Chief at the Minneapolis Veterans Affairs Health Care System in Minnesota and an Assistant Professor of Surgery at the University of Minnesota
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18
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Ramakrishnan A, Patel PK. How Far We've Come, How Far We Have to Go: a Review of Advances in Antimicrobial Stewardship in the Veterans Health Administration. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020; 12:275-284. [PMID: 33244296 PMCID: PMC7688065 DOI: 10.1007/s40506-020-00221-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW This review highlights several of the successes in antimicrobial stewardship seen in the largest integrated healthcare system in the USA, the Veterans Health Administration. RECENT FINDINGS Since deploying antimicrobial stewardship programs on a national scale in the Veterans Health Administration, decreases in overall antimicrobial use and Clostridioides difficile infections have been observed. Concurrent infection prevention initiatives have also contributed to these improvements in the Veterans Health Administration. SUMMARY By embracing multidisciplinary stewardship teams, focusing on education and research in the field of antimicrobial stewardship, and leveraging the vast data available within the national system, the Veterans Health Administration has made substantial advances in antimicrobial stewardship.
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Affiliation(s)
- Aditi Ramakrishnan
- Division of Infectious Diseases, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA, 30303, USA
| | - Payal K. Patel
- Division of Infectious Diseases, Ann Arbor VA Healthcare System and the University of Michigan Medical School, Ann Arbor, MI, USA
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19
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[Organisational and staff requirements for antimicrobial stewardship activities in hospitals : Position paper of the Commission on Anti-Infectives, Resistance and Therapy (Commission ART) at the Robert Koch Institute, with advice from professional associations]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:749-760. [PMID: 32468301 DOI: 10.1007/s00103-020-03152-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Increased awareness of the rising antimicrobial resistance problem and impending loss of suitable treatment options for infectious diseases have changed patient care. Antimicrobial/antibiotic stewardship (ABS) activities aiming to optimize antimicrobial treatment were specified in international (WHO, ECDC) and national programmes and evidence-based practice guidelines. In Germany, ABS in hospitals is enshrined in the Infection Protection Act §23 and in a national guideline. The position paper presents the goals and tasks of ABS as well as the necessary organisational and staff requirements.Qualified training and education, mandates and support from hospital directors, and the provision of sufficient resources are essential prerequisites for the successful work of the ABS team. The ABS team should work hospital-wide across clinical services. Their main tasks are developing and implementing an ABS programme tailored to local needs and the conditions of the hospital, taking into account anti-infective drug prescribing, the resistance situation and case mix. Their tasks also include drafting and implementing in-house recommendations for diagnosis, prophylaxis and treatment of important infectious diseases. The ABS team should be interdisciplinary and include specially qualified doctors and pharmacists. Doctors commissioned for ABS should support this team and take the department-specific concerns into account. The document specifies a minimum ABS staff of one full-time equivalent (FTE) per 500 beds. Depending on the case mix and specialties, additional staff may be required. It proposes that there should be 0.1 FTE doctors commissioned for ABS per 100 beds.
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20
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Du Y, Li J, Wang X, Peng X, Wang X, He W, Li Y, Wang X, Yang Q, Zhang X. Impact of a Multifaceted Pharmacist-Led Intervention on Antimicrobial Stewardship in a Gastroenterology Ward: A Segmented Regression Analysis. Front Pharmacol 2020; 11:442. [PMID: 32351389 PMCID: PMC7174747 DOI: 10.3389/fphar.2020.00442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/20/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Irrational use of antimicrobial agents for gastrointestinal diseases deserves attention, but corresponding antimicrobial stewardship programs (ASPs) are generally not a priority for managers. We conducted this study to evaluate the effectiveness of multifaceted pharmacist-led (MPL) interventions in the gastroenterology ward (GW) to provide evidence for the efficacy of ASPs in a non-priority department. METHODS This was an interventional, retrospective study implemented in China. The MPL intervention lasting 1.5 years involved daily ward rounds with physicians, regular review of medical orders, monthly indicator feedback, frequent physician training, and necessary patient education. Data on all hospitalized adults receiving antibiotics was extracted from the hospital information system over a 36-month period from January 2016 to December 2018. Segmented regression analysis of interrupted time series was performed to evaluate the effect of the MPL interventions (started in July 2017) on antibiotic use and length of hospital stay, which was calculated monthly as analytical units. RESULTS A total of 1763 patients receiving antibiotics were enrolled. Segmented regression models showed descending trends from the baseline in the intensity of antibiotic consumption (coefficient = -0.88, p = 0.01), including a significant decline in the level of change of the proportion of patients receiving combined antibiotics (coefficient = -9.91, p = 0.03) and average length of hospital stay (coefficient = -1.79, p = 0.00), after MPL interventions. The MPL interventions led to a temporary increase in the proportion of patients receiving antibiotics (coefficient = 4.95, p = 0.038), but this was part of a declining secular trend (coefficient = -0.45, p = 0.05). CONCLUSION The MPL interventions led a statistically significant decline in the number of patients receiving antibiotics, the antibiotic consumption, and the average hospital stay post-intervention compared to the pre-intervention phase of the study. Health policymakers should actively practice MPL interventions by clinical pharmacists in ASPs in those departments that are not included in priority management.
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Affiliation(s)
- Yaling Du
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Jing Li
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xinchun Wang
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xi Peng
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xiaoyi Wang
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Wenying He
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Yan Li
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xuemei Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiuxia Yang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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21
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Variability in antifungal stewardship strategies among Society for Healthcare Epidemiology of America (SHEA) Research Network facilities. Infect Control Hosp Epidemiol 2020; 41:585-589. [PMID: 32252846 DOI: 10.1017/ice.2020.76] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To characterize antifungal stewardship among antimicrobial stewardship programs (ASPs) at a diverse range of hospitals and to correlate antifungal stewardship with hospital characteristics. DESIGN Cross-sectional survey. PARTICIPANTS ASP physician and/or pharmacist members at Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) hospitals. METHODS An electronic survey administered August-September 2018 via the SRN to 111 hospitals. The χ2 test was used to test associations between ASP and hospital characteristics and use of antifungal stewardship strategies. RESULTS Of 111 hospitals, 45 (41%) responded; most were academic medical centers (65%) caring for stem-cell patients (73.3%) and solid-organ transplant patients (80.0%). Most hospitals have large, well-established ASPs: 60% had >5 team members and 68.9% had a duration ≥6 years. In 43 hospitals (95.6%), ASPs used antifungal stewardship strategies, most commonly prospective audit and feedback (73.3%) by a pharmacist (71.4%). Half of ASPs (51.1%) created guidelines for invasive fungal infection (IFI) management. Most hospitals (71.1%) offered rapid laboratory tests to diagnose IFI, but polymerase chain reaction (PCR) testing and antifungal susceptibility testing varied. Also, 29 ASPs (64.4%) perform surveillance of antifungal utilization, but only 9 (31%) reported to the CDC National Healthcare Safety Network. ASP size, duration, and presence of transplant populations were not associated with a higher likelihood of using antifungal stewardship strategies (P > .05 for all). CONCLUSIONS The use of antifungal stewardship strategies was high at SRN hospitals, but they mainly involved audit and feedback. ASPs should be encouraged (1) to disseminate guidelines for IFI management, (2) to promote access to laboratory tests for rapid and accurate IFI diagnosis, and (3) to perform surveillance for antifungal utilization with reporting to the CDC.
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Vaughn VM, Petty LA, Flanders SA, Malani AN, Patel T, Bernstein SJ, Hsaiky LM, Thyagarajan R, Osterholzer D, McLaughlin E, Horowitz JK, Gandhi TN. A Deeper Dive Into Antibiotic Stewardship Needs: A Multihospital Survey. Open Forum Infect Dis 2020; 7:ofaa007. [PMID: 32128340 PMCID: PMC7047227 DOI: 10.1093/ofid/ofaa007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/08/2020] [Indexed: 11/14/2022] Open
Abstract
In a 2016 survey of 46 Michigan hospitals, we identified four key needs for antibiotic stewardship: clinically-relevant antibiotic data, monitoring compliance, syndrome-specific interventions, and discharge stewardship. A stewardship initiative now addresses these needs within the Michigan Hospital Medicine Safety Consortium.
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Affiliation(s)
- Valerie M Vaughn
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,VA/University of Michigan Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA/University of Michigan Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA.,Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Twisha Patel
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Lama M Hsaiky
- Department of Pharmaceutical Services, Beaumont Hospital, Dearborn, Michigan, USA
| | - Rama Thyagarajan
- Department of Internal Medicine, Infectious Diseases Division, Beaumont Hospital, Dearborn, Michigan, USA
| | - Danielle Osterholzer
- Department of Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan, USA.,Michigan State University, College of Human Medicine, East Lansing, Michigan, USA
| | - Elizabeth McLaughlin
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer K Horowitz
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA/University of Michigan Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Abstract
Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.
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Appaneal HJ, Caffrey AR, Hughes MSA, Lopes VV, Jump RLP, LaPlante KL, Dosa DM. Trends in Collection of Microbiological Cultures Across Veterans Affairs Community Living Centers in the United States Over 8 Years. J Am Med Dir Assoc 2019; 21:115-120. [PMID: 31466935 DOI: 10.1016/j.jamda.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To describe and evaluate changes in the collection of microbiological cultures across Veterans Affairs (VA) Community Living Centers (CLCs) nationally. DESIGN Descriptive study. SETTING 146 VA CLCs. PARTICIPANTS We identified both positive and negative microbiological cultures collected during VA CLC admissions from January 2010 through December 2017. MEASURES We measured the average annual percentage change (AAPC) in the rate of cultures collected per 1000 bed days and per admission, overall and stratified by culture type (ie, urine, blood, skin and soft tissue, and respiratory tract). AAPCs were also calculated for the proportion and rate of positive cultures collected, overall and stratified by culture type and organism (ie, Escherichia coli, Proteus mirabilis, Staphylococcus aureus, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella spp, Enterobacter spp, Morganella morganii, Citrobacter spp, Serratia marcescens, and Streptococcus pneumoniae). Joinpoint regression software was used to assess trends and estimate AAPCs and 95% confidence intervals (CIs). RESULTS Over 8 years, 355,329 cultures were collected. The rate of cultures collected per 1000 bed days of care decreased significantly by 6.0% per year (95% CI -8.7%, -3.2%). The proportion of positive cultures decreased by 0.9% (95% CI -1.4%, -0.4%). The most common culture types were urine (48.4%), followed by blood (27.7%). The rate of cultures collected per 1000 bed days of care decreased per year by 6.3% for urine, 5.0% for blood, 4.4% for skin and soft tissue, and 4.9% for respiratory tract. In 2010, S aureus was the most common organism identified, and in all subsequent years E coli was the most common. CONCLUSION AND IMPLICATIONS We identified a significant reduction in the number of cultures collected over time among VA CLCs. Our findings may be explained by decreases in the collection of unnecessary cultures in VA CLCs nationally due to increased antibiotic stewardship efforts targeting unnecessary culturing and antibiotic treatment.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Brown University School of Public Health, Providence, RI
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Brown University School of Public Health, Providence, RI
| | - Maria-Stephanie A Hughes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) and the Specialty Care Center of Innovation at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Brown University School of Public Health, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI.
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Pharmacists' role in antimicrobial stewardship and relationship with antibiotic consumption in hospitals: An observational multicentre study. J Glob Antimicrob Resist 2019; 20:131-134. [PMID: 31323427 DOI: 10.1016/j.jgar.2019.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Antimicrobial stewardship (AMS) teams around the world include pharmacists; however, their impact is relatively unknown. This study aimed to explore the relationship between pharmacists' actions and antibiotic consumption. METHODS Hospital pharmacists involved in the French antibiotic consumption surveillance network (ATB-Raisin) were invited to participate in a retrospective observational multicentre study. Collected data were: the previous year's (2016) antibiotic consumption expressed in daily defined dose per 1000 patient-days; AMS measures, including pharmacist-specific actions; and use of a computerised prescription order entry (CPOE) system. Associations between antibiotic consumption and AMS measures were assessed by linear regression, after adjustment for hospital activities. RESULTS Annual data for 2016 from 77 hospitals (7260000 bed-days in 24000 beds) were analysed. Pharmacists were involved in AMS programs in 73% of hospitals, and were the antibiotic advisor in 25%. Pharmaceutical review of prescriptions was organised in almost all hospitals (97%). The univariable analysis identified five measures associated with lower overall antibiotic consumption: CPOE use (if >80% of prescriptions or 100%), pharmaceutical review (if >80% of beds or 100%) and the antibiotic advisor being a pharmacist (P=0.04, P=0.004 and P=0.003, respectively). In the multivariable analysis, two explanatory variables were significantly and independently associated with a lower overall antibiotic consumption: the antibiotic advisor being a pharmacist and a pharmaceutical review covering all beds (-19.9% [-31.6%; -8.1%], P=0.002 and -18.3% [-34.0%; -2.6%], P=0.03, respectively). CONCLUSIONS Antibiotic consumption was lower when the antibiotic advisor was a pharmacist and when the pharmaceutical team reviewed all prescriptions. These results highlight that actions initiated by pharmacists have a positive impact and should be supported.
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Skelton F, Suda K, Evans C, Trautner B. Effective antibiotic stewardship in spinal cord injury: Challenges and a way forward. J Spinal Cord Med 2019; 42:251-254. [PMID: 29324181 PMCID: PMC6419644 DOI: 10.1080/10790268.2017.1396183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
CONTEXT Antibiotic stewardship, defined as a multidisciplinary program to reduce the misuse of antibiotics, and in turn, antibiotic resistance, is a high priority. Persons with spinal cord injury/disorder (SCI/D) are vulnerable to receiving multiple courses of antibiotics over their lifetime given frequent healthcare exposure, and have high rates of bacterial infection with multi-drug resistant organisms. Additional challenges to evaluating appropriate use of antibiotics in this population include bacterial colonization in the urine and the differences in the presenting signs and symptoms of infection. Therefore, Veterans Health Administration (VHA) facilities with SCI/D centers need effective antibiotic stewardship programs. RESULTS We analyzed the results of a 2012 VHA-wide survey evaluating available antibiotic stewardship resources, and compared the resources present at facilities with SCI/D (n=23) versus non-SCI/D facilities (n=107). VHA facilities with SCI/D centers are more likely to have components of an antibiotic stewardship program that have led to reduced antibiotic use in previous studies. They are also more likely to have personnel with infectious diseases training. CONCLUSION VHA facilities with SCI/D centers have the resources needed for antibiotic stewardship. The next step will be to determine how to implement effective antibiotic stewardship tailored for this patient care setting.
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Affiliation(s)
- Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas,Correspondence to: Felicia Skelton, MD, BS, Michael E. DeBakey VA Medical Center, Houston Center for Innovations in Quality, Effectiveness & Safety (IQuESt), 2002 Holcombe Blvd. (152), Houston, TX77030.
| | - Katie Suda
- Center for Innovation for Complex Chronic Care (CINCCH), Edward Hines Jr. VA Hospital, Hines, Illinois,University of Illinois at Chicago, Chicago, Illinois
| | - Charlesnika Evans
- Center for Innovation for Complex Chronic Care (CINCCH), Edward Hines Jr. VA Hospital, Hines, Illinois,Northwestern University, Department of Preventive Medicine and Center for Health Care Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
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In Data We Trust? Comparison of Electronic Versus Manual Abstraction of Antimicrobial Prescribing Quality Metrics for Hospitalized Veterans With Pneumonia. Med Care 2019; 56:626-633. [PMID: 29668648 DOI: 10.1097/mlr.0000000000000916] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Electronic health records provide the opportunity to assess system-wide quality measures. Veterans Affairs Pharmacy Benefits Management Center for Medication Safety uses medication use evaluation (MUE) through manual review of the electronic health records. OBJECTIVE To compare an electronic MUE approach versus human/manual review for extraction of antibiotic use (choice and duration) and severity metrics. RESEARCH DESIGN Retrospective. SUBJECTS Hospitalizations for uncomplicated pneumonia occurring during 2013 at 30 Veterans Affairs facilities. MEASURES We compared summary statistics, individual hospitalization-level agreement, facility-level consistency, and patterns of variation between electronic and manual MUE for initial severity, antibiotic choice, daily clinical stability, and antibiotic duration. RESULTS Among 2004 hospitalizations, electronic and manual abstraction methods showed high individual hospitalization-level agreement for initial severity measures (agreement=86%-98%, κ=0.5-0.82), antibiotic choice (agreement=89%-100%, κ=0.70-0.94), and facility-level consistency for empiric antibiotic choice (anti-MRSA r=0.97, P<0.001; antipseudomonal r=0.95, P<0.001) and therapy duration (r=0.77, P<0.001) but lower facility-level consistency for days to clinical stability (r=0.52, P=0.006) or excessive duration of therapy (r=0.55, P=0.005). Both methods identified widespread facility-level variation in antibiotic choice, but we found additional variation in manual estimation of excessive antibiotic duration and initial illness severity. CONCLUSIONS Electronic and manual MUE agreed well for illness severity, antibiotic choice, and duration of therapy in pneumonia at both the individual and facility levels. Manual MUE showed additional reviewer-level variation in estimation of initial illness severity and excessive antibiotic use. Electronic MUE allows for reliable, scalable tracking of national patterns of antimicrobial use, enabling the examination of system-wide interventions to improve quality.
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Skelton F, Martin LA, Evans CT, Kramer J, Grigoryan L, Richardson P, Kunik ME, Poon IO, Holmes SA, Trautner BW. Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study. JMIR Res Protoc 2019; 8:e12272. [PMID: 30762584 PMCID: PMC6393777 DOI: 10.2196/12272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/20/2018] [Accepted: 12/09/2018] [Indexed: 12/24/2022] Open
Abstract
Background Bacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use. Objective Through a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices. Methods Aim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site. Results This protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019. Conclusions The negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition. International Registered Report Identifier (IRRID) DERR1-10.2196/12272
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Affiliation(s)
- Felicia Skelton
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,H Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Lindsey Ann Martin
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Charlesnika T Evans
- Center for Innovation for Complex Chronic HealthCare, Hines VA Hospital, Chicago, IL, United States.,Department of Preventive Medicine and Center for Health Care Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Peter Richardson
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States
| | - Mark E Kunik
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Ivy Oiyee Poon
- Department of Pharmacy Practice, Texas Southern University, Houston, TX, United States
| | - S Ann Holmes
- H Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States.,Infectious Disease Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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Burnham JP, Vazquez Guillamet MC. How Will We Pay for the New Infectious Diseases/Critical Care Medicine Subspecialty? Clin Infect Dis 2018; 64:530. [PMID: 27927850 DOI: 10.1093/cid/ciw789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Jason P Burnham
- Washington University School of Medicine, St Louis, Missouri, United States of America
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All aboard!: Involvement of medical and pharmacy trainees in antimicrobial stewardship. Infect Control Hosp Epidemiol 2018; 40:200-205. [DOI: 10.1017/ice.2018.332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractAntimicrobial stewardship (AS) involves the appropriate selection of antimicrobials. Antimicrobial stewardship programs are mandated in hospitals and are expanding to involve outpatient arenas. Multiple articles have been published describing the need for AS education for medical and pharmacy students, beginning early in the students’ career to develop into competent AS practitioners. Additionally, publications have described the role and impact of medical and pharmacy trainees on AS programs. Here, we review the published evidence describing medical and pharmacy trainees’ involvement in AS and call for future research in this area.
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Fadare JO, Ogunleye O, Iliyasu G, Adeoti A, Schellack N, Engler D, Massele A, Godman B. Status of antimicrobial stewardship programmes in Nigerian tertiary healthcare facilities: Findings and implications. J Glob Antimicrob Resist 2018; 17:132-136. [PMID: 30557686 DOI: 10.1016/j.jgar.2018.11.025] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/30/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES The problem of antimicrobial resistance (AMR) is increasing worldwide, with health-related and economic consequences. This is a concern in Africa, including Nigeria, the most populous country in Africa, with its high rates of infectious diseases. Approaches to reducing AMR include instigating antimicrobial stewardship programmes (ASPs) in hospitals. Currently, no information is available regarding the extent of ASPs in Nigerian hospitals. Consequently, the objective was to address this starting in tertiary hospitals. METHODS This was a cross-sectional, questionnaire-based study among tertiary healthcare facilities. Tertiary hospitals were chosen initially since if there are concerns in these training hospitals, such concerns will likely to be exacerbated in other hospitals. RESULTS Completed questionnaires were received from 17 of 25 tertiary healthcare facilities across five of the six geopolitical regions of Nigeria. Ten (59%), four (24%), two (12%) and one (6%) respondents were in internal medicine, infectious diseases, medical microbiology and clinical pharmacology, respectively. Only six healthcare facilities (35%) had a formal organisational structure and a team responsible for ASP. Facility-specific treatment recommendations, based on local AMR patterns, were available in only four facilities (24%). Policies on approval for prescribing specified antimicrobials and formal procedures for reviewing their appropriateness after 48h were present in only two facilities (12%). A cumulative antimicrobial susceptibility report for the previous year was available in only two facilities (12%), and only one facility routinely monitored antimicrobial use. CONCLUSION Significant inadequacies in the availability of ASPs were observed. This needs to be urgently addressed to reduce AMR rates in Nigeria.
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Affiliation(s)
- Joseph O Fadare
- Department of Pharmacology and Therapeutics, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
| | - Olayinka Ogunleye
- Departments of Pharmacology and Medicine, Lagos State University College of Medicine and Teaching Hospital, Ikeja, Lagos, Nigeria
| | - Garba Iliyasu
- Infectious Diseases Unit, Department of Medicine, Bayero University, Kano, Nigeria
| | - Adekunle Adeoti
- Department of Medicine, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
| | - Natalie Schellack
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
| | - Deirdre Engler
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
| | - Amos Massele
- Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa; Division of Clinical Pharmacology, Karolinska Institute, Stockholm, Sweden; Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK; Health Economics Centre, Liverpool University Management School, Chatham Street, Liverpool, UK.
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A pilot study using telehealth to implement antimicrobial stewardship at two rural Veterans Affairs medical centers. Infect Control Hosp Epidemiol 2018; 39:1163-1169. [PMID: 30185238 DOI: 10.1017/ice.2018.197] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To test the feasibility of using telehealth to support antimicrobial stewardship at Veterans Affairs medical centers (VAMCs) that have limited access to infectious disease-trained specialists. DESIGN A prospective quasi-experimental pilot study. SETTING Two rural VAMCs with acute-care and long-term care units.InterventionAt each intervention site, medical providers, pharmacists, infection preventionists, staff nurses, and off-site infectious disease physicians formed a videoconference antimicrobial stewardship team (VAST) that met weekly to discuss cases and antimicrobial stewardship-related education. METHODS Descriptive measures included fidelity of implementation, number of cases discussed, infectious syndromes, types of recommendations, and acceptance rate of recommendations made by the VAST. Qualitative results stemmed from semi-structured interviews with VAST participants at the intervention sites. RESULTS Each site adapted the VAST to suit their local needs. On average, sites A and B discussed 3.5 and 3.1 cases per session, respectively. At site A, 98 of 140 cases (70%) were from the acute-care units; at site B, 59 of 119 cases (50%) were from the acute-care units. The most common clinical syndrome discussed was pneumonia or respiratory syndrome (41% and 35% for sites A and B, respectively). Providers implemented most VAST recommendations, with an acceptance rate of 73% (186 of 256 recommendations) and 65% (99 of 153 recommendations) at sites A and B, respectively. Qualitative results based on 24 interviews revealed that participants valued the multidisciplinary aspects of the VAST sessions and felt that it improved their antimicrobial stewardship efforts and patient care. CONCLUSIONS This pilot study has successfully demonstrated the feasibility of using telehealth to support antimicrobial stewardship at rural VAMCs with limited access to local infectious disease expertise.
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Chou AF, Graber CJ, Zhang Y, Jones M, Goetz MB, Madaras-Kelly K, Samore M, Glassman PA. Specifying an implementation framework for Veterans Affairs antimicrobial stewardship programmes: using a factor analysis approach. J Antimicrob Chemother 2018; 73:2559-2566. [PMID: 29873721 DOI: 10.1093/jac/dky207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/06/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programmes (ASPs) may optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify organizational factors that may facilitate ASP design, development and implementation. Methods Among 130 Veterans Affairs facilities that offered acute care, we classified organizational variables supporting antimicrobial stewardship activities into three PARiHS domains: evidence to encompass sources of knowledge; contexts to translate evidence into practice; and facilitation to enhance the implementation process. We conducted a series of exploratory factor analyses to identify conceptually linked factor scales. Cronbach's alphas were calculated. Variables with large uniqueness values were left as single factors. Results We identified 32 factors, including six constructs derived from factor analyses under the three PARiHS domains. In the evidence domain, four factors described guidelines and clinical pathways. The context domain was broken into three main categories: (i) receptive context (15 factors describing resources, affiliations/networks, formalized policies/practices, decision-making, receptiveness to change); (ii) team functioning (1 factor); and (iii) evaluation/feedback (5 factors). Within facilitation, two factors described facilitator roles and tasks and five captured skills and training. Conclusions We mapped survey data onto PARiHS domains to identify factors that may be adapted to facilitate ASP uptake. Our model encompasses mostly mutable factors whose relationships with performance outcomes may be explored to optimize antimicrobial use. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance.
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Affiliation(s)
- Ann F Chou
- Department of Family and Preventive Medicine, College of Medicine, University of Oklahoma, 900 NE 10th St., Oklahoma City, OK 73104, USA.,The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA
| | - Christopher J Graber
- The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.,David Geffen School of Medicine at UCLA, Los Angeles, Box 951691, Los Angeles, CA 90095, USA
| | - Yue Zhang
- Department of Internal Medicine and Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA.,VA Salt Lake City Healthcare System, 500 S Foothill Drive, Salt Lake City, UT 84148, USA
| | - Makoto Jones
- Department of Internal Medicine and Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA.,VA Salt Lake City Healthcare System, 500 S Foothill Drive, Salt Lake City, UT 84148, USA
| | - Matthew Bidwell Goetz
- The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.,David Geffen School of Medicine at UCLA, Los Angeles, Box 951691, Los Angeles, CA 90095, USA
| | - Karl Madaras-Kelly
- Boise Veterans Affairs Medical Center, 500 W Fort Street, Boise, ID, USA.,College of Pharmacy, Idaho State University, 1311 E Central Drive, Meridian, ID 83642, USA
| | - Matthew Samore
- Department of Internal Medicine and Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA.,VA Salt Lake City Healthcare System, 500 S Foothill Drive, Salt Lake City, UT 84148, USA
| | - Peter A Glassman
- The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.,David Geffen School of Medicine at UCLA, Los Angeles, Box 951691, Los Angeles, CA 90095, USA
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Blanchette L, Gauthier T, Heil E, Klepser M, Kelly KM, Nailor M, Wei W, Suda K. The essential role of pharmacists in antibiotic stewardship in outpatient care: An official position statement of the Society of Infectious Diseases Pharmacists. J Am Pharm Assoc (2003) 2018; 58:481-484. [PMID: 30007508 DOI: 10.1016/j.japh.2018.05.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/15/2018] [Accepted: 05/29/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this position statement is to describe the essential role of pharmacists in antimicrobial stewardship in outpatient care. DATA SOURCES N/A. SUMMARY The majority of antibiotic prescribing occurs in outpatient care settings highlighting the need for antibiotic stewardship in the community. Given their expertise on medication management, pharmacists are essential to any antibiotic stewardship effort. CONCLUSION As the regulations for antibiotic stewardship in outpatient settings continue to evolve and optimal stewardship strategies are defined, pharmacists must be leaders in the implementation of these programs.
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Experience during the first year of procalcitonin implementation: a precautionary tale for smaller facilities. Infect Control Hosp Epidemiol 2018; 39:1142-1143. [DOI: 10.1017/ice.2018.161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Appaneal HJ, Luther MK, Timbrook TT, LaPlante KL, Dosa DM. Facilitators and Barriers to Antibiotic Stewardship: A Qualitative Study of Pharmacists' Perspectives. Hosp Pharm 2018; 54:250-258. [PMID: 31320775 DOI: 10.1177/0018578718781916] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results: Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that improve patient outcomes.
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Affiliation(s)
- Haley J Appaneal
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Megan K Luther
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Tristan T Timbrook
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Kerry L LaPlante
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - David M Dosa
- Veterans Affairs Medical Center, Providence, RI, USA.,Brown University School of Public Health, Providence, RI, USA
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Goto M, McDanel JS, Jones MM, Livorsi DJ, Ohl ME, Beck BF, Richardson KK, Alexander B, Perencevich EN. Antimicrobial Nonsusceptibility of Gram-Negative Bloodstream Isolates, Veterans Health Administration System, United States, 2003-2013 1. Emerg Infect Dis 2018; 23:1815-1825. [PMID: 29047423 PMCID: PMC5652419 DOI: 10.3201/eid2311.161214] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Bacteremia caused by gram-negative bacteria is associated with serious illness and death, and emergence of antimicrobial drug resistance in these bacteria is a major concern. Using national microbiology and patient data for 2003–2013 from the US Veterans Health Administration, we characterized nonsusceptibility trends of community-acquired, community-onset; healthcare-associated, community-onset; and hospital-onset bacteremia for selected gram-negative bacteria (Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter spp.). For 47,746 episodes of bacteremia, the incidence rate was 6.37 episodes/10,000 person-years for community-onset bacteremia and 4.53 episodes/10,000 patient-days for hospital-onset bacteremia. For Klebsiella spp., P. aeruginosa, and Acinetobacter spp., we observed a decreasing proportion of nonsusceptibility across nearly all antimicrobial drug classes for patients with healthcare exposure; trends for community-acquired, community-onset isolates were stable or increasing. The role of infection control and antimicrobial stewardship efforts in inpatient settings in the decrease in drug resistance rates for hospital-onset isolates needs to be determined.
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Suda KJ, Livorsi DJ, Goto M, Forrest GN, Jones MM, Neuhauser MM, Hoff BM, Ince D, Carrel M, Nair R, Knobloch MJ, Goetz MB. Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration. Infect Control Hosp Epidemiol 2018; 39:196-201. [PMID: 29417925 PMCID: PMC9793410 DOI: 10.1017/ice.2017.299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Antimicrobial stewardship is vital to reducing the spread of antimicrobial resistance. A group of investigators and clinicians within the Veterans Health Administration set forth a research agenda for antimicrobial stewardship, including research targets for inpatient and outpatient stewardship activities, metrics, and antimicrobial dosing and duration.
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Affiliation(s)
- Katie J Suda
- 1Center of Innovation for Complex Chronic Healthcare,Edward Hines Jr VA Hospital,Hines,IL
| | | | | | | | - Makoto M Jones
- 6VA Salt Lake City Health Care System and the University of Utah School of Medicine,Salt Lake City,Utah
| | | | - Brian M Hoff
- 8University of Iowa Hospital and Clinics,Iowa City,Iowa
| | - Dilek Ince
- 4Division of Infectious Diseases,Department of Internal Medicine,University of Iowa Carver College of Medicine,Iowa City,Iowa
| | - Margaret Carrel
- 9Department of Geographical and Sustainability Sciences,College of Liberal Arts and Sciences,University of Iowa,Iowa City,Iowa
| | | | - Mary Jo Knobloch
- 10University of Wisconsin School of Medicine and Public Health,Madison, Wisconsin and the William S. Middleton Memorial Veterans Hospital,Madison Wisconsin
| | - Matthew B Goetz
- 11VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA,Los Angeles,California
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National epidemiology of initial and recurrent Clostridium difficile infection in the Veterans Health Administration from 2003 to 2014. PLoS One 2017; 12:e0189227. [PMID: 29216276 PMCID: PMC5720754 DOI: 10.1371/journal.pone.0189227] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/21/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction Prior studies demonstrated marked increases in Clostridium difficile infection (CDI) in the United States (U.S.) in recent years. The objective of this study was to describe the epidemiology of initial and recurrent CDI in a national Veterans Health Administration (VHA) cohort over a 12-year period. Methods This was a retrospective cohort study of all adult VHA beneficiaries with CDI (ICD-9-CM code 008.45) plus a positive CDI stool test between October 1, 2002 and September 30, 2014. Data were obtained from the VA Informatics and Computing Infrastructure. Recurrence was defined as a second ICD-9-CM code plus a new course of CDI therapy following a minimum three-day gap after the initial therapy was completed. CDI incidence and outcomes were presented descriptively and longitudinally. Results Overall, 30,326 patients met study inclusion criteria. CDI incidence increased from FY 2003 (1.6 per 10,000) to FY 2013 (5.1 per 10,000). Thereafter, CDI incidence decreased through FY 2014 (4.6 per 10,000). A total of 5,011 patients (17%) experienced a first recurrence and, of those, 1,713 (34%) experienced a second recurrence. Recurrence incidence increased 10-fold over the study period, from (0.1 per 10,000) in FY 2003, to (1.0 per 10,000) in FY 2014. Overall, 30-day mortality and median hospital length of stay (LOS) decreased among initial episodes over the study period. Mortality was higher for initial episodes (21%) compared to first recurrences (11%) and second recurrences (7%). Median hospital LOS was longer for first episodes (13 days) compared to first (9 days) and second recurrences (8 days). Conclusions Initial and recurrent CDI episodes increased among veterans over a 12-year period. Outcomes, such as mortality and hospital LOS improved in recent years; both of these outcomes are worse for initial CDI episodes than recurrent episodes.
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Kollef MH, Bassetti M, Francois B, Burnham J, Dimopoulos G, Garnacho-Montero J, Lipman J, Luyt CE, Nicolau DP, Postma MJ, Torres A, Welte T, Wunderink RG. The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship. Intensive Care Med 2017; 43:1187-1197. [PMID: 28160023 PMCID: PMC6204331 DOI: 10.1007/s00134-017-4682-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/06/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. METHODS Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. RESULTS The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. CONCLUSIONS These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Bruno Francois
- Service de Réanimation Polyvalente, Inserm CIC-1435, CHU Dupuytren, Limoges, France
| | - Jason Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - George Dimopoulos
- Department of Critical Care, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Seville, Spain
- Institute of Biomedicine of Seville, IBiS/CSIC/University of Seville, Seville, Spain
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD, Australia
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Herston, Brisbane, QLD, Australia
| | - Charles-Edouard Luyt
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS 1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David P Nicolau
- Center for Anti-infective Research and Development and Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Maarten J Postma
- Unit of PharmacoTherapy, Epidemiology & Economics, Department of Pharmacy and Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antonio Torres
- Department of Pulmonology, Hospital Clinic of Barcelona, CIBERES, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Tobias Welte
- Department of Pulmonology, Hannover Medical School, Hannover, Germany
| | - Richard G Wunderink
- Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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A call to action for outpatient antibiotic stewardship. J Am Pharm Assoc (2003) 2017; 57:457-463. [PMID: 28499717 DOI: 10.1016/j.japh.2017.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/07/2017] [Accepted: 03/31/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To address the public health threat of antibiotic resistance, there has been an enhanced call for antibiotic stewardship programs throughout the health care continuum. SUMMARY While antibiotic stewardship programs have been well described in the inpatient setting, data on effectiveness and guidance on implementing outpatient programs is scarce. Establishing stewardship practices in the outpatient setting is necessary because more than 60% of human antibiotic use occurs in this setting. CONCLUSION In this article, we highlight the importance and need for stewardship in the outpatient setting, discuss strategies for the development of stewardship teams, and discuss potential metrics that can be used to assess effectiveness of antibiotic stewardship interventions.
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A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative. Infect Control Hosp Epidemiol 2017; 38:513-520. [PMID: 28118861 DOI: 10.1017/ice.2016.328] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program. DESIGN Observational analysis. SETTING The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities. METHODS Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities. RESULTS Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection. CONCLUSIONS The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2017;38:513-520.
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Bohan JG, Remington R, Jones M, Samore M, Madaras-Kelly K. Outcomes Associated With Antimicrobial De-escalation of Treatment for Pneumonia Within the Veterans Healthcare Administration. Open Forum Infect Dis 2016; 4:ofw244. [PMID: 28480242 PMCID: PMC5414017 DOI: 10.1093/ofid/ofw244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 11/28/2016] [Indexed: 11/14/2022] Open
Abstract
De-escalation, an antimicrobial stewardship concept, involves narrowing broad-spectrum empiric antimicrobial therapy based on clinical data. Current health outcomes evidence is lacking to support de-escalation. Studying Veterans Healthcare Administration pneumonia patients, de-escalation was associated with improved length of stay without affecting 30-day readmission or 30-day Clostridium difficile infection rates.
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Affiliation(s)
| | - Richard Remington
- Research, Boise Veterans Affairs Medical Center, Boise, Idaho
- Quantified Inc., Boise, Idaho
| | - Makoto Jones
- Department of Medicine, George E. Wahlen Veterans Affairs Medical Center and Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Matthew Samore
- Department of Medicine, George E. Wahlen Veterans Affairs Medical Center and Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Karl Madaras-Kelly
- College of Pharmacy, Idaho State University, Meridian, Idaho
- College of Pharmacy, Idaho State University, Meridian, Idaho
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