Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration

Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population

BACKGROUND

Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations.

OBJECTIVE

To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs).

METHODS

We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit.

RESULTS

From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers.

CONCLUSIONS

Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.

Perceptions of an automated benchmarking dashboard for antimicrobial stewardship programs among antimicrobial stewards within the veterans' health administration: a multicenter qualitative study

Objective

To evaluate the impact of a multicenter, try automated dashboard on ASP activities and its acceptance among ASP leaders.

Design

Frontline stewards were asked to participate in semi-structured interviews before and after implementation of a web-based ASP information dashboard providing risk-adjusted benchmarking, longitudinal trends, and analysis of antimicrobial usage patterns at each facility.

Setting

The study was performed at Iowa City VA Health Care System.

Participants

ASP team members from nine medical centers in the VA Midwest Health Care Network (VISN 23).

Methods

Semi-structured interviews were conducted pre- and post-implementation, with interview guides informed by clinical experiences and the Consolidated Framework for Implementation Research (CFIR). Participants evaluated the dashboard's ease of use, applicability to ongoing ASP activities, perceived validity and reliability, and relative advantage over other ASP monitoring systems.

Results

Compared to established stewardship data collection and reporting methods, participants found the dashboard more intuitive and accessible, allowing them to reduce dependence on other systems and staff to obtain and share data. Standardized and risk-adjusted rankings were largely accepted as a valuable benchmarking method; however, participants felt their facility's characteristics significantly influenced the rankings' validity. Participants recognized staffing, training, and uncertainty with using the dashboard as an intervention tool as barriers to consistent and comprehensive dashboard implementation.

Conclusions

Participants generally accepted the dashboard's risk-adjusted metrics and appreciated its usability. While creating automated tools to rigorously benchmark antimicrobial use across hospitals can be helpful, the displayed metrics require further validation, and the longitudinal utility of the dashboard warrants additional study.

Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans' Health Administration

OBJECTIVE

Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs).

DESIGN

This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016-2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis.

RESULTS

There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0-52.7) and sites (median, 38.2%; IQR, 31.7-49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1-68.6) and sites (median, 40.0%; IQR, 30.4-59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001).

CONCLUSIONS

Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

How Far We've Come, How Far We Have to Go: a Review of Advances in Antimicrobial Stewardship in the Veterans Health Administration

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.

Outpatient antimicrobial stewardship: Optimizing patient care via pharmacist led microbiology review

BACKGROUND

Cultures are often taken in the outpatient setting but results are not acted upon, leading to unnecessary re-presentations to the health care setting.

METHODS

This study was a prospective study with interventions made between January 1, 2018, and January 1, 2019. Cultures were reviewed to ensure appropriate antimicrobial coverage. The objective was to compare outcomes with accepted versus rejected interventions. Descriptive statistics were used to summarize data.

RESULTS

A total of 7,360 antibiotic orders were reviewed by the infectious diseases pharmacists. Pharmacists intervened on 20.1% (n = 194) of encounters with related cultures. Interventions were most frequent in the emergency department (42%). Ciprofloxacin required the most interventions (26%), followed by third-generation cephalosporins (22%). The intervention acceptance rate was 76%, which was associated with decreased rates of 30-day treatment failure (5% vs 28%, P < .001) and 30-day admission (0.7% vs 11%, P = .001), when interventions were accepted rather than rejected.

DISCUSSION

Approximately 20% of patients required intervention. Culture review services may be beneficial in a variety of outpatient settings. Outpatient stewardship literature is limited, and our study found a decrease in admission and treatment failure.

CONCLUSIONS

Microbiology review and intervention positively impacted care for outpatients. Intervention was associated with significantly decreased rates of treatment failure and admission when interventions were accepted.

Antimicrobial stewardship staffing: How much is enough?

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.