Predictors of Antimicrobial Stewardship Program Recommendation Disagreement

Indication-driven order entry decreases stewardship and pharmacist interventions

Indication-driven order entry (IDOE) was implemented at our pediatric institution for cefazolin, piperacillin-tazobactam, and meropenem; the 3 most intervened upon antibiotics during prospective audit and feedback (PAF) by the antimicrobial stewardship program (ASP). IDOE was associated with a significant reduction in both ASP PAF recommendations and clinical pharmacist interventions.

Antifungal stewardship in practice: Insights from a prospective audit and feedback program

OBJECTIVE

To identify characteristics of antifungal prospective audit and feedback (PAF) and to compare rates of PAF recommendation and acceptance between antifungal and antibiotic agents.

DESIGN

Retrospective cohort study of antifungal and antibiotic audits by a children's hospital antimicrobial stewardship program (ASP) from November 1, 2020, to October 31, 2022.

METHODS

Antimicrobial audit data were retrieved from the ASP data warehouse. We characterized antifungal PAF using descriptive statistics. We then compared the overall rates of PAF recommendation and recommendation acceptance between antifungals and antibiotics. We also compared the differences in antifungal and antibiotic PAF recommendation and acceptance rates across various factors, including infectious problem, medical service, and recommendation type.

RESULTS

Of 10,402 antimicrobial audits identified during the study period, 8,599 (83%) were for antibiotics and 1,803 (17%) were for antifungals. The highest antifungal recommendation rates were for liposomal amphotericin B, antifungals used for sepsis or respiratory tract infection, and antifungals prescribed in the cardiovascular intensive care unit. The rate of PAF recommendation was higher for antibiotics than for antifungals (29% vs 21%; P < .001); however, the rates of recommendation acceptance were similar. Recommendations to discontinue or for medication monitoring were more common for antifungals.

CONCLUSIONS

Our analysis of antifungal PAF identified key opportunities to improve antifungal use, including the optimized use of specific agents and targeted use by certain medical services. Moreover, antifungal PAF, despite identifying fewer recommendations compared to antibiotic PAF, were associated with similarly high rates of acceptance, highlighting a promising opportunity for antifungal stewardship.

Impact of prolonged carbapenem use-focused antimicrobial stewardship on antimicrobial consumption and factors affecting acceptance of recommendations: a quasi-experimental study

This study aimed to assess the impact of a prolonged carbapenem use-focused antimicrobial stewardship program (ASP) on antimicrobial consumption and clinical outcomes and to analyze factors affecting adherence to interventions. Patients prescribed carbapenems for ≥ 2 weeks received intervention. Interrupted time-series analysis was performed to compare antimicrobial consumption before and after intervention. Factors associated with non-adherence to intervention were investigated. Of 273 patients who were eligible for intervention, discontinuation or de-escalation was recommended in 256 (94.1%) and intervention was accepted in 136 (53.1%) patients. Before intervention, carbapenem consumption significantly increased to 1.14 days of therapy (DOT)/1000 patient days (PD)/month (P = 0.018). However, it significantly declined by - 2.01 DOT/1000 PD/month without an increase in other antibiotic consumption (P < 0.001). Factors affecting non-adherence to intervention were younger age (odds ratio [OR] = 0.98; 95% confidence interval [CI] 0.96-1.00), solid organ malignancy (OR = 2.53, 95% CI 1.16-5.50), and pneumonia (OR = 2.59, 95% CI 1.08-6.17). However, ASP intervention was not associated with clinical outcomes such as length of hospital stay or mortality. Prolonged carbapenem prescription-focused ASP significantly reduced carbapenem consumption without adverse outcomes. Non-adherence to interventions was attributed more to prescriber-related factors, such as attitude, than patient-related factors including clinical severity.

Pharmacist gender and physician acceptance of antibiotic stewardship recommendations: An analysis of the reducing overuse of antibiotics at discharge home intervention

OBJECTIVE

To assess association of pharmacist gender with acceptance of antibiotic stewardship recommendations.

DESIGN

A retrospective evaluation of the Reducing Overuse of Antibiotics at Discharge (ROAD) Home intervention.

SETTING

The study was conducted from May to October 2019 in a single academic medical center.

PARTICIPANTS

The study included patients receiving antibiotics on a hospitalist service who were nearing discharge.

METHODS

During the intervention, clinical pharmacists (none who had specialist postgraduate infectious disease residency training) reviewed patients on antibiotics and led an antibiotic timeout (ie, structured conversation) prior to discharge to improve discharge antibiotic prescribing. We assessed the association of pharmacist gender with acceptance of timeout recommendations by hospitalists using logistic regression controlling for patient characteristics.

RESULTS

Over 6 months, pharmacists conducted 295 timeouts: 158 timeouts (53.6%) were conducted by 12 women, 137 (46.4%) were conducted by 8 men. Pharmacists recommended an antibiotic change in 82 timeouts (27.8%), of which 51 (62.2%) were accepted. Compared to male pharmacists, female pharmacists were less likely to recommend a discharge antibiotic change: 30 (19.0%) of 158 versus 52 (38.0%) of 137 (P < .001). Female pharmacists were also less likely to have a recommendation accepted: 10 (33.3%) of 30 versus 41 (8.8%) of 52 (P < .001). Thus, timeouts conducted by female versus male pharmacists were less likely to result in an antibiotic change: 10 (6.3%) of 158 versus 41 (29.9%) of 137 (P < .001). After adjustments, pharmacist gender remained significantly associated with whether recommended changes were accepted (adjusted odds ratio [aOR], 0.10; 95%confidence interval [CI], 0.03-0.36 for female versus male pharmacists).

CONCLUSIONS

Antibiotic stewardship recommendations made by female clinical pharmacists were less likely to be accepted by hospitalists. Gender bias may play a role in the acceptance of clinical pharmacist recommendations, which could affect patient care and outcomes.

Factors Associated with Acceptance of Telehealth-based Antimicrobial Stewardship Program Recommendations in a Community Hospital Health System

Background

Telehealth-based antimicrobial stewardship programs (TeleASPs) have led to reduced broad-spectrum antimicrobial utilization. Data on factors associated with acceptance of stewardship recommendations are limited.

Methods

A TeleASP, facilitated by remote infectious disease physicians and local pharmacists, was implemented in 2 community hospitals from February 2018 through July 2020. Variables potentially affecting acceptance of TeleASP recommendations were tracked. Odds ratios of acceptance were determined utilizing multiple logistic regression.

Results

During the 30-month period, 4863 (91.2%) of the total 5333 recommendations were accepted. Factors associated with a higher odds of acceptance in multivariable analysis were recommendations for antimicrobial dose/frequency adjustment (odds ratio [OR], 2.63; 95% CI, 1.6–4.3) and order for labs/tests (OR, 3.30; 95% CI, 2.1–5.2), while recommendations for antimicrobial de-escalation (OR, 0.75; 95% CI, 0.60–0.95) and antimicrobial discontinuation (OR, 0.57; 95% CI, 0.42–0.76) were associated with lower odds of acceptance. Female physicians were more likely to accept recommendations compared with males (93.1% vs 90.3% acceptance; OR, 1.65; 95% CI, 1.3–2.2). Compared with physicians with <3 years of experience, who had the highest acceptance rate (96.3%), physicians with ≥21 years of experience had the lowest (87.1%; OR, 0.26; 95% CI, 0.15–0.45).

Conclusions

TeleASP recommendations were accepted at a high rate. Acceptance rates were higher among female physicians, and recommendations to stop or de-escalate antimicrobials led to lower acceptance. Recommendations made to the most experienced physicians were the least accepted, which may be an important factor for stewardship programs to consider in education and intervention efforts.

A national study of antibiotic use in Greek pediatric hematology oncology and bone marrow transplant units

OBJECTIVE

We surveyed antimicrobials used in Greek pediatric hematology-oncology (PHO) and bone marrow transplant (BMT) units before and after an intervention involving education regarding the 2017 clinical practice guidelines (CPG) for the management of febrile neutropenia in children with cancer and hematopoietic stem-cell transplant recipients.

DESIGN

Antibiotic prescribing practices were prospectively recorded between June 2016 and November 2017.

INTERVENTION

In December 2017, baseline data feedback was provided, and CPG education was provided. Prescribing practices were followed for one more year. For antibiotic stewardship, days of therapy, and length of therapy were calculated.

SETTING

Five of the 6 PHO units in Greece and the single pediatric BMT unit participated.

PARTICIPANTS

Admitted children in each unit who received the first 15 new antibiotic courses each month.

RESULTS

Administration of ≥4 antibiotics simultaneously and administration of antibiotics with overlapping activity for ≥2 days were significantly more common in PHO units in general hospitals compared to children's hospitals. Use of at least 1 antifungal was recorded in ∼47% of the patients before and after the intervention. De-escalation and/or discontinuation of antibiotics on day 6 of initial treatment increased significantly from 43% to 53.5% (P = .032). Although the number of patients requiring intensive care support for sepsis did not change, a significant drop was noted in all-cause mortality (P = .008).

CONCLUSIONS

We recorded the antibiotic prescribing practices in Greek PHO and BMT units, we achieved improved prescribing with a simple intervention, and we identified areas in need of improvement.

OUP accepted manuscript

Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents’ perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.

Use of Prospective Audit and Feedback to Reduce Antibiotic Exposure in a Pediatric Cardiac ICU

OBJECTIVES

We sought to determine whether a prospective audit and feedback intervention decreased antibiotic utilization in a pediatric cardiac ICU and to describe the characteristics of prospective audit and feedback audits and recommendations.

DESIGN

Before-after study.

SETTING

Pediatric cardiac ICU of a freestanding children's hospital.

PATIENTS

All patients admitted to the cardiac ICU.

INTERVENTIONS

A prospective audit and feedback program was established in our hospital's pediatric cardiac ICU on December 7, 2015. The antimicrobial stewardship program audited IV antibiotics, communicated prospective audit and feedback recommendations to the cardiac ICU, and regularly reviewed recommendation adherence. Mean monthly antibiotic utilization 18 months before ("preprospective audit and feedback"; from June 1, 2014 to November 30, 2015) and 24 months after ("prospective audit and feedback"; from January 1, 2016 to December 31, 2017) prospective audit and feedback implementation was compared. Antibiotic audit data during the prospective audit and feedback period were reviewed to capture the characteristics of prospective audit and feedback audits, recommendations, and adherence.

MEASUREMENTS AND MAIN RESULTS

Mean cardiac ICU IV antibiotic use decreased 20% (701 vs 880 days of therapy per 1,000 patient days, p = 0.001) during the prospective audit and feedback period compared with the preprospective audit and feedback period. There was no difference in mean cardiac ICU length of stay (p = 0.573), mean hospital length of stay (p = 0.722), or the rate of discharge due to death (p = 0.541). There were 988 antibiotic audits and 370 prospective audit and feedback recommendations (37% recommendation rate) during the study period. The most commonly audited antibiotic category was broad-spectrum gram-negative agents and the most common indication for use was sepsis. Broad-spectrum gram-positive agents were more likely to be associated with a recommendation.

CONCLUSIONS

There was a significant reduction in antibiotic use following implementation of a prospective audit and feedback program in our pediatric cardiac ICU. Over one-third of antibiotics audited in our cardiac ICU were associated with a prospective audit and feedback recommendation, revealing important targets for future antimicrobial stewardship efforts in this population.

Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study

Objectives:

An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist.

Design, Setting, Participants, and Methods:

In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes.

Results:

Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds.

Conclusions:

Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing—choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.

Standardization of post-operative antimicrobials reduced exposure while maintaining good outcomes in pediatric liver transplant recipients

Infections following orthotopic liver transplant (OLT) result in significant morbidity and mortality, warranting careful consideration of risks associated with antibiotic overuse and benefits of infection prevention. In the absence of specific guidelines for antimicrobial prophylaxis in pediatric OLT, we developed a standardized approach to post-operative (post-op) antimicrobial therapy including 48 hours of antibiotics, no vancomycin for post-op fever within the first 48 hours, and caspofungin only for certain situations. The goal was to reduce antimicrobial utilization and adverse outcomes associated with longer duration of and broader treatment while maintaining good outcomes. The impact of this standardization on antimicrobial utilization and clinical outcomes at the largest pediatric liver transplant center in the United States is described. All individuals receiving an OLT from 1/1/17-9/30/17 (N = 38) and 3/14/18-12/13/18 (N = 27) were included in the pre-intervention (PreI) and post-intervention (PostI) groups, respectively. The intervention resulted in a significant reduction in individuals receiving post-op broad-spectrum gram-negative antibiotics for >48 hours (76% PreI vs 44% PostI OLT recipients, P = .01) and post-op vancomycin use (50% PreI, vs 7.4% PostI, P < .001). There were no statistically significant differences between groups for post-op fever, positive pre-/post-operative cultures, receipt of massive transfusion, or hospital length of stay. In conclusion, following the implementation of a standardized approach to post-op prophylaxis, antimicrobial exposure was significantly reduced without affecting OLT recipient outcomes.

Antibiotics: easier to start than to stop? Predictors of antimicrobial stewardship recommendation acceptance

OBJECTIVES

Acceptance of prospective audit and feedback antimicrobial stewardship programme (ASP) recommendations has been shown to vary, but the drivers of recommendation acceptance are not well understood. We sought to identify the factors associated with recommendation acceptance at a large community teaching hospital.

METHODS

Data from an ASP recommendation registry were collected from 2010 to 2018. Variables included data about the infection, the prescriber, and the recommendation, categorized by whether they increase, decrease, or are neutral to antibiotic exposure. The primary outcome was acceptance of ASP recommendations. Adjusted odds ratios and 95% confidence intervals were estimated using logistic regression models with random intercepts in order to account for clustering by prescriber.

RESULTS

Over the 8-year period, a total of 11 014 evaluable recommendations were made to 146 prescribers, and 9058 (82.2%) were accepted. The most common recommendations were: reduce duration (n = 2796; 25%), stop antibiotics (n = 2184; 20%), de-escalate (n = 1876; 17%) and increase duration (n = 1176; 11%). Acceptance by service ranged from 70% (n = 843/1196) (surgery) to 86% (n = 6378/7444) (general medicine). In the multivariable analysis, compared to recommendations that have a neutral impact on antibiotic exposure, recommendations to decrease antibiotic exposure had lower odds of acceptance (aOR 0.73; 95%CI 0.64-0.84) while recommendations to increase exposure were associated with greater acceptance (aOR 2.00; 95%CI 1.62-2.45). Other factors associated with increased acceptance included the presence of the ASP physician during rounds and making the recommendation verbally.

CONCLUSIONS

Recommendations to decrease antibiotic exposure had lower odds of acceptance than those to increase antibiotic exposure. This study presents important considerations for ASPs with prospective audit and feedback programmes aiming to evaluate and increase the impact of their recommendations.

Barriers to Adherence to Antimicrobial Stewardship Postprescription Review and Feedback For Broad-Spectrum Antimicrobial Agents: A Nested Case-Control Study

Background

Postprescription review and feedback (PPRF) is one of the most common strategies in antimicrobial stewardship program (ASP) intervention. However, disagreements between the prescribers and ASP personnel can occur. The aim of the present study was to identify the factors associated with nonadherence to PPRF intervention.

Methods

The present retrospective nested case-control study was performed at a tertiary care center, which has been conducting a once-weekly PPRF for carbapenems and piperacillin/tazobactam since 2014. Nonadherence to ASP recommendations was defined as the failure of the primary care team to modify or stop antimicrobial therapy 72 hours after the issuance of PPRF recommendations. Factors associated with nonadherence to PPRF intervention were identified using multivariate logistic regression analysis.

Results

In total, 2466 instances of PPRF in 1714 cases between April 2014 and September 2019 were found. The nonadherence rate was 5.9%, and 44 cases were found in which carbapenems or piperacillin/tazobactam continued to be used against PPRF recommendations. Factors associated with nonadherence to PPRF recommendations were a previous history of hospitalization within 90 days (adjusted odds ratio [aOR], 2.62; 95% confidence interval [CI], 1.18-5.81) and a rapidly fatal McCabe score at the time of PPRF intervention (aOR, 2.87; 95% CI, 1.18-6.98). A review of the narrative comments in the electronic medical records indicated that common reasons for nonadherence were "the patient was sick" (n = 12; 27.3%) and "the antimicrobial seemed to be clinically effective" (n = 9; 20.5%).

Conclusions

Nonadherence to PPRF recommendations was relatively uncommon at the study institution. However, patients with a severe disease condition frequently continued to receive broad-spectrum antimicrobials against PPRF recommendations. Understanding physicians' cognitive process in nonadherence to ASP recommendations and ASP interventions targeting medical subspecialties caring for severely ill patients is needed to improve ASP.

Identification of High-Yield Targets for Antimicrobial Stewardship Program Efforts Within a Nonfreestanding Children's Hospital

OBJECTIVES

Identify diagnoses with the highest likelihood of prompting antimicrobial stewardship program (ASP) recommendations and lowest probability of recommendation acceptance, investigate the impact of provider years in practice on recommendation receipt and acceptance, and simultaneously assess the influence of patient and provider-level variables associated with recommendations within a nonfreestanding children's hospital.

METHODS

Retrospective cohort study of antibiotic courses reviewed by the ASP staff from December 1, 2014 to November 30, 2016. Poisson regression was used to detect associations between diagnoses, provider years in practice, and the probability of recommendation receipt and acceptance. Multivariable logistic regression was used to simultaneously examine the influence of patient and provider-level characteristics on recommendation probability.

RESULTS

A total of 938 inpatient encounters and 1170 antibiotic courses were included. Diagnoses were associated with provider receipt (P < .001) and acceptance (P < .001) of recommendations, with ear, nose, and throat and/or sinopulmonary diagnoses most likely to prompt recommendations (56%; 95% confidence interval [CI], 48-64) and recommendations for neonatal and/or infant diagnoses accepted least often (67%; 95% CI, 58-76). No associations were initially found between provider experience and recommendation receipt or acceptance, although multivariable analysis revealed a trend between increasing years in practice and recommendation likelihood (P = .001). Vancomycin usage (64%; 95% CI, 56-72) and ear, nose, and throat and/or sinopulmonary diagnoses (56%; 95% CI, 47-65) had the highest probability of a recommendation. Sensitivity analyses revealed that use of diagnosis-related clinical practice guidelines decreased recommendations and increased acceptance rates, especially for the surgery diagnosis category.

CONCLUSIONS

High-yield targets for ASP activities at our nonfreestanding children's hospital were identified. Clinical practice guidelines have the potential to decrease ASP workload, and their development should be particularly encouraged for ASPs with limited resources.

Who listens and who doesn't? Factors associated with adherence to antibiotic stewardship intervention in a Singaporean tertiary hospital

INTRODUCTION

Antibiotic stewardship programmes (ASPs) can improve patient outcomes by prospective audit and feedback with interventions. However, adherence to ASP interventions is not mandatory. Identifying factors associated with improved adherence may help to enhance ASP recommendations and activities.

METHODS

A retrospective cohort study was conducted, comprising all ASP interventions performed as part of the prospective audit and feedback strategy in our institution (an acute tertiary-care hospital in Singapore) from January 2016 to July 2018. Adherence to ASP intervention was ascertained based on documented compliance with the recommended interventions within 48h. Factors associated with adherence to ASP interventions, such as patient demographics, clinical condition, type of infection, and characteristics of ASP interventions were identified using the χ² test for categorical variables. On multivariate analysis, factors independently associated with adherence to ASP intervention were identified using logistic regression.

RESULTS

Adherence to ASP intervention was 81.9% (5758/7028). On univariate and multivariate analysis, interventions coupled with direct communication via phone call (adjusted odds ratio [aOR] 1.61, 95% CI 1.23-2.08) were associated with higher odds of adherence, whereas admission to a surgical unit, intervention involving carbapenem use, and recommendation to de-escalate or discontinue antibiotics were associated with lower odds of adherence to ASP interventions.

CONCLUSION

Although adherence rates to ASP interventions were relatively high, interventions made to the surgical unit and recommendations related to carbapenem use were not so well received. Interventions communicated verbally via phone call were well received, highlighting the need for a close working relationship between ASP teams and hospital physicians.