1
|
Zeng Y, Li W, Zhao M, Li J, Liu X, Shi L, Yang X, Xia H, Yang S, Yang L. The association between ambient temperature and antimicrobial resistance of Klebsiella pneumoniae in China: a difference-in-differences analysis. Front Public Health 2023; 11:1158762. [PMID: 37361142 PMCID: PMC10285064 DOI: 10.3389/fpubh.2023.1158762] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Antimicrobial resistance (AMR) of Klebsiella pneumoniae (K. pneumoniae) poses a significant global public health threat and is responsible for a high prevalence of infections and mortality. However, knowledge about how ambient temperature influences the AMR of K. pneumoniae is limited in the context of global warming. Methods AMR data of 31 Chinese provinces was collected from the China Antimicrobial Resistance Surveillance System (CARSS) between 2014 and 2020. Socioeconomic and meteorological data were collected from the China Statistical Yearbook during the same period. A modified difference-in-differences (DID) approach was applied to estimate the association between ambient temperature and third-generation cephalosporin-resistant K. pneumoniae (3GCRKP) and carbapenem-resistant K. pneumoniae (CRKP). Furthermore, moderating effects of socioeconomic factors were also evaluated. Results Every 1°C increase in annual average temperature was associated with a 4.7% (relative risk (RR):1.047, 95% confidence intervals (CI): 1.031-1.082) increase in the detection rate of 3GCRKP, and a 10.7% (RR:1.107, 95% CI: 1.011-1.211) increase in the detection rate of CRKP. The relationships between ambient temperature and 3GCRKP and CRKP were found to be moderated by socioeconomic status (GDP per capita, income per capita, and consumption per capita; the interaction p-values <0.05), where higher economic status was found to strengthen the effects of temperature on the detection rate of 3GCRKP and weaken the effects on the detection rate of CRKP. Discussion Ambient temperature was found to be positively associated with AMR of K. pneumoniae, and this association was moderated by socioeconomic status. Policymakers should consider the impact of global warming and high temperatures on the spread of 3GCRKP and CRKP when developing strategies for the containment of AMR.
Collapse
Affiliation(s)
- Yingchao Zeng
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Weibin Li
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Manzhi Zhao
- Department of Pulmonary and Critical Care Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University. Guangzhou, Guangdong, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xu Liu
- Department of Infectious Disease, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Lin Shi
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Xinyi Yang
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Haohai Xia
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Shifang Yang
- Department of Pulmonary and Critical Care Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University. Guangzhou, Guangdong, China
| | - Lianping Yang
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
2
|
Moehring RW, Yarrington ME, Warren BG, Lokhnygina Y, Atkinson E, Bankston A, Collucio J, David MZ, Davis AE, Davis J, Dionne B, Dyer AP, Jones TM, Klompas M, Kubiak DW, Marsalis J, Omorogbe J, Orajaka P, Parish A, Parker T, Pearson JC, Pearson T, Sarubbi C, Shaw C, Spivey J, Wolf R, Wrenn RH, Dodds Ashley ES, Anderson DJ. Evaluation of an Opt-Out Protocol for Antibiotic De-Escalation in Patients With Suspected Sepsis: A Multicenter, Randomized, Controlled Trial. Clin Infect Dis 2023; 76:433-442. [PMID: 36167851 DOI: 10.1093/cid/ciac787] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/09/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sepsis guidelines recommend daily review to de-escalate or stop antibiotics in appropriate patients. This randomized, controlled trial evaluated an opt-out protocol to decrease unnecessary antibiotics in patients with suspected sepsis. METHODS We evaluated non-intensive care adults on broad-spectrum antibiotics despite negative blood cultures at 10 US hospitals from September 2018 through May 2020. A 23-item safety check excluded patients with ongoing signs of systemic infection, concerning or inadequate microbiologic data, or high-risk conditions. Eligible patients were randomized to the opt-out protocol vs usual care. Primary outcome was post-enrollment antibacterial days of therapy (DOT). Clinicians caring for intervention patients were contacted to encourage antibiotic discontinuation using opt-out language. If continued, clinicians discussed the rationale for continuing antibiotics and de-escalation plans. To evaluate those with zero post-enrollment DOT, hurdle models provided 2 measures: odds ratio of antibiotic continuation and ratio of mean DOT among those who continued antibiotics. RESULTS Among 9606 patients screened, 767 (8%) were enrolled. Intervention patients had 32% lower odds of antibiotic continuation (79% vs 84%; odds ratio, 0.68; 95% confidence interval [CI], .47-.98). DOT among those who continued antibiotics were similar (ratio of means, 1.06; 95% CI, .88-1.26). Fewer intervention patients were exposed to extended-spectrum antibiotics (36% vs 44%). Common reasons for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was unsafe (31%). Thirty-day safety events were similar. CONCLUSIONS An antibiotic opt-out protocol that targeted patients with suspected sepsis resulted in more antibiotic discontinuations, similar DOT when antibiotics were continued, and no evidence of harm. CLINICAL TRIALS REGISTRATION NCT03517007.
Collapse
Affiliation(s)
- Rebekah W Moehring
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Michael E Yarrington
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Bobby G Warren
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Erica Atkinson
- Department of Pharmacy, Southeastern Regional Medical Center, Lumberton, North Carolina, USA
| | - Allison Bankston
- Department of Pharmacy, Piedmont Newnan Hospital, Newnan, Georgia, USA
| | - Julia Collucio
- Department of Pharmacy, Piedmont Atlanta Hospital, Atlanta, Georgia, USA
| | - Michael Z David
- Department of Medicine, Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angelina E Davis
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Janice Davis
- Department of Pharmacy, Piedmont Fayette Hospital, Fayette, Georgia, USA
| | - Brandon Dionne
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pharmacy and Health Systems Sciences, Northeastern University School of Pharmacy and Pharmaceutical Sciences, Boston, Massachusetts, USA
| | - April P Dyer
- Department of Medicine, Infectious Diseases, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Travis M Jones
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Michael Klompas
- Department of Medicine, Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - David W Kubiak
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John Marsalis
- Department of Pharmacy, Piedmont Newnan Hospital, Newnan, Georgia, USA
| | | | - Patricia Orajaka
- Department of Pharmacy, Iredell Health, Statesville, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Todd Parker
- Department of Pharmacy, Piedmont Atlanta Hospital, Atlanta, Georgia, USA
| | - Jeffrey C Pearson
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tonya Pearson
- Department of Pharmacy, Piedmont Fayette Hospital, Fayette, Georgia, USA
| | - Christina Sarubbi
- Department of Pharmacy, UNC REX Healthcare, Raleigh, North Carolina, USA
| | - Christian Shaw
- Department of Pharmacy, Wilson Medical Center, Wilson, North Carolina, USA
| | - Justin Spivey
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.,Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Robert Wolf
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rebekah H Wrenn
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.,Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth S Dodds Ashley
- Department of Medicine, Infectious Diseases, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Deverick J Anderson
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | | |
Collapse
|
3
|
Tacconelli E, Mendelson M, Carrara E. New tools for antibiotic stewardship: a lesson for prescribers, researchers, or policy makers? THE LANCET. INFECTIOUS DISEASES 2023; 23:135-136. [PMID: 36206792 DOI: 10.1016/s1473-3099(22)00546-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Evelina Tacconelli
- Infectious Disease, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
| | - Marc Mendelson
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Elena Carrara
- Infectious Disease, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| |
Collapse
|
4
|
Motaganahalli S, Batrouney A, Perera D, Vogrin S, Trubiano JA. Retrospective study of outcomes of short versus long duration of antibiotic therapy for residual osteomyelitis in surgically resected diabetic foot infection. J Antimicrob Chemother 2022; 78:284-288. [PMID: 36418157 DOI: 10.1093/jac/dkac390] [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: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Optimal treatment duration for residual osteomyelitis (OM) post-amputation in diabetic foot infection (DFI) remains unclear, with resultant heterogeneity in prescribing noted in clinical practice. We aimed to identify a difference in outcomes of long duration of antibiotics (LD) with short duration (SD) in patients with culture-positive proximal bone specimen post-amputation. METHODS In this single-centre retrospective cohort study (Melbourne, Australia), we analysed antibiotic duration of DFI patients requiring amputation with culture-positive proximal bone specimen over a 31 month period (January 2019-September 2021). Primary outcome was reamputation or debridement at the same and/or contiguous site of amputation at 6 months. Secondary outcomes were readmission to hospital and/or recommencement of antibiotics for DFI at the same and/or contiguous site at 6 months. RESULTS Among 92 patients (83% male, median age 67 years), 26 received <4 weeks (SD) and 66 received ≥4 weeks (LD) antibiotic therapy. In the SD group, primary outcome occurred in 9 patients (35%) compared with 15 patients (23%) in the LD group (P = 0.246). Both secondary outcomes occurred in 12 patients (46%) in the SD group compared with 18 patients (27%) in the LD group (P = 0.086). Adjusted logistic regression analysis showed SD was not significantly associated with primary outcome [OR 1.12 (95% CI 0.38-3.31)] or secondary outcomes [OR 1.67 (95% CI 0.60-4.66)]. CONCLUSIONS This single-centre experience did not demonstrate significant difference in outcomes between antibiotic duration of <4 weeks and ≥4 weeks in DFI patients with culture-positive proximal bone specimen post-amputation. These data provide background for larger international randomized control trials to establish optimal treatment duration.
Collapse
Affiliation(s)
- S Motaganahalli
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
| | - A Batrouney
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
- Department of Pharmacy, Austin Health, Heidelberg, Victoria
| | - D Perera
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
- Department of Pharmacy, Austin Health, Heidelberg, Victoria
| | - S Vogrin
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Victoria
| | - J A Trubiano
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
- Department of Pharmacy, Austin Health, Heidelberg, Victoria
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria
| |
Collapse
|
5
|
Molina J, Rosso-Fernández CM, Montero-Mateos E, Paño-Pardo JR, Solla M, Guisado-Gil AB, Álvarez-Marín R, Pachón-Ibáñez ME, Gimeno A, Martín-Gutiérrez G, Lepe JA, Cisneros JM. Study protocol for a randomized clinical trial to assess 7 versus 14-days of treatment for Pseudomonas aeruginosa bloodstream infections (SHORTEN-2 trial). PLoS One 2022; 17:e0277333. [PMID: 36548225 PMCID: PMC9778939 DOI: 10.1371/journal.pone.0277333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Research priorities in Antimicrobial Stewardship (AMS) have rapidly evolved in the last decade. The need for a more efficient use of antimicrobials have fueled plenty of studies to define the optimal duration for antibiotic treatments, and yet, there still are large areas of uncertainty in common clinical scenarios. Pseudomonas aeruginosa has been pointed as a priority for clinical research, but it has been unattended by most randomized trials tackling the effectiveness of short treatments. The study protocol of the SHORTEN-2 trial is presented as a practical example of new ways to approach common obstacles for clinical research in AMS. OBJECTIVE To determine whether a 7-day course of antibiotics is superior to 14-day schemes for treating bloodstream infections by P. aeruginosa (BSI-PA). METHODS A superiority, open-label, randomized controlled trial will be performed across 30 Spanish hospitals. Adult patients with uncomplicated BSI-PA will be randomized to receive a 7 versus 14-day course of any active antibiotic. The primary endpoint will be the probability for the 7-day group of achieving better outcomes than the control group, assessing altogether clinical effectiveness, severe adverse events, and antibiotic exposure through a DOOR/RADAR analysis. Main secondary endpoints include treatment failure, BSI-PA relapses, and mortality. A superiority design was set for the primary endpoint and non-inferiority for treatment failure, resulting in a sample size of 304 patients. CONCLUSIONS SHORTEN-2 trial aligns with some of the priorities for clinical research in AMS. The implementation of several methodological innovations allowed overcoming common obstacles, like feasible sample sizes or measuring the clinical impact and unintended effects. TRIAL REGISTRATION EudraCt: 2021-003847-10; ClinicalTrials.gov: NCT05210439.
Collapse
Affiliation(s)
- José Molina
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Enrique Montero-Mateos
- Department of Pathology and Institute of Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Salamanca, Spain
| | - José Ramón Paño-Pardo
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
| | - María Solla
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Unidad de Investigación Clínica y Ensayos Clínicos (CTU), Hospital Virgen del Rocío, Sevilla, Spain
| | - Ana Belén Guisado-Gil
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacy, Virgen del Rocío University Hospital, Seville, Spain
| | - Rocío Álvarez-Marín
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - María Eugenia Pachón-Ibáñez
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Adelina Gimeno
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Guillermo Martín-Gutiérrez
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - José Antonio Lepe
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - José Miguel Cisneros
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- * E-mail:
| | | |
Collapse
|
6
|
Amin AN, Dellinger EP, Harnett G, Kraft BD, LaPlante KL, LoVecchio F, McKinnell JA, Tillotson G, Valentine S. It's about the patients: Practical antibiotic stewardship in outpatient settings in the United States. Front Med (Lausanne) 2022; 9:901980. [PMID: 35966853 PMCID: PMC9363693 DOI: 10.3389/fmed.2022.901980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/27/2022] [Indexed: 12/01/2022] Open
Abstract
Antibiotic-resistant pathogens cause over 35,000 preventable deaths in the United States every year, and multiple strategies could decrease morbidity and mortality. As antibiotic stewardship requirements are being deployed for the outpatient setting, community providers are facing systematic challenges in implementing stewardship programs. Given that the vast majority of antibiotics are prescribed in the outpatient setting, there are endless opportunities to make a smart and informed choice when prescribing and to move the needle on antibiotic stewardship. Antibiotic stewardship in the community, or "smart prescribing" as we suggest, should factor in antibiotic efficacy, safety, local resistance rates, and overall cost, in addition to patient-specific factors and disease presentation, to arrive at an appropriate therapy. Here, we discuss some of the challenges, such as patient/parent pressure to prescribe, lack of data or resources for implementation, and a disconnect between guidelines and real-world practice, among others. We have assembled an easy-to-use best practice guide for providers in the outpatient setting who lack the time or resources to develop a plan or consult lengthy guidelines. We provide specific suggestions for antibiotic prescribing that align real-world clinical practice with best practices for antibiotic stewardship for two of the most common bacterial infections seen in the outpatient setting: community-acquired pneumonia and skin and soft-tissue infection. In addition, we discuss many ways that community providers, payors, and regulatory bodies can make antibiotic stewardship easier to implement and more streamlined in the outpatient setting.
Collapse
Affiliation(s)
- Alpesh N. Amin
- Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | | | - Glenn Harnett
- No Resistance Consulting, Birmingham, AL, United States
| | - Bryan D. Kraft
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kerry L. LaPlante
- College of Pharmacy, University of Rhode Island, Kingston, RI, United States
| | - Frank LoVecchio
- Department of Emergency Medicine, Valleywise Health, Arizona State University, Phoenix, AZ, United States
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Lundquist Research Institute at Harbor-UCLA, Torrance, CA, United States
| | | | | |
Collapse
|
7
|
Keller SC, Caballero TM, Tamma PD, Miller MA, Dullabh P, Ahn R, Shah SV, Gao Y, Speck K, Cosgrove SE, Linder JA. Assessment of Changes in Visits and Antibiotic Prescribing During the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic. JAMA Netw Open 2022; 5:e2220512. [PMID: 35793084 PMCID: PMC9260475 DOI: 10.1001/jamanetworkopen.2022.20512] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aimed to improve antibiotic prescribing in ambulatory care practices by engaging clinicians and staff to incorporate antibiotic stewardship into practice culture, communication, and decision-making. Little is known about implementation of antibiotic stewardship in ambulatory care practices. OBJECTIVE To examine changes in visits and antibiotic prescribing during the AHRQ Safety Program. DESIGN, SETTING, AND PARTICIPANTS This cohort study evaluated a quality improvement intervention in ambulatory care throughout the US in 389 ambulatory care practices from December 1, 2019, to November 30, 2020. EXPOSURES The AHRQ Safety Program used webinars, audio presentations, educational tools, and office hours to engage stewardship leaders and clinical staff to address attitudes and cultures that challenge judicious antibiotic prescribing and incorporate best practices for the management of common infections. MAIN OUTCOMES AND MEASURES The primary outcome of the Safety Program was antibiotic prescriptions per 100 acute respiratory infection (ARI) visits. Data on total visits and ARI visits were also collected. The number of visits and prescribing rates from baseline (September 1, 2019) to completion of the program (November 30, 2020) were compared. RESULTS Of 467 practices enrolled, 389 (83%) completed the Safety Program; of these, 292 (75%) submitted complete data with 6 590 485 visits to 5483 clinicians. Participants included 82 (28%) primary care practices, 103 (35%) urgent care practices, 34 (12%) federally supported practices, 39 (13%) pediatric urgent care practices, 21 (7%) pediatric-only practices, and 14 (5%) other practice types. Visits per practice per month decreased from a mean of 1624 (95% CI, 1317-1931) at baseline to a nadir of 906 (95% CI, 702-1111) early in the COVID-19 pandemic (April 2020), and were 1797 (95% CI, 1510-2084) at the end of the program. Total antibiotic prescribing decreased from 18.2% of visits at baseline to 9.5% at completion of the program (-8.7%; 95% CI, -9.9% to -7.6%). Acute respiratory infection visits per practice per month decreased from baseline (n = 321) to a nadir of 76 early in the pandemic (May 2020) and gradually increased through completion of the program (n = 239). Antibiotic prescribing for ARIs decreased from 39.2% at baseline to 24.7% at completion of the program (-14.5%; 95% CI, -16.8% to -12.2%). CONCLUSIONS AND RELEVANCE In this study of US ambulatory practices that participated in the AHRQ Safety Program, significant reductions in the rates of overall and ARI-related antibiotic prescribing were noted, despite normalization of clinic visits by completion of the program. The forthcoming AHRQ Safety Program content may have utility in ambulatory practices across the US.
Collapse
Affiliation(s)
- Sara C. Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tania M. Caballero
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranita D. Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa A. Miller
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Roy Ahn
- NORC at the University of Chicago, Chicago, Illinois
| | | | - Yue Gao
- NORC at the University of Chicago, Chicago, Illinois
| | - Kathleen Speck
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sara E. Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey A. Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
8
|
Khadem TM, Ergen HJ, Salata HJ, Andrzejewski C, McCreary EK, Abdel Massih RC, Bariola JR. Impact of Clinical Decision Support System Implementation at a Community Hospital with an Existing Tele-Antimicrobial Stewardship Program. Open Forum Infect Dis 2022; 9:ofac235. [PMID: 35836746 PMCID: PMC9274440 DOI: 10.1093/ofid/ofac235] [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] [Received: 02/27/2022] [Accepted: 05/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background Lack of on-site antimicrobial stewardship expertise is a barrier to establishing successful programs. Tele-antimicrobial stewardship programs (TASPs) utilizing a clinical decision support system (CDSS) can address these challenges. Methods This interrupted time series study reports the impact of CDSS implementation (February 2020) within an existing TASP on antimicrobial usage in a community hospital. Segmented regression analysis was used to assess differences in antimicrobial usage from January 2018 through December 2021. Pre- and post-CDSS frequencies of intravenous vs oral antimicrobials, time to optimal therapy (TTOT), pharmacist efficiency (number of documented interventions per month), and percentage of hospitalized patients receiving antimicrobials were compared with descriptive statistics. Results Implementation of a CDSS into an existing TASP was associated with an immediate 11% reduction in antimicrobial usage (level change, P < .0001). Antimicrobial usage was already trending down by 0.25% per month (pre-CDSS slope, P < .0001) and continued to trend down at a similar rate after implementation (post-CDSS slope, P = .0129). Frequency of use of select oral agents increased from 38% to 57%. Median TTOT was 1 day faster (2.9 days pre-CDSS vs 1.9 days post-CDSS). On average, pharmacists documented 2.2-fold more interventions per month (198 vs 90) and patients received 1.03 fewer days of antimicrobials per admission post-CDSS. Conclusions Implementation of a CDSS within an established TASP at a community hospital resulted in decreased antimicrobial usage, higher rates of oral usage, faster TTOT, and improved pharmacist efficiency.
Collapse
Affiliation(s)
- Tina M. Khadem
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | | | | | | | - Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - Rima C. Abdel Massih
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| |
Collapse
|
9
|
The Current State and Future Directions of Inpatient Pediatric Antimicrobial Stewardship. Infect Dis Clin North Am 2022; 36:173-186. [DOI: 10.1016/j.idc.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
10
|
So M, Hand J, Forrest G, Pouch SM, Te H, Ardura MI, Bartash RM, Dadhania DM, Edelman J, Ince D, Jorgenson MR, Kabbani S, Lease ED, Levine D, Ohler L, Patel G, Pisano J, Spinner ML, Abbo L, Verna EC, Husain S. White paper on antimicrobial stewardship in solid organ transplant recipients. Am J Transplant 2022; 22:96-112. [PMID: 34212491 PMCID: PMC9695237 DOI: 10.1111/ajt.16743] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/17/2021] [Accepted: 06/25/2021] [Indexed: 01/25/2023]
Abstract
Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, although ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid organ transplant recipients in particular are at increased risk of infections from multidrug-resistant organisms, due to host and donor factors and immunosuppressive therapy, there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus, no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in situ may modify the risk of infection. As such, it is not feasible to have a "one-size-fits-all" style of stewardship for this patient population. The objective of this white paper is to identify opportunities, risk factors, and ASP strategies that should be assessed with solid organ transplant recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance and identification of research opportunities.
Collapse
Affiliation(s)
- Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Medical Center, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Graeme Forrest
- Department of Internal Medicine, Division of Infectious Diseases, Rush Medical College, Chicago, Illinois
| | - Stephanie M. Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Helen Te
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, Illinois
| | - Monica I. Ardura
- Department of Pediatrics, Infectious Diseases and Host Defense, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio
| | - Rachel M. Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Darshana M. Dadhania
- Department of Transplantation Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Jeffrey Edelman
- Transplant Services at UW Medical Center, Seattle, Washington
| | - Dilek Ince
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Health Care, Carver College of Medicine, Iowa City, Iowa
| | | | - Sarah Kabbani
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erika D. Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Deborah Levine
- Division of Pulmonary and Critical Care Medicine and CT Surgery, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Linda Ohler
- Transplant Institute New York University Langone Health, New York, New York
| | - Gopi Patel
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Pisano
- Antimicrobial Stewardship and Infection Control, U Chicago Medicine, Chicago, Illinois
| | | | - Lilian Abbo
- Department of Medicine, Miami Transplant Institute, Jackson Health System, University of Miami, Miller School of Medicine, Miami, Florida
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, New York
| | - Shahid Husain
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Ajmera Transplant Center, Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Woods-Hill CZ, Xie A, Lin J, Wolfe HA, Plattner AS, Malone S, Chiotos K, Szymczak JE. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlab195. [PMID: 35098126 PMCID: PMC8794647 DOI: 10.1093/jacamr/dlab195] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Corresponding author. E-mail:
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St., Baltimore, MD 21202, USA
| | - John Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Heather A. Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Alex S. Plattner
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Sara Malone
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Kathleen Chiotos
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Julia E. Szymczak
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| |
Collapse
|
12
|
O'Donnell JN, Rhodes NJ, Miglis CM, Zembower TR, Qi C, Hoff BM, Barr VO, Gilbert EM, Bolon MK, Malczynski M, Gener J, Tran C, Catovic L, Postelnick MJ, Sutton SH, Scheetz MH. Impact of early antimicrobial stewardship intervention in patients with positive blood cultures: results from a randomized comparative study: Impact of stewardship on BSI outcomes. Int J Antimicrob Agents 2021; 59:106490. [PMID: 34871745 DOI: 10.1016/j.ijantimicag.2021.106490] [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: 05/11/2021] [Revised: 09/30/2021] [Accepted: 11/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antimicrobial stewardship intervention (ASI) appears necessary to realize the full benefits of rapid diagnostic technologies in clinical practice. This study aimed to compare clinical outcomes between early ASI paired with MALDI-TOF compared to MALDI-TOF with standard of care (SOC) reporting in patients with positive blood cultures. METHODS Adult patients with positive blood cultures and organism speciation via MALDI-TOF admitted between 2/2015 and 9/2015 were randomized to ASI or SOC in a 1:1 fashion. Patients admitted for at least 48 hours following positive culture were included in analyses. ASI was defined as a clinical assessment by a stewardship team member with non-binding treatment recommendations offered to the primary team. The primary outcome was time to definitive therapy. Secondary outcomes included post-culture length of stay (LOS), time to first change in antibiotics, and in-hospital mortality. RESULTS A total of 149 patients were included in analyses (76 in the ASI group and 73 in the SOC group). ASI and SOC arms did not differ according to age, sex, comorbidities, or severity of illness. Gram-positive organisms were common in both SOC and ASI arms (74.0 vs 61.8%, p=0.11). Time-to-definitive therapy was reduced, on average, by 30.3 hours in the ASI group (71.6 vs. 41.3 hours, p=0.01). Hospital LOS following the first positive blood culture was significantly shorter in the ASI group (8.7 vs. 11.2 days, p=0.049). CONCLUSIONS ASI combined with MALDI-TOF reduced the time to definitive therapy, time to first change in antibiotics, and was associated with a shorter post-culture LOS.
Collapse
Affiliation(s)
- J Nicholas O'Donnell
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA.
| | - Nathaniel J Rhodes
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA.
| | - Cristina M Miglis
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA.
| | - Teresa R Zembower
- Department of Internal Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL, USA.
| | - Chao Qi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Brian M Hoff
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.
| | | | | | - Maureen K Bolon
- Department of Internal Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL, USA.
| | - Michael Malczynski
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Joshua Gener
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA.
| | - Chau Tran
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA.
| | - Lejla Catovic
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA.
| | | | - Sarah H Sutton
- Department of Internal Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL, USA.
| | - Marc H Scheetz
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA.
| |
Collapse
|
13
|
Leveraging implementation science to advance antibiotic stewardship practice and research. Infect Control Hosp Epidemiol 2021; 43:139-146. [PMID: 34852212 DOI: 10.1017/ice.2021.480] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
14
|
van den Bergh D, Brink A. A commitment and call to strengthen and expand qualitative research efforts to improve the impact of antimicrobial stewardship. JAC Antimicrob Resist 2021; 3:dlab151. [PMID: 34604749 PMCID: PMC8485075 DOI: 10.1093/jacamr/dlab151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Inadequate recognition of the value of qualitative research in healthcare, notably in antimicrobial stewardship (AMS), in addition to a lack of publishing space in medical journals has prompted JAC-Antimicrobial Resistance to focus on a qualitative series of AMS papers to incite interest in and support for pivotal qualitative approaches that make an indispensable contribution to our understanding of antibiotic use and how to address antimicrobial resistance. In this series, invited authors with diverse backgrounds and considerable expertise address and review intricate and varying qualitative research methods, behaviour change determinants, interventions and qualitative perspectives, with the aim of strengthening commitment and expanding qualitative initiatives to further the impact of AMS globally.
Collapse
Affiliation(s)
- Dena van den Bergh
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital University of Cape Town, Cape Town, South Africa
| | - Adrian Brink
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
15
|
Mei-Sheng Riley M, Olans R. Implementing an Antimicrobial Stewardship Program in the Intensive Care Unit by Engaging Critical Care Nurses. Crit Care Nurs Clin North Am 2021; 33:369-380. [PMID: 34742494 DOI: 10.1016/j.cnc.2021.07.001] [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] [Indexed: 11/15/2022]
Abstract
The continuing rise in the incidence of multidrug-resistant organism infections has made combating this grave threat a national imperative. One of the most potent weapons in our arsenal against such organisms is the prudent use of antibiotics. Antimicrobial stewardship (AMS) programs aim to slow the development of antimicrobial resistance through judicious, monitored use of antibiotics. Traditionally, AMS programs have included pharmacists and physicians with training in AWS, infectious disease physicians, hospital leadership, microbiologists, and infection prevention professionals. Nurses are missing from AMS programs, especially intensive care nurses. Critical care nurses provide the majority of patient care to ICU patients and monitor the progress of the patient's condition. The ICU nurse is an obvious asset to the AMS programs. ICU nurses are well-educated autonomous professionals with a unique role in coordinating with the critical care team. Critical care nurses already perform numerous nursing tasks with AWS functions. This, together with their unique perspective makes them a valuable asset that has often been overlooked. Traditionally, perceived barriers have kept ICU nurses from joining AMS teams. By removing these barriers and engaging critical care nurses in the important work of AWS, we can strengthen our AMS team and achieve optimal outcomes for our patients.
Collapse
Affiliation(s)
- May Mei-Sheng Riley
- Providence Saint Joseph Health System, 2700 Dolbeer Street, Eureka, CA 95501, USA; Stanford Health Care, 300 Pasteur Drive, Room H0105, M/C 5221, Stanford, CA 94305-5623, USA.
| | - Rita Olans
- MGH Institute of Health Professions, School of Nursing, 36 First Avenue, Boston, MA 02128, USA
| |
Collapse
|
16
|
Green SB, Stover KR, Barber K, Bouchard JL, Brown ML, Deri CR, Francis BJ, Gauthier TP, Hayes JE, Marx AH, McGee EU, Mediwala K, Musgrove RJ, Slain D, Stramel SA, Bland CM, Bookstaver PB. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020. Open Forum Infect Dis 2021; 8:ofab422. [PMID: 34557559 PMCID: PMC8454524 DOI: 10.1093/ofid/ofab422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
The number of articles related to antimicrobial stewardship published each year has increased significantly over the last decade. Keeping up with the literature, particularly the most innovative, well-designed, or applicable to one’s own practice area, can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network reviewed antimicrobial stewardship–related, peer-reviewed literature from 2020 that detailed actionable interventions. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for teaching and training, and to identify novel or optimized stewardship opportunities within one’s institution.
Collapse
Affiliation(s)
- Sarah B Green
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Katie Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Matthew L Brown
- Department of Pharmacy, University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Bailey J Francis
- Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, North Carolina, USA
| | - Timothy P Gauthier
- Baptist Health South Florida, Clinical Pharmacy Enterprise, Miami, Florida, USA
| | - Jillian E Hayes
- Department of Pharmacy AdventHealth Orlando, Orlando, Florida, USA
| | - Ashley H Marx
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Edoabasi U McGee
- Department of Pharmacy Practice, Philadelphia College of Osteopathic Medicine-Georgia Campus, School of Pharmacy, Suwanee, Georgia, USA
| | - Krutika Mediwala
- Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Rachel J Musgrove
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Douglas Slain
- Department of Clinical Pharmacy and Section of Infectious Diseases, West Virginia University, Morgantown, West Virginia, USA
| | - Stefanie A Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, Texas, USA
| | - Christopher M Bland
- Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Georgia, USA
| | - P Brandon Bookstaver
- Department of Pharmacy, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
| |
Collapse
|
17
|
Knobloch MJ, Musuuza J, Baubie K, Saban KL, Suda KJ, Safdar N. Nurse practitioners as antibiotic stewards: Examining prescribing patterns and perceptions. Am J Infect Control 2021; 49:1052-1057. [PMID: 33524451 DOI: 10.1016/j.ajic.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Advanced practice providers in the outpatient setting play a key role in antibiotic stewardship, yet little is known about how to engage these providers in stewardship activities and what factors influence their antibiotic prescribing practices. METHODS We used mixed methods to obtain data on practices and perceptions related to antibiotic prescribing by nurse practitioners (NP) and Veteran patients. We interviewed NPs working in the outpatient setting at one Veterans Affairs facility and conducted focus groups with Veterans. Emerging themes were mapped to the Systems Engineering Initiative for Patient Safety framework. We examined NP antibiotic prescribing data from 2017 to 2019. RESULTS We interviewed NPs and conducted Veteran focus groups. Nurse practitioners reported satisfaction with resources, including ready access to pharmacists and infectious disease specialists. Building patient trust was reported as essential to prescribing confidence level. Veterans indicated the need to better understand differences between viral and bacterial infections. NP prescribing patterns revealed a decline in antibiotics prescribed for upper respiratory illnesses over a 3-year period. CONCLUSION Outpatient NPs focus on educating the patient while balancing organizational access challenges. Further research is needed to determine how to include both NPs and patients when implementing outpatient antibiotic stewardship strategies. Further research is also needed to understand factors associated with the decline in nurse practitioner antibiotic prescribing observed in this study.
Collapse
|
18
|
Arieti F, Göpel S, Sibani M, Carrara E, Pezzani MD, Murri R, Mutters NT, Lòpez-Cerero L, Voss A, Cauda R, Tacconelli E. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the outpatient sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2021; 75:ii42-ii51. [PMID: 33280045 PMCID: PMC7719405 DOI: 10.1093/jac/dkaa428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The outpatient setting is a key scenario for the implementation of antimicrobial stewardship (AMS) activities, considering that overconsumption of antibiotics occurs mainly outside hospitals. This publication is the result of a joint initiative by the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks, which is aimed at formulating a set of target actions for linking surveillance data with AMS activities in the outpatient setting. Methods A scoping review of the literature was carried out in three research areas: AMS leadership and accountability; antimicrobial usage and AMS; antimicrobial resistance and AMS. Consensus on the actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine or public health, from 18 low-, middle- and high-income countries. Results Evidence was retrieved from 38 documents, and an initial 25 target actions were proposed, differentiating between essential or desirable targets according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for all targets. Further to a second review, 6 statements were re-considered and 3 were deleted, leading to a final list of 22 target actions in the form of a practical checklist. Conclusions This White Paper is a pragmatic and flexible tool to guide the development of calibrated surveillance-based AMS interventions specific to the outpatient setting, which is characterized by substantial inter- and intra-country variability in the organization of healthcare structures, maintaining a global perspective and taking into account the feasibility of the target actions in low-resource settings.
Collapse
Affiliation(s)
- Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
| | - Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Rita Murri
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Nico T Mutters
- Institute of Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Lorena Lòpez-Cerero
- Microbiology and Infectious Diseases Unit, University Hospital Virgen Macarena, Sevilla, Spain
| | - Andreas Voss
- Department of Clinical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Roberto Cauda
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
| | | |
Collapse
|
19
|
Identifying global research gaps to mitigate antimicrobial resistance: A scoping review. Am J Infect Control 2021; 49:818-824. [PMID: 33253763 DOI: 10.1016/j.ajic.2020.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Identify research gaps relevant to the global effort to combat antimicrobial resistance. METHODS Web of Science, PubMed, Scopus, and Ovid MEDLINE were searched for reviews on antimicrobial resistance published between January 1, 2015 and December 31, 2019. Recommendations for future research were identified. FINDINGS Seventy-four reviews met inclusion criteria; 300 research gaps and recommendations were identified. The largest number were from the human health sector (105; 35%) followed by environmental health (72; 23%), animal health (66; 22%), food and feed (14; 5%), and plants and crops (8; 3%); 35 (12%) involved more than one sector. The largest number of gaps concerned surveillance of resistance (68; 23%), followed by study design or methodology (52; 17%), interventions (41; 14%), risk assessment and modeling (35; 12%), ecological (26; 9%) and biochemical (28; 9%) aspects of resistance, interface between reservoirs of resistant pathogens (24; 8%), and economic (15; 5%) and awareness- and behavior-related (11; 4%) aspects of antimicrobial resistance. CONCLUSIONS Important research gaps remain in our complete understanding of antimicrobial resistance, and more research is needed about its development, transmission, and impact across the interface of human, animal, and environmental reservoirs.
Collapse
|
20
|
Szymczak J, Trautner B. Support to scale antibiotic stewardship in long-term care homes: how much is enough? BMJ Qual Saf 2021; 31:79-82. [PMID: 34059558 DOI: 10.1136/bmjqs-2021-013073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Julia Szymczak
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
21
|
Skodvin B, Høgli JU, Gravningen K, Neteland MI, Harthug S, Akselsen PE. Nationwide audit and feedback on implementation of antibiotic stewardship programmes in Norwegian hospitals. JAC Antimicrob Resist 2021; 3:dlab063. [PMID: 34223125 PMCID: PMC8210241 DOI: 10.1093/jacamr/dlab063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background Implementation of antibiotic stewardship programmes (ASPs) in hospitals is challenging and there is a knowledge gap on how to pursue this process efficiently. Objectives To evaluate whether audit and feedback (A&F) is a feasible and useful methodology to assess and support the implementation of ASPs in hospitals. Methods A multidisciplinary team performed document reviews and on-site interviews with professionals involved in the implementation of ASPs. Oral feedback on preliminary findings and areas of improvement were provided on-site, followed by feedback reports summarizing major findings and recommendations. Descriptive statistics were used to present number of hospital trusts, interviewees, professions, disciplines, workload and costs. Results All 22 hospital trusts in Norway participated in the A&F conducted October 2017 to April 2019. Altogether, 446 leaders and healthcare workers were interviewed: 110 leaders, 336 health professionals of whom 89 were antimicrobial stewardship team members. Median number of days from audits were performed till reporting were 36 (IQR 30-49). Median workload for auditors per visit was 7 days (6-8). Total costs were €133 952. Main audit findings were that ASP structures were established in most hospital trusts, but leadership commitment and implementation of interventions were often lacking. The hospital trusts received feedback on establishing governance structures, setting local targets, implementing interventions and increased involvement of nurses. Conclusions Nationwide A&F provides a unique and comprehensive insight into the implementation of ASPs in hospitals and is feasible with a reasonable amount of resources. This approach can identify targets for improved implementation of ASPs in hospitals.
Collapse
Affiliation(s)
- Brita Skodvin
- Norwegian Advisory Unit for Antibiotic Use in Hospitals, Department of Research and Development, Haukeland University Hospital, Haukelandsveien 22, 5021, Bergen, Norway
| | - June U Høgli
- Regional Centre for Infection Control, University Hospital of North Norway, 9038, Tromsø, Norway
| | - Kirsten Gravningen
- Regional Centre for Infection Control, University Hospital of North Norway, 9038, Tromsø, Norway.,Department of Antibiotic Resistance and Infection Prevention, Norwegian Institute of Public Health, 0213, Oslo, Norway
| | - Marion I Neteland
- Norwegian Advisory Unit for Antibiotic Use in Hospitals, Department of Research and Development, Haukeland University Hospital, Haukelandsveien 22, 5021, Bergen, Norway
| | - Stig Harthug
- Norwegian Advisory Unit for Antibiotic Use in Hospitals, Department of Research and Development, Haukeland University Hospital, Haukelandsveien 22, 5021, Bergen, Norway.,Department of Clinical Science, University of Bergen, Jonas Lies vei 87, 5020, Bergen, Norway
| | - Per E Akselsen
- Norwegian Advisory Unit for Antibiotic Use in Hospitals, Department of Research and Development, Haukeland University Hospital, Haukelandsveien 22, 5021, Bergen, Norway
| |
Collapse
|
22
|
Petersen MR, Cosgrove SE, Quinn TC, Patel EU, Kate Grabowski M, Tobian AAR. Prescription Antibiotic Use Among the US population 1999-2018: National Health and Nutrition Examination Surveys. Open Forum Infect Dis 2021; 8:ofab224. [PMID: 34295941 PMCID: PMC8291435 DOI: 10.1093/ofid/ofab224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/29/2021] [Indexed: 01/21/2023] Open
Abstract
Background Antibiotic resistance has been identified as a public health threat both in the United States and globally. The United States published the National Strategy for Combating Antibiotic Resistance in 2014, which included goals to reduce inappropriate outpatient antibiotic use. Methods This cross-sectional study was conducted using National Health and Nutrition Examination Surveys (NHANES) years 1999–2018. Weighted prevalence of past 30-day nontopical outpatient antibiotic use was calculated, as well as the change in prevalence from 1999–2002 to 2015–2018 and 2007–2010 to 2015–2018, both overall and for subgroups. Associations with past 30-day nontopical outpatient antibiotic use in 2015–2018 were examined using predictive margins calculated by multivariable logistic regression. Results The overall prevalence of past 30-day nontopical outpatient antibiotic use adjusted for age, sex, race/ethnicity, poverty status, time of year of the interview, and insurance status from 1999–2002 to 2015–2018 changed significantly from 4.9% (95% CI, 3.9% to 5.0%) to 3.0% (95% CI, 2.6% to 3.0%), with the largest decrease among children age 0–1 years. From 2007–2010 to 2015–2018, there was no significant change (adjusted prevalence ratio [adjPR], 1.0; 95% CI, 0.8 to 1.2). Age was significantly associated with antibiotic use, with children age 0–1 years having significantly higher antibiotic use than all other age categories >6 years. Being non-Hispanic Black was negatively associated with antibiotic use as compared with being non-Hispanic White (adjPR, 0.6; 95% CI, 0.4 to 0.8). Conclusions While there were declines in antibiotic use from 1999–2002 to 2015–2018, there were no observed declines during the last decade.
Collapse
Affiliation(s)
- Molly R Petersen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M Kate Grabowski
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
23
|
Livorsi DJ, Nair R, Dysangco A, Aylward A, Alexander B, Smith MW, Kouba S, Perencevich EN. Using Audit and Feedback to Improve Antimicrobial Prescribing in Emergency Departments: A Multicenter Quasi-Experimental Study in the Veterans Health Administration. Open Forum Infect Dis 2021; 8:ofab186. [PMID: 34113685 DOI: 10.1093/ofid/ofab186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background In this pilot trial, we evaluated whether audit-and-feedback was a feasible strategy to improve antimicrobial prescribing in emergency departments (EDs). Methods We evaluated an audit-and-feedback intervention using a quasi-experimental interrupted time-series design at 2 intervention and 2 matched-control EDs; there was a 12-month baseline, 1-month implementation, and 11-month intervention period. At intervention sites, clinicians received (1) a single, one-on-one education about antimicrobial prescribing for common infections and (2) individualized feedback on total and condition-specific (uncomplicated acute respiratory infection [ARI]) antimicrobial use with peer-to-peer comparisons at baseline and every quarter. The primary outcome was the total antimicrobial-prescribing rate for all visits and was assessed using generalized linear models. In an exploratory analysis, we measured antimicrobial use for uncomplicated ARI visits and manually reviewed charts to assess guideline-concordant management for 6 common infections. Results In the baseline and intervention periods, intervention sites had 28 016 and 23 164 visits compared to 33 077 and 28 835 at control sites. We enrolled 27 of 31 (87.1%) eligible clinicians; they acknowledged receipt of 33.3% of feedback e-mails. Intervention sites compared with control sites had no absolute reduction in their total antimicrobial rate (incidence rate ratio = 0.99; 95% confidence interval, 0.98-1.01). At intervention sites, antimicrobial use for uncomplicated ARIs decreased (68.6% to 42.4%; P < .01) and guideline-concordant management improved (52.1% to 72.5%; P < .01); these improvements were not seen at control sites. Conclusions At intervention sites, total antimicrobial use did not decrease, but an exploratory analysis showed reduced antimicrobial prescribing for viral ARIs. Future studies should identify additional targets for condition-specific feedback while exploring ways to make electronic feedback more acceptable.
Collapse
Affiliation(s)
- Daniel J Livorsi
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Rajeshwari Nair
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Andrew Dysangco
- Indiana University School of Medicine and the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Andrea Aylward
- Sioux Falls VA Health Care System, Sioux Falls, South Dakota, USA
| | - Bruce Alexander
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Matthew W Smith
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Sammantha Kouba
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eli N Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
24
|
McGough SF, MacFadden DR, Hattab MW, Mølbak K, Santillana M. Rates of increase of antibiotic resistance and ambient temperature in Europe: a cross-national analysis of 28 countries between 2000 and 2016. ACTA ACUST UNITED AC 2021; 25. [PMID: 33183408 PMCID: PMC7667635 DOI: 10.2807/1560-7917.es.2020.25.45.1900414] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The rapid increase of bacterial antibiotic resistance could soon render our most effective method to address infections obsolete. Factors influencing pathogen resistance prevalence in human populations remain poorly described, though temperature is known to contribute to mechanisms of spread. Aim To quantify the role of temperature, spatially and temporally, as a mechanistic modulator of transmission of antibiotic resistant microbes. Methods An ecologic analysis was performed on country-level antibiotic resistance prevalence in three common bacterial pathogens across 28 European countries, collectively representing over 4 million tested isolates. Associations of minimum temperature and other predictors with change in antibiotic resistance rates over 17 years (2000–2016) were evaluated with multivariable models. The effects of predictors on the antibiotic resistance rate change across geographies were quantified. Results During 2000–2016, for Escherichia coli and Klebsiella pneumoniae, European countries with 10°C warmer ambient minimum temperatures compared to others, experienced more rapid resistance increases across all antibiotic classes. Increases ranged between 0.33%/year (95% CI: 0.2 to 0.5) and 1.2%/year (95% CI: 0.4 to 1.9), even after accounting for recognised resistance drivers including antibiotic consumption and population density. For Staphylococcus aureus a decreasing relationship of −0.4%/year (95% CI: −0.7 to 0.0) was found for meticillin resistance, reflecting widespread declines in meticillin-resistant S. aureus across Europe over the study period. Conclusion We found evidence of a long-term effect of ambient minimum temperature on antibiotic resistance rate increases in Europe. Ambient temperature might considerably influence antibiotic resistance growth rates, and explain geographic differences observed in cross-sectional studies. Rising temperatures globally may hasten resistance spread, complicating mitigation efforts.
Collapse
Affiliation(s)
- Sarah F McGough
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, United States.,Computational Health Informatics Program, Boston Children's Hospital, Boston, United States
| | - Derek R MacFadden
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, United States.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mohammad W Hattab
- Wyss Institute for Biologically Inspired Engineering, Harvard Medical School, Boston, United States
| | - Kåre Mølbak
- Statens Serum Institut, Copenhagen, Denmark.,Institute of Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mauricio Santillana
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, United States.,Computational Health Informatics Program, Boston Children's Hospital, Boston, United States.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, United States
| |
Collapse
|
25
|
From 'molecules of life' to new therapeutic approaches, an evolution marked by the advent of artificial intelligence: the cases of chronic pain and neuropathic disorders. Drug Discov Today 2021; 26:1070-1075. [PMID: 33482341 DOI: 10.1016/j.drudis.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/25/2020] [Accepted: 01/12/2021] [Indexed: 11/21/2022]
Abstract
The large families of the molecules of life are at the origin of the discovery of new compounds with which to treat disease. The arrival of artificial intelligence (AI) has considerably modified the search for innovative bioactive drugs and their therapeutic applications. Conventional approaches at different organizational research levels have emerged and, thus, AI associated with gene and cell therapies could supplant conventional pharmacotherapy and facilitate the diagnosis of pathologies. Using the examples of chronic pain and neuropathic disorders, which affect a large number of patients, I illustrate here how AI could generate new therapeutic approaches, why some compounds are seen as recreational drugs and others as medicinal drugs, and why, in some countries, psychedelic drugs are considered as potential therapeutic drugs but not in others.
Collapse
|
26
|
Rapid conversion of an in-patient hospital unit to accommodate COVID-19: An interdisciplinary human factors, ethnography, and infection prevention and control approach. PLoS One 2021; 16:e0245212. [PMID: 33481807 PMCID: PMC7822252 DOI: 10.1371/journal.pone.0245212] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In response to the Coronavirus disease-19 (COVID-19) pandemic, in-patient units in hospitals around the world have altered their patient care routines and Infection Prevention and Control (IPC) practices. Our interdisciplinary team of applied Human Factors (HF), ethnography, and IPC experts assisted one Unit, normally serving general surgical and orthopedic patients, as it rapidly converted to deliver COVID-19-specific care. This paper describes the conversion experience of the Unit, and outlines broader lessons for other acute care teams faced with similar issues. METHODS We deployed walkthroughs, simulations, and ethnography to identify important safety gaps in care delivery processes on the Unit. These interventions were undertaken using interdisciplinary theories of implementation that combined systems-level HF perspectives, ethnographic approaches, and individual-level IPC perspectives. Timely recommendations were developed and delivered to Unit staff for feedback and implementation. RESULTS We describe three interventions on the Unit: 1) the de-cluttering and re-organization of personal protective equipment (PPE); 2) the reconfiguring of designated 'dirty' tray tables and supplies; and 3) the redesign of handling pathways for 'dirty' linens and laundry. Each of these interventions was implemented to varying degrees, but all contributed to discussions of safety and IPC implementation that extended beyond the Unit and into the operations of the broader hospital. CONCLUSIONS Leveraging our team's interdisciplinary expertise and blended approaches to implementation, the interventions assisted in the Unit's rapid conversion towards providing COVID-19-specific care. The deployment and implementation of the interventions highlight the potential of collaboration between HF, ethnography, and IPC experts to support frontline healthcare delivery under pandemic conditions in an effort to minimize nosocomial transmission potential in the acute healthcare setting.
Collapse
|
27
|
Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans' Health Administration. Infect Control Hosp Epidemiol 2020; 42:694-701. [PMID: 33308352 DOI: 10.1017/ice.2020.1289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
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.
Collapse
|
28
|
MRSA prevalence and hospital-level antibiotic use: A retrospective study across 122 acute-care hospitals. Infect Control Hosp Epidemiol 2020; 42:353-355. [PMID: 32938506 DOI: 10.1017/ice.2020.429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We evaluated the relationship between local MRSA prevalence rates and antibiotic use across 122 VHA hospitals in 2016. Higher hospital-level MRSA prevalence was associated with significantly higher rates of antibiotic use, even after adjusting for case mix and stewardship strategies. Benchmarking anti-MRSA antibiotic use may need to adjust for MRSA prevalence.
Collapse
|
29
|
Severe influenza/respiratory syncytial virus infections and hospital antimicrobial stewardship opportunities: impact of a 4-year surveillance including molecular diagnosis. Infect Control Hosp Epidemiol 2020; 41:1184-1189. [PMID: 32624029 DOI: 10.1017/ice.2020.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the prevalence of influenza and respiratory syncytial virus (RSV) in adults hospitalized for a respiratory infection in the winter months and to evaluate the impact of a viral diagnosis on empirical antimicrobial management (antibiotics and antivirals). DESIGN Observational cohort study. SETTING Acute-care university hospital. PATIENTS The study included 963 adult patients hospitalized over a 4-year surveillance period. METHODS Annual surveillance timelines were defined according to epidemiological criteria related to the circulation of RSV and influenza viruses in the general population. Patients were screened following a severe acute respiratory infection (SARI) case definition at the emergency department and were enrolled for molecular assay targeting influenza/RSV viruses after oral informed consent. Epidemiological and clinical data were recorded prospectively, microbiological investigations, antimicrobial management, and outcome data were reviewed retrospectively. RESULTS An influenza or RSV virus was documented in 316 of 963 patients (33%). Optimization of antimicrobial management (AM) was achieved in 162 of 265 patients (61%) with a positive viral diagnosis and no bacterial infection at admission (AM treatment not initiated, n = 111; discontinued, n = 51). In contrast, only 128 of 462 patients (28%) with negative microbiological investigations did not have AM treatment initiated (n = 116) or had such treatment discontinued (n = 12). Early, targeted antiviral treatment was prescribed in 235 of 253 patients (93%) confirmed with influenza. Epidemiological, clinical, and outcome data were similar in both groups. CONCLUSION Epidemiological surveillance associated with influenza/RSV molecular diagnosis in adults hospitalized for severe winter respiratory infections dramatically enhanced antimicrobial management.
Collapse
|
30
|
Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
Collapse
Affiliation(s)
- Fredrik Resman
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
| |
Collapse
|
31
|
Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy. Part II: Ten questions reflecting knowledge gaps and issues of controversy in the field of antimicrobial stewardship. Ther Adv Infect Dis 2020; 7:2049936120945083. [PMID: 32913648 PMCID: PMC7443983 DOI: 10.1177/2049936120945083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023] Open
Abstract
Regardless of one's opinion on antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and include aspects not only of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name but a few. This review aims to take several of these aspects and the scientific evidence from antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? and Which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. The first part, published separately, is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps; (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. This second part formulates 10 critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
Collapse
Affiliation(s)
- Fredrik Resman
- Clinical Infection Medicine, Department of
Translational Medicine, Lund University, Rut Lundskogs gata 3, plan 6, Malmö,
20502, Sweden
| |
Collapse
|