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Qureshi N, Kroger J, Zangwill KM, Joshi NS, Payton K, Mendel P. Changes in perceptions of antibiotic stewardship among neonatal intensive care unit providers over the course of a learning collaborative: a prospective, multisite, mixed-methods evaluation. J Perinatol 2024; 44:62-70. [PMID: 38001155 PMCID: PMC10783543 DOI: 10.1038/s41372-023-01823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE To assess clinician perceptions towards the value and implementation of antibiotic stewardship (AS) in neonatal intensive care units (NICU). STUDY DESIGN We performed a mixed-methods study of AS perceptions (prescribing appropriateness, importance, activity, capacity) using surveys and interviews in 30 California NICUs before and after a multicenter collaborative (Optimizing Antibiotic Use in California NICUs [OASCN]). RESULTS Pre-OASCN, 24% of respondents felt there was "a lot of" or "some" inappropriate prescribing, often driven by fear of a bad outcome or reluctance to change existing practice. Clinicians reported statistically significant increases in AS importance (71 v 79%), perceived AS activity (67 v 87%), and more openness to change after OASCN (59 v 70%). We identified other concerns that lessen AS effort. CONCLUSION OASCN increased perceived AS activity and openness to change in AS practices among NICU prescribers. Greater attention to subjective concerns should augment AS improvement.
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Affiliation(s)
- Nabeel Qureshi
- RAND Corporation, Santa Monica, CA, USA.
- Pardee RAND Graduate School, Santa Monica, CA, USA.
| | - Jack Kroger
- RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Kenneth M Zangwill
- Division of Pediatric Infectious Diseases and The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Neha S Joshi
- Stanford University, Division of Pediatric Hospital Medicine, Palo Alto, CA, USA
| | - Kurlen Payton
- Cedars-Sinai Medical Center, Department of Pediatrics, Division of Neonatology, Los Angeles, CA, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, USA
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2
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Advani SD, Claeys K. Behavioral Strategies in Diagnostic Stewardship. Infect Dis Clin North Am 2023; 37:729-747. [PMID: 37537001 DOI: 10.1016/j.idc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.
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Affiliation(s)
- Sonali D Advani
- Department of Internal Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710, USA.
| | - Kimberly Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Bork JT, Heil EL. What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research. Infect Dis Clin North Am 2023; 37:901-915. [PMID: 37586930 DOI: 10.1016/j.idc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.
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Affiliation(s)
- Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology in the Department of Medicine, University of Maryland, School of Medicine, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland, School of Pharmacy, 20 N Pine Street, Baltimore, MD 21201, USA.
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4
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Sadeq AA, Issa FA, Bakhit M, Al-Tamimi MAA, Babiker ZOE, Alshabebi RSI, Abdallah J, Nsutebo EF, Moukarzel MB, Abukhater R, Conway BR, Bond SE, Khan S, Aldeyab MA. Exploring drivers and challenges influencing antibiotic prescribing in outpatient settings and possible mitigation strategies in the United Arab Emirates: a qualitative study. JAC Antimicrob Resist 2023; 5:dlad109. [PMID: 37818393 PMCID: PMC10561535 DOI: 10.1093/jacamr/dlad109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 09/18/2023] [Indexed: 10/12/2023] Open
Abstract
Objectives Healthcare institutions implement antimicrobial stewardship (AMS) programmes to optimize the use of antibiotics. The focus is often on inpatient rather than outpatient settings. We aimed to explore perceptions of AMS stakeholders on effective interventions for appropriate antibiotic use in outpatient settings, and the role of clinical pharmacists in the AMS multidisciplinary team. Methods A qualitative semi-structured interview study using thematic analysis by two researchers independently. Participants that practice AMS programmes were recruited from healthcare facilities in the United Arab Emirates (UAE). Interviews were conducted face to face or online and transcribed verbatim. Results Four themes emerged: (i) Perceived factors leading to unnecessary or inappropriate antibiotic prescribing and their impact on patients and the community; (ii) current outpatient AMS activities and perceived barriers and facilitators for their sustainability; (iii) suggested outpatient AMS strategies to be implemented in outpatient settings; and (iv) perceived future AMS implementation barriers and suggested mitigation strategies. Conclusions Several AMS interventions, together with the presence of a clinical pharmacist, may be effective in improving antibiotic use in UAE outpatient settings. Future research should investigate the most appropriate AMS strategy considering barriers and possible mitigation strategies to ensure sustainability.
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Affiliation(s)
- Ahmed A Sadeq
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO BOX 11001, United Arab Emirates
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Farah Ahmed Issa
- Department of Medicine, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO BOX 11001, United Arab Emirates
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD 4226, Australia
| | - Maitha Abdul-Aziz Al-Tamimi
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO BOX 11001, United Arab Emirates
| | - Zahir Osman Eltahir Babiker
- Division of Infectious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO Box 11001, United Arab Emirates
| | - Raghad S Ismail Alshabebi
- Department of Intensive Care, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO BOX 11001, United Arab Emirates
| | - Jehad Abdallah
- Infectious Disease Department, Al Rahba Hospital, Abu Dhabi Health Services (SEHA), Abu Dhabi, United Arab Emirates
| | - Emmanuel Fru Nsutebo
- Division of Infectious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO Box 11001, United Arab Emirates
| | - Marleine B Moukarzel
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO BOX 11001, United Arab Emirates
| | - Rawan Abukhater
- Department of Medicine, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, PO BOX 11001, United Arab Emirates
| | - Barbara R Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Institute of Skin Integrity and Infection Prevention and Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Stuart E Bond
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Department of Pharmacy, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK
| | - Sidra Khan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Mamoon A Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
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5
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Heil EL, Justo JA, Bork JT. Improving the Efficiency of Antimicrobial Stewardship Action in Acute Care Facilities. Open Forum Infect Dis 2023; 10:ofad412. [PMID: 37674632 PMCID: PMC10478156 DOI: 10.1093/ofid/ofad412] [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: 06/01/2023] [Accepted: 07/28/2023] [Indexed: 09/08/2023] Open
Abstract
Inpatient antimicrobial stewardship (AS) programs are quality improvement programs tasked with improving antibiotic practices by augmenting frontline providers' antibiotic prescription. Prospective audit and feedback (PAF) and preauthorization (PRA) are essential activities in the hospital that can be resource intensive for AS teams. Improving efficiency in AS activities is needed when there are limited resources or when programs are looking to expand tasks beyond PAF and PRA, such as broad education or guideline development. Guidance on the creation and maintenance of alerts for the purpose of PAF reviews, modifications of antibiotic restrictions for PRA polices, and overall initiative prioritization strategies are reviewed. In addition, daily prioritization tools, such as the tiered approach, scoring systems, and regression modeling, are available for stewards to prioritize their daily workflow. Using these tools and guidance, AS programs can be productive and impactful in the face of resource limitation or competing priorities in the hospital.
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Affiliation(s)
- Emily L Heil
- Department of Practice, Sciences and Health Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, South Carolina, USA
| | - Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology, Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland, USA
- Veterans Affairs (VA) Maryland Health Care System, Baltimore, Maryland, USA
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6
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Lake JG, Durkin MJ, Polgreen PM, Beekmann SE, Hersh AL, Newland JG. Pediatric infectious disease physician perceptions of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1155-1158. [PMID: 35938450 PMCID: PMC10369220 DOI: 10.1017/ice.2022.183] [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: 02/02/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/07/2022]
Abstract
Pediatric antimicrobial stewardship programs (ASPs) improve antibiotic use for hospitalized children. Prescriber surveys indicate acceptance of ASPs, but data on infectious diseases (ID) physician opinions of ASPs are lacking. We conducted a survey of pediatric ID physicians, ASP and non-ASP, and their perceptions of ASP practices and outcomes.
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Affiliation(s)
- Jason G. Lake
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael J. Durkin
- Division of Adult Infectious Diseases, Department of Internal Medicine, Washington University in St Louis, St Louis, Missouri
| | - Philip M. Polgreen
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Susan E. Beekmann
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jason G. Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
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7
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Exploring unintended consequences of adult antimicrobial stewardship programs: An Emerging Infections Network survey. Infect Control Hosp Epidemiol 2022; 44:791-793. [DOI: 10.1017/ice.2022.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
We performed a survey of adult infectious diseases (ID) physicians to explore unintended consequences of antimicrobial stewardship programs (ASP). ID physicians worried about disagreement with colleagues, provider autonomy, and remote recommendations. Non-ASP ID physicians expressed more concern regarding ASPs focus on costs, provider efficiency, and unintended consequences of ASP guidance.
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8
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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]
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Monsees EA, Burns AN, Lee BR, Wirtz A, El Feghaly RE. Considerations for implementation: Pediatric outpatient antimicrobial stewardship program. Am J Infect Control 2021; 49:1543-1546. [PMID: 34358544 DOI: 10.1016/j.ajic.2021.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 11/15/2022]
Abstract
It is encouraging that most acute care centers have formal antimicrobial stewardship (AS) programs; though, most antibiotic use occurs in outpatient settings where access to infectious diseases specialists are limited. Stewardship programs often target dichotomous populations (adult or pediatric), but most children receive care in nonacademic, community outpatient settings. We propose 3 considerations for adult providers and infection preventionists seeking to incorporate outpatient AS elements and implement quality improvement initiatives that optimize pediatric care.
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Affiliation(s)
- Elizabeth A Monsees
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Alaina N Burns
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Brian R Lee
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Ann Wirtz
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Rana E El Feghaly
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO.
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10
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Probst V, Islamovic F, Mirza A. Antimicrobial stewardship program in pediatric medicine. Pediatr Investig 2021; 5:229-238. [PMID: 34589677 PMCID: PMC8458720 DOI: 10.1002/ped4.12292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/21/2021] [Indexed: 12/31/2022] Open
Abstract
The rising threats from antimicrobial resistance due to inappropriate utilization of antimicrobial agents in health care including the pediatric population has been a topic of concern at the global level for the last several decades. The antimicrobial stewardship program (ASP) is a multidisciplinary institutional initiative focusing primarily on the improvement of antimicrobial prescribing practices and limiting inappropriate use. ASPs play an important role in the implementation of healthcare strategies in pediatrics worldwide to reduce antimicrobial resistance. Many published reports demonstrate how adapted ASPs in pediatrics result in improvement of unnecessary antimicrobial utilization, decreasing drug resistance and treatment failure, minimization of adverse clinical outcomes, decreasing healthcare costs and hospital length of stay, and optimization of diagnostic strategies. However, some barriers in pediatric ASP still exist. This narrative review describes core elements of ASP, the impact of implemented ASPs on pediatric healthcare, and challenges of pediatric ASP as seen by the authors.
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Affiliation(s)
- Varvara Probst
- University of FloridaCollege of MedicineJacksonvilleFLUSA
| | | | - Ayesha Mirza
- University of FloridaCollege of MedicineJacksonvilleFLUSA
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11
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Rowe TA, Brown T, Doctor JN, Linder JA, Persell SD. Examining primary care physician rationale for not following geriatric choosing wisely recommendations. BMC FAMILY PRACTICE 2021; 22:95. [PMID: 33992080 PMCID: PMC8126116 DOI: 10.1186/s12875-021-01440-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/22/2021] [Indexed: 01/22/2023]
Abstract
Background The objective is to understand why physicians order tests or treatments in older adults contrary to published recommendations. Methods Participants: Physicians above the median for ≥ 1 measures of overuse representing 3 Choosing Wisely topics. Measurements: Participants evaluated decisions in a semi-structured interview regarding: 1) Screening men aged ≥ 76 with prostate specific antigen 2) Ordering urine studies in women ≥ 65 without symptoms 3) Overtreating adults aged ≥ 75 with insulin or oral hypoglycemic medications. Two investigators independently coded transcripts using qualitative analysis. Results Nineteen interviews were conducted across the three topics resulting in four themes. First, physicians were aware and knowledgeable of guidelines. Second, perceived patient preference towards overuse influenced physician action even when physicians felt strongly that testing was not indicated. Third, physicians overestimated benefits of a test and underemphasized potential harms. Fourth, physicians were resistant to change when patients appeared to be doing well. Conclusions Though physicians expressed awareness to avoid overuse, deference to patient preferences and the tendency to distort the chance of benefit over harm influenced decisions to order testing. Approaches for decreasing unnecessary testing must account for perceived patient preferences, make the potential harms of overtesting salient, and address clinical inertia among patients who appear to be doing well. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01440-w.
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Affiliation(s)
- Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA.,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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12
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MacBrayne CE, Williams MC, Levek C, Child J, Pearce K, Birkholz M, Todd JK, Hurst AL, Parker SK. Sustainability of Handshake Stewardship: Extending a Hand Is Effective Years Later. Clin Infect Dis 2021; 70:2325-2332. [PMID: 31584641 DOI: 10.1093/cid/ciz650] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Children's Hospital Colorado created a unique method of antimicrobial stewardship, called handshake stewardship, that effectively decreased hospital anti-infective use and costs in its pilot year (2013). Handshake stewardship is distinguished by: (1) the lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to supporting providers. We sought to reevaluate the outcomes of the program after 5 years of experience, totaling 8 years of data. METHODS We retrospectively measured anti-infective (antibiotic, antiviral, antifungal) use hospital-wide by unit and by drug for an 8-year period spanning October 2010 to October 2018. Aggregated monthly use was measured in days of therapy per thousand patient days (DOT/1000 PD). The percentage of children admitted ever receiving an anti-infective was also measured, as well as severity-adjusted mortality, readmissions, and lengths of stay. RESULTS Hospital-wide mean anti-infective use significantly decreased, from 891 (95% confidence interval [CI] 859-923) in the pre-implementation phase to 655 (95% CI 637-694) DOT/1000 PD in post-implementation Year 5; in a segmented regression time series analysis, this was a rate of -2.6 DOT/1000 PD (95% CI -4.8 to -0.4). This is largely attributable to decreased antibacterial use, from 704 (95% CI 686-722) to 544 (95% CI 525 -562) DOT/1000 PD. The percentage of children ever receiving an anti-infective during admission likewise declined, from 65% to 52% (95% CI 49-54). There were no detrimental effects on severity adjusted mortality, readmissions, or lengths of stay. CONCLUSIONS The handshake method is an effective and sustainable approach to stewardship.
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Affiliation(s)
- Christine E MacBrayne
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Manon C Williams
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Claire Levek
- Department of Pediatrics and Child Health Research Biostatistical Core, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jason Child
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Kelly Pearce
- Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Meghan Birkholz
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - James K Todd
- Department of Pediatrics, Section of Pediatric Infectious Diseases and Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amanda L Hurst
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Sarah K Parker
- Department of Pediatrics, Section of Pediatric Infectious Diseases and Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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13
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Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e11. [PMID: 36168511 PMCID: PMC9495538 DOI: 10.1017/ash.2021.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
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.
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Urinary tract infection stewardship: A urinary antibiogram and electronic medical record alert nudging narrower-spectrum antibiotics for urinary tract infections. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e8. [PMID: 36168507 PMCID: PMC9495411 DOI: 10.1017/ash.2021.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 12/02/2022]
Abstract
An antimicrobial stewardship intervention consisting of a urinary antibiogram and an electronic health record best-practice advisory promoted narrower-spectrum antibiotics for uncomplicated urinary tract infections in hospitalized patients. Over 20 months, the intervention significantly reduced ceftriaxone orders by 48% (P < .001) and increased cefazolin use 19 times from baseline (P < .001).
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15
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Interventions to optimize antimicrobial stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e46. [PMID: 36168471 PMCID: PMC9495515 DOI: 10.1017/ash.2021.210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/27/2021] [Indexed: 12/14/2022]
Abstract
Abstract
Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.
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Petty LA, Vaughn VM, Flanders SA, Patel T, Malani AN, Ratz D, Kaye KS, Pogue JM, Dumkow LE, Thyagarajan R, Hsaiky LM, Osterholzer D, Kronick SL, McLaughlin E, Gandhi TN. Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department. Open Forum Infect Dis 2020; 7:ofaa537. [PMID: 33324723 PMCID: PMC7724506 DOI: 10.1093/ofid/ofaa537] [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: 09/18/2020] [Accepted: 10/29/2020] [Indexed: 02/04/2023] Open
Abstract
Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018-February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.
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Affiliation(s)
- Lindsay A Petty
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Internal Medicine, Division of General Internal Medicine, University of Utah Medical School, Salt Lake City, Utah, USA
| | - Scott A Flanders
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Twisha Patel
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - David Ratz
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa E Dumkow
- Department of Pharmacy, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | | | - Lama M Hsaiky
- Department of Pharmacy, Beaumont Hospital, Dearborn, Michigan, USA
| | - Danielle Osterholzer
- Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan, USA
| | - Steven L Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth McLaughlin
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
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17
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Klatte JM. Pediatric Antimicrobial Stewardship Programs: Current Perspectives. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2020; 11:245-255. [PMID: 32801990 PMCID: PMC7383043 DOI: 10.2147/phmt.s224774] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022]
Abstract
With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.
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Affiliation(s)
- J Michael Klatte
- Division of Infectious Disease, Dayton Children's Hospital, Dayton, OH, USA
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18
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Affiliation(s)
- Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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19
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Rynkiewich K. Finding "What's Wrong With Us": Antibiotic Prescribing Practice Among Physicians in the United States. FRONTIERS IN SOCIOLOGY 2020; 5:5. [PMID: 33869414 PMCID: PMC8022448 DOI: 10.3389/fsoc.2020.00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/27/2020] [Indexed: 05/15/2023]
Abstract
Antibiotic stewardship-or the responsible use of antibiotics-has been touted as a solution to the problem of antibiotic resistance. Antibiotic stewardship in medical institutions attempts to change the antibiotic prescribing "behaviors" and "habits" of physicians. Interventions abound targeting "problem prescribers," or those physicians whose practice is out of line with physician peers. Thus, the locus of decision-making in antibiotic prescribing is thought to be the found with the individual physician. Based on 18 months of participant observation and in-depth interviewing of antibiotic-prescribing physicians at two medical institutions in the United States, this paper will question notions of antibiotic stewardship that center on individual "behaviors" and "habits." Many physicians have taken to heart a reductionist approach in studies of antibiotic prescribing, including several physicians I encountered during research who enthusiastically located the benefit of my research in the ability to identify "what's wrong with us." In this paper, I use two representative ethnographic case studies to argue that antibiotic stewardship interventions aimed at identifying and correcting "bad" physician practice limit the possibilities of understanding the social dynamics of the institution. Through an analysis of everyday encounters in the hospital setting, I show how decision-making in antibiotic prescribing can more productively be located between and among institutions, physicians, patient charts, and other hospital-based staff members (e.g., pharmacists, nurses). By demonstrating that antibiotic prescribing is a collective practice occurring through engagement with social and material surroundings, I argue that we can better account for the weighted ways in which social action and relations unfold over time.
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