Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship

Launch of Board Certification in Pediatric Infectious Diseases in Japan

To cultivate specialists in pediatric infectious diseases (ID) in Japan, the Japanese Society for Pediatric Infectious Diseases initiated board certification for pediatric ID in 2017. Previously, in 2014, we had formed a committee for board certification in pediatric ID and discussed the fundamentals of the board certification system, including the goals, requirements for designated training institutions, provisional certification of pediatric ID specialists and eligibility for and content of the board certification examination. After approval from 31 programs, the pediatric ID programs started in 2017 with 8 fellows in 7 programs. The first 6 graduates received board certification in 2020. To date, 61 pediatricians have been board certified as pediatric ID specialists. In parallel, we introduced board certification for pediatricians who work mainly in primary care settings and have a special interest in pediatric ID. This system has certified 338 pediatricians. During and after the development of the programs, we achieved substantial progress in highlighting the pivotal role of pediatric ID specialists, including the establishment and maintenance of antimicrobial stewardship programs, pediatric ID consultations and introduction of viral diagnosis by polymerase chain reaction at institutions. However, several issues need to be addressed, including the establishment of independent pediatric ID departments in institutions, payment of consultation fees, program site visits, maintenance of certification and cultivation of physician-scientists. These challenges will be the focus of future efforts.

Empowered Hospitalised Patients are involved in Shared Decision Making on Antibiotic Therapy: A Quantitative Analysis

BACKGROUND

Half of hospitalised patients receive antibiotics, but they are rarely involved in shared decision making (SDM) on antibiotic therapy. We sought to understand the association between patient empowerment and their involvement in SDM on antibiotic therapy.

METHODS

From March 2021 to April 2022, we conducted a cross-sectional survey on hospitalised patients receiving antibiotic therapy for ≥1 day in a 1600-bed adult general hospital in Singapore. The questionnaire included 7 items (5-point Likert scale) on involvement in SDM from SDM-Q-9 (Kriston,2012) and 10 items (4-point Likert scale) on patient empowerment from HCEQ-10 (Gagnon,2006). A multivariable logistic regression model was constructed to assess for independent associations between the three constructs of patient empowerment and involvement in SDM on antibiotic therapy.

RESULTS

Of 636 hospitalised patients, mean age was 57.6 (SD 15.5) years, 61% were males and 37% had tertiary-level education. The majority (90%) were aware that they were on antibiotic therapy, but only 11% of them knew the name of the antibiotic given. After adjusting for age, gender, ethnicity, educational level, and duration of hospital stay, patients with a high-level of involvement in decisions (Adjusted odds ratio[AOR] 3.63, 95% CI 2.19-6.01), interactions with healthcare professionals (AOR 1.77, 95% CI 1.03-3.02), and degree of control over their hospital care (AOR 1.90, 95% CI 1.15-3.12) were more likely to have a high-level of involvement in SDM on antibiotic therapy.

CONCLUSIONS

Empowering hospitalised patients with involvement in decisions, interactions with healthcare professionals, and control of their hospital care can increase their participation in SDM on antibiotic therapy in hospitals.

European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for Antimicrobial Stewardship in Emergency Departments (endorsed by European Association of Hospital Pharmacists)

SCOPE

This ESCMID guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are: 1) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? 2) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? 3) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? 4) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing?

METHODS

An expert panel was convened by ESCMID and the guideline chair. The panel selected in consensus the four most relevant AMS topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes as well as stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively.

RECOMMENDATIONS

The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e., withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very-low- and low-certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.

Influence of the COVID-19 pandemic on the defined daily dose of antimicrobials in patients requiring elective and emergency surgical procedures

BACKGROUND

The COVID-19 pandemic has resulted in great incertitude and overwhelming changes in healthcare that have had a direct impact on antibiotic prescription. However, the influence of this pandemic on antibiotic consumption in patients undergoing surgery has not yet been analysed. The goal of this study was to analyse antimicrobial consumption and prescription in the same period of 2019 (pre-COVID-19), 2020 (beginning of the COVID-19 pandemic) and 2021 (established COVID-19) according to the DDD system in surgical patients at a tertiary-level hospital.

METHODS

A prospectively maintained database was analysed. All patients who underwent elective or emergency gastrointestinal surgery during the same period (2019, 2020 and 2021) were included. Those who received at least 1 of the 10 most frequently prescribed antimicrobials during those periods were analysed.

RESULTS

A total of 2975 patients were included in this study. In 2020, the number of procedures performed decreased significantly (653 versus 1154 and 1168 in 2020 versus 2019 and 2021, respectively; P = 0.005). Of all patients who underwent surgery during these periods, 45.08% received at least one of the antimicrobials studied (45.8% in 2020 versus 22.9% and 22.97% in 2019 and 2021, respectively; P = 0.005). Of these, 22.97% of the patients received a combination of these antimicrobials, with ceftriaxone/metronidazole being the most frequent. Hepato-Pancreato-Biliary and Liver Transplant, Emergency Surgery and Colorectal Surgery units had higher antibiotic consumption.

CONCLUSIONS

The COVID-19 pandemic has resulted in a significant decrease in surgical activity and higher post-operative antimicrobial prescription compared with previous and subsequent years.

Extended period of selection for antimicrobial resistance due to recirculation of persistent antimicrobials in broilers

OBJECTIVES

Antimicrobials can select for antimicrobial-resistant bacteria. After treatment the active compound is excreted through urine and faeces. As some antimicrobials are chemically stable, recirculation of subinhibitory concentrations of antimicrobials may occur due to coprophagic behaviour of animals such as chickens.

METHODS

The persistence of three antimicrobials over time and their potential effects on antimicrobial resistance were determined in four groups of broilers. Groups were left untreated (control) or were treated with amoxicillin (unstable), doxycycline or enrofloxacin (stable). Antimicrobials were extracted from the faecal samples and were measured by LC-MS/MS. We determined the resistome genotypically using shotgun metagenomics and phenotypically by using Escherichia coli as indicator microorganism.

RESULTS

Up to 37 days after treatment, doxycycline and enrofloxacin had concentrations in faeces equal to or higher than the minimal selective concentration (MSC), in contrast to the amoxicillin treatment. The amoxicillin treatment showed a significant difference (P ≤ 0.01 and P ≤ 0.0001) in the genotypic resistance only directly after treatment. On the other hand, the doxycycline treatment showed approximately 52% increase in phenotypic resistance and a significant difference (P ≤ 0.05 and P ≤ 0.0001) in genotypic resistance throughout the trial. Furthermore, enrofloxacin treatment resulted in a complete non-WT E. coli population but the quantity of resistance genes was similar to the control group, likely because resistance is mediated by point mutations.

CONCLUSIONS

Based on our findings, we suggest that persistence of antimicrobials should be taken into consideration in the assessment of priority classification of antimicrobials in livestock.

Investigating the Variability among Indicators for Quantifying Antimicrobial Use in the Intensive Care Units: Analysis of Real-world Evidence

This study investigated variability among four indicators for quantifying antimicrobial use in intensive care units (ICUs): defined daily doses (DDD), prescribed daily doses (PDD), duration of therapy (DOT), and length of therapy (LOT) and recommended the most clinically relevant approach. Retrospective data from patients who had received at least one antimicrobial was analyzed. Patients whose records were incomplete or expired were excluded. Duration of therapy (24433/1000 PDs) and LOTs (12832/1000 PDs) underestimated the overall consumption of antimicrobials compared with DDD of 28391/1000 PDs. Whereas PDD (46699/1000 PDs) overestimated it. Comparison analysis detected % differences of 13.94, 23.92, and 54.80% between DDD and DOT, DDD and PDD, and DDD and LOT, indicators respectively. Linear regression revealed stronger (r 2 = 0.86), moderate (r 2 = 0.50), and moderate (r 2 =0.60) correlation between DDD and DOT, DDD and PDD and DDD and LOT indicators respectively. According to findings, combining DOT and DDD is a more practical method to quantify antimicrobial consumption in hospital ICUs.

How to cite this article

Deshwal PR, Tiwari P. Investigating the Variability among Indicators for Quantifying Antimicrobial Use in the Intensive Care Units: Analysis of Real-world Evidence. Indian J Crit Care Med 2024;28(7):662-676.

Effective Treatment of Lymphogranuloma Venereum With a 7-Day Course of Doxycycline

BACKGROUND

Lymphogranuloma venereum (LGV) remains endemic in the United Kingdom, primarily among gay, bisexual or other men who have sex with men (GBMSM). Current treatment guidelines recommend 21 days of doxycycline, but recent evidence suggests shorter antibiotic duration is as effective. We evaluated clinical outcomes in a cohort with LGV treated with 7 days of doxycycline.

METHODS

We reviewed case notes of all LGV cases at a South London sexual health service between November 2016 and September 2022, treated with only 7 days of doxycycline and anonymized data were collected from electronic patient records.

RESULTS

Fifty-two individuals with detected LGV-specific DNA were treated with 7 days of doxycycline 100 mg twice daily. All were GBMSM, median age of 35 years (range, 21-64 years), 21 (40%) were living with HIV, and 18 (35%) had concomitant sexually transmitted infections. Thirty-four (65%) were asymptomatic, whereas 18 (35%) reported symptoms: 7 (13%) urethral, 11 (21%) anorectal, and 2 (4%) other symptoms. Twenty-two (42%) were prescribed additional antimicrobials; however, none were active against Chlamydia trachomatis . All 52 underwent follow-up testing (range, 4-481 days). Chlamydia trachomatis was detected in one individual, but negative for LGV-specific DNA, and so considered to be a reinfection. All other cases were C. trachomatis -negative, indicating successful LGV eradication.

CONCLUSIONS

Our data support the approach of offering a 7-day doxycycline course routinely for asymptomatic or clinically mild C. trachomatis infections, and contacts of LGV infection, regardless of their LGV status. This may simplify patient management, reduce cost, and improve antimicrobial stewardship.

Postdiscontinuation Antibiotic Exposure in Hospitalized Infants at Risk for Late-onset Sepsis in the Neonatal Intensive Care Unit

BACKGROUND

In the neonatal intensive care unit, infants are at risk for late-onset sepsis. When blood cultures are negative, antibiotic stewardship efforts encourage stopping antibiotics, yet the duration of therapeutic exposure after the last dose is unknown.

METHODS

This retrospective cohort study of simulated antibiotic exposures used published population pharmacokinetic models within drug-specific neonatal intensive care unit cohorts of preterm and term infants, postnatal age 7-60 days and exposed to cefepime, piperacillin-tazobactam or tobramycin. Monte Carlo simulations (NONMEM 7.3) were used to predict steady-state exposures after a 72-hour antibiotic course per Neofax dosing. Exposure was assessed relative to drug-specific minimum inhibitory concentration (MIC) targets between 1 and 16 mcg/mL for Pseudomonas and Enterobacteriaceae species. Postdiscontinuation antibiotic exposure (PDAE) was defined as the time from the last dose to when antibiotic concentration decreased below a specific MIC.

RESULTS

Piperacillin-tazobactam, cefepime and tobramycin cohorts included infants with median gestation age 29, 32 and 32 weeks and postnatal age 17, 19 and 15 days, respectively. The mean PDAE was 19-68 hours, depending on the specific antibiotic/MIC combination. PDAE was longer for infants <28 days old and preterm (vs. term) infants. Cefepime exhibited the longest mean PDAE of 68 hours for Enterobacteriaceae MIC 1. Piperacillin mean PDAE was 25 hours for Enterobacteriaceae MIC 8. Tobramycin had a short mean PDAE of 19 hours.

CONCLUSIONS

Piperacillin and cefepime exposures remained therapeutic long after the expected 8- to 12-hour dosing interval. PDAE is an important consideration for antibiotic stewardship among hospitalized infants, particularly premature infants and those within 1 month postbirth.

Assessment of challenges and opportunities in antibiotic stewardship program implementation in Northwest Ethiopia

Background

Indiscriminate use of antibiotics leads to antibiotic resistance (AMR) and results in mortality, morbidity, and financial burden. Antibiotic stewardship programs (ASPs) with education can resolve a number of barriers recognized in the implementation of successful ASPs. The aim of this study was to assess health professionals' perceptions and status of ASPs in hospitals in 2022.

Methods

A cross-sectional study was conducted from September 1, 2022 to October 30, 2022. A total of 181 health professionals were included, and a self-administered questionnaire was used to collect data. The status of hospitals was assessed using a checklist. The data were analyzed using SPSS version 23, and descriptive statistics and Chi-square tests (X2) at a P-value of <0.05 were used.

Results

Of the 181 respondents, 163 (90.1 %), and 161 (89.0 %) believed that AMR is a significant problem in Ethiopia and globally, respectively. Easy access to antibiotics 155 (85.6 %), and inappropriate use 137 (75.7 %) were perceived as key contributors to AMR. Antibiotics were believed to be prescribed/dispensed without laboratory results 86 (47.5 %), and antibiotic susceptibility patterns were not considered to guide empiric therapy 81 (44.8 %). ASP was believed to reduce the duration of hospital stays and associated costs 137 (75.7 %), and improve the quality of patient care 133 (73.5 %), whereas 151 (83.4 %), 143 (79 %), and 142 (78.5 %) suggested education, institutional guidelines, and prospective audits with feedback interventions to combat AMR in their hospitals, respectively. There were significant differences in perception among professionals based on professional category and attempts by hospitals to implement ASPs. Although ASPs were not functioning according to standard, there have been attempts to implement it in three hospitals. The issue of ASP had never been heard in general hospitals. Currently, it is feasible to implement ASPs in four hospitals.

Conclusion

The status of ASP in hospitals was very poor. Despite a lack of prior knowledge on ASPs, most respondents do have a positive perception of AMR and the implementation of ASPs. Pharmacist-led prospective audits and feedback with education and institutional guidelines for empiric antibiotic use can be better implemented in hospitals. Involvement of representatives from infection prevention and control, and collaboration among hospitals in ASP implementation will help establish a strong ASP in the area.

The Trend of Antibiotic Consumption After the COVID-19 Pandemic: Approach to Future Outbreaks

Background

Earlier reports suggested high rates of antibiotic utilization among COVID-19 patients despite the lack of direct evidence of their activity against viral pathogens. Different trends in antibiotic consumption during 2020 compared to 2019 have been reported.

Purpose

The objective of this study is to assess the impact of COVID-19 pandemic on antibiotic consumption in the presence of active Antibiotic Stewardship Program.

Methods

This study represented a five years assessment of the consumption of the commonly prescribed antibiotics measured as DDDs/100-Bed Days. We analyzed the data by using nonparametric Friedman and Friedman tests to compare the antibiotic consumption before and during the three subsequent waves of COVID-19.

Results

Antibiotic consumption through the DDDs/100-BD has shown reduction in the median of antibiotics consumption of most antibiotics during the period of COVID-19 as compared to the pre-COVID-19 period, which was significant for meropenem and ciprofloxacin, except colomycin that slightly increased. Significant reduction in the consumption of imipenem and meropenem during the second and third waves as compared to the pre-COVID period. Throughout the years, significant reductions were observed between 2018 and 2019 (p=<.001), 2018 and 2020 (p=0.008), and 2018 and 2022 (p=0.002).

Conclusion

The reduction in antibiotic consumption is attributed to the strong influence if the ASP and the reluctance of people to visit hospitals during the COVID-19 pandemic. Other related COVID-19 precautions such as physical distance, good hand hygiene, facemasks, that resulted in the prevention of secondary bacterial infections have contributed to the reduction in antibiotic utilization during the pandemic.

Impact of Urine Culture Reflex Policy Implementation in a Large County Hospital Inpatient Rehabilitation Unit-A Pilot Study

OBJECTIVE

To promote antimicrobial stewardship, many institutions have implemented a policy of reflexing to a urine culture based on a positive urinalysis result. The rehabilitation patient population, including individuals with brain and spinal cord injuries, may have atypical presentations of urinary tract infections. The study objective is to determine the effects of implementing a urine culture reflex policy in this specific patient population.

DESIGN

In an inpatient rehabilitation unit, 348 urinalyses were analyzed from August 2019 to June 2021. Urinalysis with greater than or equal to 10 white blood cells per high power field was automatically reflexed to a urine culture in this prospective study. Primary outcome was return to acute care related to urinary tract infection. Secondary outcomes included adherence to reflex protocol, antibiotic utilization and appropriateness, adverse outcomes related to antibiotic use, and reduction in urine cultures processed and the associated reduction in healthcare costs.

RESULTS

There was no statistically significant difference before and after intervention related to the primary outcome. Urine cultures processed were reduced by 58% after intervention.

CONCLUSIONS

Urine culture reflex policy is likely an effective intervention to reduce the frequency of urine cultures without significantly affecting the need to transfer patients from inpatient rehabilitation back to the acute care setting.

Challenges of antimicrobial stewardship among older adults

Older adults hospitalized in internal medicine wards or long-term care facilities (LTCF) are progressively increasing. Older adults with multimorbidity are more susceptible to infections, as well as to more vulnerable to adverse effects (and interactions) of antibiotics, resulting in a need for effective and safer strategies for antimicrobial stewardship (ASM), both in hospitalization wards and long-term care facilities. Studies on antimicrobial stewardship in older patients are scarce and guidelines are required. Given the peculiarities of the optimization of antimicrobial prescription in individual older adults for common infections, tactics to overcome barriers need an update. The use of rapid diagnosis tests, biomarkers, de-escalation and switching from intravenous to oral/subcutaneous therapy strategies are examples of successful AMS interventions. AMS interventions are associated with reduced side effects, lower mortality, shorter hospital stays, and reduced costs. The proposed AMS framework in LTCF should focus on five domains: strategic vision, team, interventions, patient-centred care and awareness. Internists can partner with geriatrists, pharmacists and infectious disease specialists to address barriers and to improve patient care.

Pharmacist roles in antimicrobial stewardship: a qualitative study from India, South Africa and the United Kingdom

Objective

To explore pharmacist roles in antimicrobial stewardship (AMS) in India, South Africa (SA), United Kingdom (UK) and the factors that contribute to their participation in the programme in these countries.

Methods

Data were collected between April 2019 and March 2022 through semi-structured interviews with key AMS stakeholders from India (Kerala); SA (Western Cape province) and the UK (England). Interviews were conducted face to face or via Zoom and Skype platforms, audio recordings were transcribed verbatim and thematically analysed using a grounded theory approach aided by NVivo 12 software.

Results

We interviewed 38 key AMS stakeholders (pharmacists and doctors). India and the UK have dedicated AMS pharmacists (Doctor of Pharmacy and Master of Pharmacy graduates with opportunities for additional post-graduate qualifications respectively). Pharmacists in the UK lead AMS programmes, while in India, predominantly in the private sector, pharmacists drive AMS in collaboration with clinicians. In SA, pharmacists (Bachelor of Pharmacy graduates) participate in AMS out of their own commitment in addition to their pharmacy responsibilities. Private sector pharmacists drive AMS while public sector pharmacists participate in clinician-led AMS programmes. Current pharmacy curricula do not provide adequate training in AMS, and this limitation shapes pharmacist roles and acceptance in AMS among clinicians in India and SA. Support of mentors (doctors/senior pharmacists) and self-motivated learning are key factors for effective pharmacist involvement in AMS.

Conclusions

A contextually developed, standardized and accessible AMS training programme along with pharmacy curricula modification to include AMS, may facilitate prominent pharmacist roles in AMS.

Antibiotic management programme in a tertiary intensive care unit: effects of a carbapenem-restricted period on clinical and laboratory parameters and costs of infections

BACKGROUND

Carbapenems are antibiotics used for serious infections. The consumption of carbapenems has increased worldwide due to increasing microbial resistance.

AIM

To investigate the effects of a carbapenem-restricted antimicrobial stewardship programme (ASP) on changes in the resistance profiles of infectious agents, the amount of antibiotics used, length of stay in the intensive care unit (ICU), mortality, and costs.

METHODS

Patients hospitalized in ICU between July 1st, 2020 and May 1st, 2021 were divided into two periods: the carbapenem-non-restricted period (CNRP); and the carbapenem-restricted period (CRP) in which alternative antibiotics to carbapenems were preferred during infection. The defined daily dose (DDD) per 100 patient-day methodology was used to calculate the antibiotic consumption.

FINDINGS

Of the 572 patients included in the study, 62.2% were male, and mean age was 70.5 years. In the blood culture the most frequently Gram-negative agent was Acinetobacter baumannii (25%). A. baumannii bloodstream infections with multidrug-resistant and extensively drug resistant micro-organisms were significantly different between the two periods (CNRP: 95.6% (N = 22), CRP: 66.6% (N = 8); P = 0.04). There was a gradual decrease in the incidence density and rate of nosocomial infection (P = 0.06), and a significant decrease in meropenem consumption between the two periods (CNRP vs CRP: 21.19 vs 6.37 DDD per 100 patient-days respectively; P = 0.007). ASP yielded US$8,600 of antibiotic cost savings and a total of 14% patient cost savings (P < 0.05) per patient.

CONCLUSION

Combining an effective ASP with a comprehensive infection control programme may mitigate the emergence of antimicrobial-resistant bacteria.

Impact of COVID-19 on antimicrobial stewardship activities in Italy: a region-wide assessment

BACKGROUND

In the region of Piedmont, in Northern Italy, formal monitoring of antimicrobial stewardship (AMS) programs has been in place since 2012. The objective of our study was to provide an updated assessment of AMS programs operating in our region, and to assess the impact of the COVID-19 pandemic on stewardship activities.

METHODS

A retrospective observational study was conducted to investigate AMS programs implemented in acute-care trusts participating in a broader healthcare-associated infections and antimicrobial resistance (AMR) prevention and control program, promoted by the regional health department. Within this program, structure, process, and outcome indicators of AMS programs were investigated, using a previously developed scoring system. Differences between scores prior to (2019) and during the pandemic (2021) were assessed. Linear regression was used to assess whether the 5-year trends (2017-2021) in outcome measures in relation to structure and process scores were statistically significant. Compound annual growth rates (CAGR) for each outcome were calculated to illustrate changes in outcome rates over time.

RESULTS

All public trusts in the Region (20) and a small number of private institutions (3) provided data for this study. A modest, non-significant improvement was found for 2021 structure, process, and total scores compared to respective 2019 scores. A significant improvement was found concerning the definition of a formal mission statement, whereas significantly less trusts included monitoring adherence to antimicrobial policy or treatment guidelines in their programs. Overall consumption of antibiotics for systemic use saw an increase in 2021, with 2021 recording the highest median overall consumption compared to all previous years considered in this study. Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) rates decreased over the 5-year period. Significant downwards trends in MRSA rates were identified for high-outlier structure and process groups.

CONCLUSIONS

Results of this study suggest AMS programs in Piedmont were not set back following the pandemic. This outcome was possible thanks to well-established programs, coordinated within a regional framework. Continued efforts should be dedicated to supporting AMS programs and contrasting AMR, even when the focus is shifted towards other public health emergencies.

Antibiotic appropriateness at outpatient settings in Ethiopia: the need for an antibiotic stewardship programme

Background

Antibiotics are drugs of natural or synthetic origin used to treat various infections. The practice of excessive and inappropriate antibiotics use is the main global cause of bacterial resistance, which is one of the most serious global public health threats. It is estimated that about 50% of global antibiotic prescriptions are inappropriate. This study assesses the prevalence and pattern of inappropriate prescriptions of antibiotics amongst ambulatory care visits in Ethiopia.

Methods

A facility-based, cross-sectional study with a quantitative approach was conducted amongst randomly selected prescriptions issued for outpatients from May to June 2022 at Debre Markos Specialized Comprehensive Hospital, Northwest Ethiopia. Descriptive statistics, such as frequencies and percentages, were computed. For group comparisons, χ2 and independent sample t-tests were computed. The statistical significance of the association was considered at p<0.05.

Results

A total of 2640 antibiotics were prescribed for patients in the outpatient setting with various bacterial infections via 911 prescriptions, of which 49.5% were non-compliant with the national treatment guideline. Guideline non-compliant prescriptions increased remarkably amongst patients in the outpatient setting diagnosed with community-acquired pneumonia (38.8% versus 30.1%; p=0.006) and peptic ulcer disease (14.9% versus 9%; p=0.006). Moreover, inappropriate prescription was significantly higher amongst patients taking amoxicillin/clavulanic acid (33.2% versus 48.2%; p<0.001) and cephalexin (17.8% versus 24.3%; p=0.016).

Conclusion

Large proportions of antibiotic prescriptions for outpatients were non-compliant with the national treatment guideline, suggesting that prescribers need to give special attention to outpatients whilst ordering antibiotics such as amoxicillin/clavulanic acid and cephalexin. Antibiotic stewardship efforts to optimize outpatient antibiotic prescriptions and reduce the use of potentially inappropriate antibiotics are needed in Ethiopia.

Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections

BACKGROUND

Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months.

METHODS

We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures.

RESULTS

Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions.

CONCLUSIONS

We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.

Blood culture algorithm implementation in emergency department patients as a diagnostic stewardship intervention

OBJECTIVE

Blood cultures (BCx) are important for selecting appropriate antibiotic treatment. Ordering BCx for conditions with a low probability of bacteremia has limited utility, thus improved guidance for ordering BCx is needed. Inpatient studies have implemented BCx algorithms, but no studies examine the intervention in an Emergency Department (ED) setting.

METHODS

We performed a quasi-experimental pre and postintervention study from January 12, 2020, to October 31, 2023, at a single academic adult ED and implemented a BCx algorithm. The primary outcome was the blood culture event rates (BCE per 100 ED admissions) pre and postintervention. Secondary outcomes included adverse event rates (30-day ED and hospital readmission and antibiotic days of therapy). Seven ED physicians and APP reviewed BCx for appropriateness, with monthly feedback provided to ED leadership and physicians.

RESULTS

After the BCx algorithm implementation, the BCE rate decreased from 12.17 BCE/100 ED admissions to 10.50 BCE/100 ED admissions. Of the 3,478 reviewed BCE, we adjudicated 2,153 BCE (62%) as appropriate, 653 (19%) as inappropriate, and 672 (19%) as uncertain. Adverse safety events were not statistically different pre and postintervention.

CONCLUSIONS

Implementation of an ED BCx algorithm demonstrated a reduction in BCE, without increased adverse safety events. Future studies should compare outcomes of BCx algorithm implementation in a community hospital ED without intensive chart review.

Principles and practices of antimicrobial stewardship programs in Korea

This review addresses the escalating challenge posed by antibiotic resistance, highlighting its profound impact on global public health, including increased mortality rates and healthcare expenditures. The review focuses on the need to adopt the One Health approach to effectively manage antibiotic usage across human, animal, and environmental domains. Antimicrobial stewardship programs (ASPs) are considered as comprehensive strategies that encompass both core and supplementary initiatives aimed at enhancing prudent antibiotic use. The 2021 "Guidelines on Implementing ASP in Korea" introduced such strategies, with a strong emphasis on fostering multidisciplinary and collaborative efforts. Furthermore, the "Core Elements for Implementing ASPs in Korean General Hospitals," established in 2022, provide a structured framework for ASPs, delineating leadership responsibilities, the composition of interdisciplinary ASP teams, a range of interventions, and continuous monitoring and reporting mechanisms. In addition, this review examines patient-centric campaigns such as "Speak Up, Get Smart" and emphasizes the pivotal role of a multidisciplinary approach and international cooperation in addressing the multifaceted challenges associated with antibiotic resistance.

Optimizing Antimicrobial Stewardship in the Emergency Department

Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.

Current state of education, training and practices in antimicrobial stewardship among pharmacy students: A cross-sectional survey from Kerala, India

PURPOSE

Pharmacists are recognised in guidelines from across the globe as key stakeholders in antimicrobial stewardship (AMS) initiatives. The current study aims to assess the current practices and level of training and education in relation to AMS among pharmacy students from Kerala, India.

METHODS

A cross-sectional web-based survey was developed and disseminated among doctor of pharmacy 5th year students and interns from selected pharmacy colleges across Kerala through key informants. Descriptive statistics were used to analyse the responses.

RESULTS

The response rate was 34.8% (157/450). Whilst the majority of respondents (89.8%, 141/157) recalled being taught about antimicrobial resistance (AMR) as part of the pharmacy curricula, 84.7% (133/157) believed they didn't have sufficient knowledge about AMR. Most of the respondents (64.9%, 102/157) had not received any AMS training. Clinical posting in AMS was the preferred mode of training suggested by most respondents. Respondents who audited antimicrobials as part of their clinical postings (77.9%, 88/113) reported their main responsibility was review of patient records for assessing the appropriateness of antimicrobials (68.2%, 60/88). Inappropriate selection of antimicrobials was the most common error identified by respondents (38.1%, 43/113) and the key method of communicating their recommendation was informing the prescriber in person (46%, 52/113).

CONCLUSION

Whilst pharmacy students are reviewing antimicrobial prescriptions as part of their clinical postings, their education and training in AMR and AMS remain low. The inclusion of practical clinical training for pharmacy students as part of their curricula can be a cost-effective way to promote AMS initiatives.

Using Implementation Mapping to develop an intervention program to support veterinarians' adherence to the guideline on Streptococcus suis clinical practice in weaned pigs

Streptococcus suis (S. suis) infections in weaned pigs are common and responsible for a high consumption of antimicrobials, and their presence is assumed to be multi-factorial. A specific evidence-based veterinary guideline to support the control of S. suis in weaned pigs was developed for veterinary practitioners in the Netherlands in 2014. Adherence to the S. suis clinical practice guideline helps veterinary practitioners to prevent and control the disease in a systematical approach and thereby improve antimicrobial stewardship and contribute to the prevention of antimicrobial resistance in animals and humans. The impact of such a clinical practice guideline on (animal) disease management depends not only on its content, but also largely on the extent to which practitioners adhere to the clinical guideline in practice. When the S. suis guideline was published, no specific activities were undertaken to support veterinarians' uptake and implementation, thereby contributing to suboptimal adherence in clinical practice. As the S. suis guideline was comprehensively written by veterinary experts following an evidence-based approach, our aim was not to judge the (scientific) quality of the guideline but to study the possibility to improve the currently low adherence of this guideline in veterinary practice. This paper describes the systematic development, using Implementation Mapping, of a theory-based intervention program to support swine veterinarians' adherence to the S. suis guideline. The knowledge, skills, beliefs about capabilities, and beliefs about consequences domains are addressed in the program, which includes seven evidence-based methods (modelling, tailoring, feedback, discussion, persuasive communication, active learning, and self-monitoring) for use in program activities such as a peer-learning meeting and an e-learning module. The intervention program has been developed for practicing swine veterinarians, lasts eight months, and is evaluated through a stepped-wedge design. The Implementation Mapping approach ensured that all relevant adopters and implementers were involved, and that outcomes, determinants (influencing factors), and objectives were systematically discussed.

Gut resident Escherichia coli profile predicts the eighteen-month probability and antimicrobial susceptibility of urinary tract infections

Background

Community-acquired UTI is the most common bacterial infection managed in general medical practice that can lead to life-threatening outcomes. While UTIs are primarily caused by Escherichia coli colonizing the patient's gut, it is unclear whether the gut resident E. coli profiles can predict the person's risks for UTI and optimal antimicrobial treatments. Thus, we conducted an eighteen-month long community-based observational study of fecal E. coli colonization and UTI in women aged 50 years and above.

Methods and Findings

We enrolled a total of 1,804 women distributed among age groups 50-59 yo (437 participants), 60-69 yo (632), 70-79 yo (532), and above 80 yo (203), lacking antibiotic prescriptions for at least one year. The provided fecal samples were plated for the presence of E. coli and other enterobacteria resistant to trimethoprim/sulfamethoxazole (TMP/STX), ciprofloxacin (CIP) and 3rd generation cephalosporins (3GC). E. coli was also characterized as belonging to the pandemic multi-drug resistant clonal groups ST131 (subclone H30) and ST1193. Following sample collection, the women were monitored for 18 months for occurrence of UTI.E. coli was cultured from 90.8% fecal samples, with 24.1% containing bacteria resistant to TMP/STX, 19.4% to CIP, and 7.9% to 3GC. In 62.5% samples, only all-susceptible E. coli were present. Overall, there were no age-related differences in resistance prevalence. However, while the total E. coli H30 and ST1193 carriage rates were similar (4.3% and 4.2%, respectively), there was a notable increase of H30 carriage with age (P = .001), while carriage decreased with age for ST1193 (P = .057).Within 18 months, 184 women (10.2%) experienced at least one episode of UTI - 10.9% among the gut E. coli carriers and 3.0% among the non-carriers (P=.0013). The UTI risk among carriers of E. coli H30 but not ST1193 was significantly above average (24.3%, P = .0004). The UTI probability increased with age, occurring in 6.4% of 50-59 yo and 19.7% of 80+ yo (P<.001), with the latter group being especially at high risk for UTI, if they were colonized by E. coli H30 (40.0%, P<.001).E. coli was identified in 88.1% of urine samples, with 16.1% resistant to TMP/STX, 16.1% to CIP, 4.2% to 3GC and 73.1% to none of the antibiotics. Among tested urinary E. coli resistant to antibiotics, 86.1% matched the resistance profile of E. coli in the fecal samples, with the clonotyping and whole genome sequencing confirming the matching strains' identity. Positive predictive value (PPV) of using gut resistance profiles to predict UTI pathogens' susceptibility to TMP/STX, CIP, 3GC and all three antibiotics were 98.4%, 98.3%, 96.6% and 95.3%, respectively. Corresponding negative predictive values (NPV) were 63.0%, 54.8%, 44.4% and 75.8%, respectively. The AUC ROC curve values for the accuracy of fecal diagnostic testing for the prediction of UTI resistance ranged .86-.89. The fecal test-guided drug-bug mismatch rate for empirical (pre-culture) prescription of TMP-SXT or CIP is reduced to ≤2% in 89.6% of patients and 94.8% of patients with an optional 3GC prescription.

Conclusion

The resistance profile and clonal identity of gut colonizing E. coli, along with the carrier's age, can inform personalized prediction of a patients' UTI risk and the UTI pathogen's antibiotic susceptibility within an 18-month period.

Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study

OBJECTIVE

To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.

DESIGN

Multi-centre observational cohort study using data from 2009 to 2018 clinical records.

SETTING

Canadian children's hospitals (7) and community hospitals (3).

PATIENTS

Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections.

INTERVENTIONS

Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation.

MAIN OUTCOME MEASURES

Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates.

RESULTS

Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018.

CONCLUSIONS

Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.

Antibiotic Stewardship in Surgical Departments

Antimicrobial resistance (AMR) has emerged as one of the leading public health threats of the 21st century. New evidence underscores its significance in patients' morbidity and mortality, length of stay, as well as healthcare costs. Globally, the factors that contribute to antimicrobial resistance include social and economic determinants, healthcare governance, and environmental interactions with impact on humans, plants, and animals. Antimicrobial stewardship (AS) programs have historically overlooked surgical teams as they considered them more difficult to engage. This review aims to summarize the evolution and significance of AS in surgical wards, including the surgical intensive care unit (SICU) and the role of diagnostic stewardship (DS). The contribution of AS team members is presented. The new diagnostic modalities and the new technologies including artificial intelligence (AI) are also reviewed.

Rethinking Perioperative Antibiotic Prophylaxis for Low-Risk Head and Neck Procedures

OBJECTIVE

For true clean-contaminated head and neck procedures, the literature supports ≤24 hours of perioperative antibiotics. However, there are certain otolaryngology procedures with low surgical site infection (SSI) risk for which there is negligible benefit from antibiotic prophylaxis. The objective of this evaluation was to describe antibiotic use and adherence to evidence-based institutional guidelines in low-risk head and neck procedures.

METHODS

This was a single-center, retrospective cohort study of patients undergoing low-risk clean-contaminated head and neck procedures wherein antibiotic prophylaxis was not indicated, based on evidence-based institutional guidelines.

RESULTS

Among the 291 included patients, perioperative antibiotics were unnecessarily administered in 29% of patients. Among patients who received antibiotics, 76% received preoperative antibiotics and 41% received postoperative antibiotics, for a median duration of 7 days. There were no significant differences in SSIs, mortality, and length of stay for those receiving perioperative antibiotics versus those not receiving perioperative antibiotics.

CONCLUSION

These data highlight the need for antibiotic stewardship interventions and partnerships between antibiotic stewardship teams and surgical services.

Plasma levels of neurogenic inflammation related neuropeptides in pediatric patients with community-acquired pneumonia and their potential diagnostic value in distinguishing viral and bacterial pneumonia

Neurogenic inflammation is involved in the development and progression of respiratory inflammatory diseases. However, its role in community-acquired pneumonia (CAP) remains unclear. We therefore aimed to investigate plasma levels of neurogenic inflammation-related neuropeptides, calcitonin gene-related peptide (CGRP), substance P (SP), vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY), and procalcitonin (PCT) in pediatric patients with CAP and to assess their diagnostic value in viral and bacterial/mixed pneumonia. A total of 124 pediatric patients with CAP (1 month-18 years old) and 56 healthy children of similar ages were prospectively enrolled. The patients were classified as viral (n = 99) and bacterial/mixed (n = 25) pneumonia. Plasma levels of the peptides were quantified by ELISA. ROC analysis was performed to evaluate possible diagnostic value of the peptides. While plasma levels of CGRP, VIP and PCT were significantly higher in patients with CAP than in the control group, respectively, NPY levels were significantly lower. Moreover, plasma levels of all neuropeptides and PCT were significantly higher in bacterial pneumonia patients compared to viral pneumonia patients. ROC analysis revealed that CGRP, SP and NPY had a diagnostic value in distinguishing viral and bacterial/mixed pneumonia.

CONCLUSIONS

Our findings suggest that these neuropeptides may be implicated in pediatric CAP. CGRP, SP and NPY together may be a promising candidate in distinguishing viral and bacterial/mixed pneumonia, however, for this, further studies are needed.

WHAT IS KNOWN

• Neurogenic inflammation contributes to the development and progression of respiratory inflammatory diseases such as chronic obstructive pulmonary disease and bronchial asthma.

WHAT IS NEW

• Plasma levels of neurogenic inflammation related neuropeptides calcitonin gene-related peptide, substance P, vasoactive intestinal peptide and neuropeptide Y are changed in pediatric community-acquired pneumonia. Calcitonin gene-related peptide, substance P and neuropeptide Y are promising candidates in distinguishing viral and bacterial/mixed pneumonia.

Relationship between Antibiotic Consumption and Resistance: A Systematic Review

Background

Unreserved use of antibiotics exerted selective pressure on susceptible bacteria, resulting in the survival of resistant strains. Despite this, the relationship between antibiotic resistance (ABR) and antibiotic consumption (ABC) is rarely studied. This systematic review aims to review the relationship between ABC and ABR from 2016 to 2022.

Methods

Articles published over 7 years (2016-2022) were searched from December 23 to 31, 2022. The search strategy was developed by using keywords for ABC and ABR. From 3367 articles, 58 eligible articles were included in the final review.

Results

The pooled ABC was 948017.9 DPDs and 4108.6 DIDs where over 70% of antibiotics were from the Watch and Reserve category based on the WHO AWaRe classification. The average pooled prevalence of ABR was 38.4%. Enterococcus faecium (59.4%), A. baumannii (52.6%), and P. aeruginosa (48.6%) were the most common antibiotic-resistant bacteria. Cephalosporins (76.8%), penicillin (58.3%), and aminoglycosides (52%) were commonly involved antibiotics in ABR. The positive correlation between ABR and consumption accounted for 311 (81%). The correlation between ABR P. aeruginosa and ABC accounted for 87 (22.7%), followed by 78 (20.3%) and 77 (20.1%) for ABR E. coli and K. pneumoniae with ABCs, respectively. Consumption of carbapenems and fluoroquinolones was most commonly correlated with resistance rates of P. aeruginosa, K. pneumoniae, E. coli, and A. baumannii.

Conclusion

There is a positive correlation between ABC and the rate of ABR. The review also revealed a cross-resistance between the consumption of different antibiotics and ABR. Optimizing antibiotic therapy and reducing unnecessary ABC will prevent the emergence and spread of ABR. Thus, advocating the implementation of stewardship programs plays a pivotal role in containing ABR.

Provider Perceptions of Antibiotic Initiation Strategies for Hospital-Acquired Pneumonia

Background: The practice of rapidly initiating antibiotic therapy for patients with suspected infection has recently been criticized yet remains commonplace. Provider comfort level has been an understudied aspect of this practice. Hypothesis: We hypothesized that there would be no significant differences in provider comfort level between the two treatment groups. Methods: We prospectively surveyed critical care intensivists who provided care for patients enrolled in the Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter cluster-randomized crossover trial that evaluated an immediate antibiotic initiation protocol compared with a protocol of specimen-initiated antibiotic initiation in ventilated patients with suspected new-onset pneumonia. At the end of each enrollment arm, physicians at each center were surveyed regarding their overall comfort level with the recently completed treatment arm, and perception of adherence. Both a paired and unpaired analysis was performed. Results: We collected 51 survey responses from 31 unique participants. Providers perceived a higher rate of adherence to the immediate initiation arm than the specimen-initiated arm (Always Adherent: 37.5% vs. 11.1%; p = 0.045). Providers were less comfortable waiting for objective evidence of infection in the specimen-initiated arm than with starting antibiotic agents immediately (Very Comfortable: 83.3% vs. 40.7%; p = 0.004). For the smaller paired analysis, there was no longer a difference in comfort level. Conclusions: There may be differences in provider comfort levels and perceptions of adherence when considering two different antibiotic initiation strategies for suspected pneumonia in ventilated patients. These findings should be considered when planning future studies.

Global-PPS targets for antimicrobial stewardship in paediatric patients at hospitals in Sanandaj, Western Iran, compared with Southeast Asian and European hospitals

OBJECTIVES

Point prevalence surveys (PPS) provide valuable data on patterns of hospital antimicrobial administration. To identify quality improvement indicators, we evaluated antimicrobial prescribing patterns in children and neonates admitted to three referral centres in Sanandaj, Western Iran, and compared these with Southeast Asian and European paediatric benchmark data.

METHODS

The standardised Global-PPS was performed to assess antimicrobial use in Southeast Asia, including Sanandaj and European hospitals, in 2019.

RESULTS

Of the 4118, 2915, and 443 paediatric patients enrolled in Southeast Asian, European and Sanandaj hospitals, 2342 (56.9%), 833 (28.6%) and 332 (74.9%), respectively, received at least one antimicrobial in 2019. The most administered antibiotics in neonates were ampicillin in Southeast Asia (30.3%) and Sanandaj (41.5%, often in combination with cefotaxime (29.0%)), compared with amoxicillin in Europe (20.0%). In children, ceftriaxone was most prescribed in Sanandaj (62.4%) and Southeast Asia (20.5%) as opposed to amoxicillin (11.8%) in Europe. Twice as many Watch antibiotics (83.0%) were prescribed on paediatric wards in Sanandaj compared with European paediatric wards (41.1%). All antimicrobials in Sanandaj hospitals were prescribed empirically, and prolonged surgical prophylaxis was common (75.5%).

CONCLUSION

The high prevalence of antibiotic prescribing, high empirical therapies, and poor outcomes for antibiotic quality indicators strongly suggest the urgent need for an antibiotic stewardship program in Sanandaj hospitals, where improved diagnostic laboratory capacity and reconsideration of training may be good targets for intervention in their hospitals.

Implementation and Perceived Effectiveness of Prospective Audit and Feedback and Preauthorization by US Pediatric Antimicrobial Stewardship Programs

BACKGROUND

Antimicrobial stewardship programs (ASPs) promote optimal antimicrobial use to prevent resistance, improve outcomes, and reduce costs. We explored how pediatric ASPs enact prospective audit and feedback (PAF) and preauthorization and characterized programs' perceptions of how these choices affected attainment of stewardship goals.

METHODS

We conducted focus groups with US pediatric ASP practitioners, organized by predominant strategy: PAF, preauthorization, or a hybrid. We asked open-ended questions about organization, staffing, and operation of these strategies, as well as rationales for and perceived advantages and disadvantages of these choices. We used applied thematic analysis to analyze transcripts, organizing coded text into themes and categories. We formulated a conceptual model for how the design and performance of PAF and preauthorization affect stewardship goals and stewards' work experiences.

RESULTS

Eighteen physicians and 14 pharmacists from 24 hospitals participated in five focus groups. Stewards described myriad advantages and limitations of PAF and preauthorization that support or detract from stewardship goals. For example, PAF uncovered institutional trends in antibiotic use and fostered relationship building but was time-consuming. Preauthorization efficiently reduced broad-spectrum antimicrobial use, yet offered limited educational opportunities. How these strategies facilitated or impeded appropriate antimicrobial use in turn affected stewards' professional satisfaction, creating a feedback loop that could reinforced positive or negative outcomes.

CONCLUSIONS

ASPs reported differing emphasis on and implementation of PAF and preauthorization. Each strategy entailed contrasting benefits and trade-offs for steward satisfaction and perceived efficacy, suggesting that a hybrid approach could enable ASPs to maximize strengths of each to mitigate drawbacks of the other.

Patterns and predictors of positive multiplex polymerase chain reaction respiratory panel among patients with acute respiratory infections in a single center in Lebanon

BACKGROUND

Infectious agents associated with community-acquired acute respiratory infections (ARIs) remain understudied in Lebanon. We aim to assess the microbiological profiles of ARIs by employing polymerase chain reaction (PCR) and identifying predictors of positive PCR results among patients admitted for ARI.

METHODS AND RESULTS

We conducted a retrospective single-center study at the American University of Beirut Medical Center, including all respiratory PCR panels performed on pediatric (< 18) and adult (≥ 18) patients presenting with an ARI from January 2015 to March 2018, prior to the onset of the COVID-19 pandemic. We aimed to identify the epidemiological patterns of ARIs and the factors associated with positive PCRs in both adult and pediatric patients. Among 281 respiratory PCRs, 168 (59.7%) were positive for at least one pathogen, with 54.1% positive PCR for viruses, 7.8% for bacteria species, and 3.9% with virus-bacteria codetection. Almost 60% of the patients received antibiotics prior to PCR testing. PCR panels yielded more positive results in pediatric patients than in adults (P = 0.005). Bacterial detection was more common in adults compared to pediatrics (P < 0.001). The most common organism recovered in the entire population was Human Rhinovirus (RhV) (18.5%). Patients with pleural effusion on chest CT were less likely to have a positive PCR (95% Cl: 0.22-0.99). On multivariate analysis, pediatric age group (P < 0.001), stem cell transplant (P = 0.006), fever (P = 0.03) and UTRI symptoms (P = 0.004) were all predictive of a positive viral PCR.

CONCLUSION

Understanding the local epidemiology of ARI is crucial for proper antimicrobial stewardship. The identification of factors associated with positive respiratory PCR enhances our understanding of clinical characteristics and potential predictors of viral detection in our population.

Early de-escalation of antibiotic therapy in hospitalized cellular therapy adult patients with febrile neutropenia

Febrile neutropenia (FN) is an oncologic emergency frequently encountered in hematopoietic cell transplant (HCT) and chimeric antigen receptor (CAR) T-cell therapy patients, which requires immediate initiation of broad-spectrum antibiotics. Data regarding antibiotic de-escalation (DE) in neutropenic patients are limited, and guideline recommendations vary. A clinical protocol for antibiotic DE of broad-spectrum agents was implemented if patients were afebrile after 72 hours and had no clinical evidence of infection. The primary endpoint was the difference in the number of antibiotic therapy days between the pre-and post-DE protocol implementation group. Secondary endpoints included rates of subsequent bacteremia during index hospitalization, 30-day mortality, and hospital length of stay. Retrospective chart reviews were conducted to assess outcomes for patients who received allogeneic HCT, autologous HCT, or CAR T-cell therapy under the antibiotic de-escalation protocol (post-DE) compared to those who did not (pre-DE). The pre-DE group underwent HCT/CAR T-cell from February 2018 through September 2018 (n=64), and the post-DE group from February 2019 through September 2019 (n=67). The median duration of antibiotics was significantly lower in the post-DE group (6 days; range 3-60 days) compared to the pre-DE group (8 days; range 3-31 days) (p=0.034). There were no differences in any secondary endpoints. We conclude that antibiotic DE in neutropenic HCT or CAR T-cell therapy patients treated with broad-spectrum antibiotics for at least three days who are afebrile and without documented infection appears to be a safe and effective practice. Adopting it significantly reduces the number of days of antibiotics without compromising patient outcomes.

Cross-sectional evaluation of a large-scale antimicrobial stewardship trial in Australian companion animal practices

BACKGROUND

Antimicrobial stewardship programmes (ASPs) are critically important for improving the appropriate use of antimicrobial agents in veterinary practice.

METHODS

One of three ASPs was implemented in 135 Australian general veterinary practices in 2018-2020. The ASP interventions and the perceived impact they had on antimicrobial prescribing were assessed by the veterinarians working in these veterinary practices. An online survey was distributed to all 520 veterinarians working in the trial practices and 267 responses were analysed.

RESULTS

Most veterinarians (174/267, 65%) thought they had an ASP at their clinic and most respondents who said that they were aware that they had an ASP at their clinic indicated that they had changed the way they prescribed antimicrobials because of the trial (125/170, 74%). Antimicrobial prescribing guidelines, the traffic light system for indicating antimicrobial importance, delayed prescribing and antimicrobial stewardship champions were reported to have had the biggest impact.

LIMITATIONS

All practices in the trial belong to a single corporate group, which may impact the external validity of these results when applied to general small animal practice.

CONCLUSION

Antimicrobial stewardship has a positive impact on antimicrobial prescribing in veterinary medicine and future interventions should focus on the implementation of the effective interventions identified in this study.

Understanding clinical implementation coordinators' experiences in deploying evidence-based interventions

PURPOSE

The fluoroquinolone restriction for the prevention of Clostridioides difficile infection (FIRST) trial is a multisite clinical study in which sites carry out a preauthorization process via electronic health record-based best-practice alert (BPA) to optimize the use of fluoroquinolone antibiotics in acute care settings. Our research team worked closely with clinical implementation coordinators to facilitate the dissemination and implementation of this evidence-based intervention. Clinical implementation coordinators within the antibiotic stewardship team (AST) played a pivotal role in the implementation process; however, considerable research is needed to further understand their role. In this study, we aimed to (1) describe the roles and responsibilities of clinical implementation coordinators within ASTs and (2) identify facilitators and barriers coordinators experienced within the implementation process.

METHODS

We conducted a directed content analysis of semistructured interviews, implementation diaries, and check-in meetings utilizing the conceptual framework of middle managers' roles in innovation implementation in healthcare from Urquhart et al.

RESULTS

Clinical implementation coordinators performed a variety of roles vital to the implementation's success, including gathering and compiling information for BPA design, preparing staff, organizing meetings, connecting relevant stakeholders, evaluating clinical efficacy, and participating in the innovation as clinicians. Coordinators identified organizational staffing models and COVID-19 interruptions as the main barriers. Facilitators included AST empowerment, positive relationships with staff and oversight/governance committees, and using diverse implementation strategies.

CONCLUSION

When implementing healthcare innovations, clinical implementation coordinators facilitated the implementation process through their roles and responsibilities and acted as strategic partners in improving the adoption and sustainability of a fluoroquinolone preauthorization protocol.

Identifying a competency improvement strategy for infection prevention and control professionals: A rapid systematic review and cluster analysis

Remarkable progress has been made in infection prevention and control (IPC) in many countries, but some gaps emerged in the context of the coronavirus disease 2019 (COVID-19) pandemic. Core capabilities such as standard clinical precautions and tracing the source of infection were the focus of IPC in medical institutions during the pandemic. Therefore, the core competences of IPC professionals during the pandemic, and how these contributed to successful prevention and control of the epidemic, should be studied. To investigate, using a systematic review and cluster analysis, fundamental improvements in the competences of infection control and prevention professionals that may be emphasized in light of the COVID-19 pandemic. We searched the PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, and CBM databases for original articles exploring core competencies of IPC professionals during the COVID-19 pandemic (from January 1, 2020 to February 7, 2023). Weiciyun software was used for data extraction and the Donohue formula was followed to distinguish high-frequency technical terms. Cluster analysis was performed using the within-group linkage method and squared Euclidean distance as the metric to determine the priority competencies for development. We identified 46 studies with 29 high-frequency technical terms. The most common term was "infection prevention and control training" (184 times, 17.3%), followed by "hand hygiene" (172 times, 16.2%). "Infection prevention and control in clinical practice" was the most-reported core competency (367 times, 34.5%), followed by "microbiology and surveillance" (292 times, 27.5%). Cluster analysis showed two key areas of competence: Category 1 (program management and leadership, patient safety and occupational health, education and microbiology and surveillance) and Category 2 (IPC in clinical practice). During the COVID-19 pandemic, IPC program management and leadership, microbiology and surveillance, education, patient safety, and occupational health were the most important focus of development and should be given due consideration by IPC professionals.

Pharmacist insights into antimicrobial stewardship: A social marketing approach

BACKGROUND

Antimicrobial resistance is a worldwide public health problem. Antimicrobial stewardship programs (ASPs) optimize antimicrobial use within hospitals. The social marketing framework has been used in analyzing systems and devising best practices.

OBJECTIVE

(s): To use the social marketing framework to explore pharmacist experiences and perceptions of structural, behavioral and interventional strategies that support ASPs.

METHODS

A qualitative approach utilizing semi-structured individual interviews was utilized. A purposive sample of hospital pharmacists was invited to participate. An interview guide was constructed to describe participant experience and perceptions regarding ASPs in their institutions based on elements of social marketing: Behavioral goals; Customer Insight; Segmentation and Targeting; Competition; Exchange; and Marketing and Interventional mix. Interviews were recorded digitally and transcribed verbatim. Thematic analysis was conducted using deductive methods. A combination of case-based and code-based approaches allowed individual and holistic analyses respectively. Codes were collated into themes and subthemes.

RESULTS

Saturation of themes occurred with 25 interviews from 17 hospitals. ASP metrics included: consumption of antibiotics using days of therapy and defined daily dose, rates of C. difficile and multidrug resistant organisms, resistance patterns, and provider adherence to the ASP. Active stewardship tools such as preauthorization, and prospective feedback/audit were preferred over passive tools such as order sets and automatic stop orders. A physician champion and a clinical pharmacist with infectious disease training were core elements in the multidisciplinary team. Despite certain areas being considered key for stewardship, participants emphasized a hospital-wide approach including outpatient departments; discharge stewardship emerged as a primary theme. Leadership supported ASPs with finances, rapid and novel diagnostics, Clinical Decision Support Systems, mobile technology, and continuous staff training.

CONCLUSIONS

The social marketing framework has been used to explore pharmacist perceptions that inform successful qualities including metrics, restriction methods, personnel, benefits, barriers, training needs/modes, and promotional avenues that support ASPs in hospitals.

Examining the Perspectives and Attitudes Towards Antibiotic Use and Resistance Among the General Public in Muzaffarpur in Bihar, India

Objective This study aimed to examine the current understanding and perspectives about the use of antibiotics among the general public living in the city of Muzaffarpur, Bihar, and the surrounding areas. Methodology A cross-sectional study was carried out from March 2023 to August 2023 in Muzaffarpur. Data was obtained through interviews based on a standardized questionnaire derived from a prior study. The findings were summarized using descriptive statistics, frequencies, and percentages, and then presented in tabular form. Results This study recruited 384 participants in total; the majority of them (n=200, 52.1%) were females, while the remaining 184 (47.9%) participants were males. Our findings revealed that 368 (96%) participants agreed on the necessity of prescribing distinct antibiotics for the treatment of various ailments. Nevertheless, the participants held divergent perspectives regarding the efficacy of antibiotics in treating coughs and colds, as well as their effectiveness against viruses and bacteria. Overall, 354 (92.1%) participants agreed with the importance of finishing the prescribed antibiotic regimen, and 335 (87.2%) agreed that people should refrain from retaining drugs for future use. Of note, 90% of the participants (n=346) stated that they did not think it was advisable to get antibiotics from friends and family without first consulting a doctor. Conclusion The current study documented a prevalent utilization of antibiotics among the study participants, with a significant proportion of these medications being obtained without a prescription. The respondents demonstrated a general lack of understanding, particularly concerning the significance of antibiotics in treating mild viral illnesses.

Public hospital pharmacists' knowledge, attitudes, and practices for antibiotic stewardship implementation in Limpopo Province, South Africa

BACKGROUND

Hospital pharmacists are important in antibiotic stewardship programs (ASP), a global strategy to combat antibiotic resistance (ABR). South African public hospitals have limited ASP implementation. This study describes Limpopo Provincial Hospital pharmacists' knowledge, attitudes, and practice toward ASP implementation.

METHOD

A questionnaire to explore pharmacists' knowledge, attitudes and practices regarding ASP implementation comprised 43 questions hosted online. A link was sent by invitation e-mail to eligible respondents in November 2021. Five questions on respondents' demographics, 15 questions on ASP knowledge, 10 Likert scale questions on attitude, and 13 on ASP practices were included. Mean (standard deviation (SD)) knowledge and attitude scores and a median (interquartile range (IQR)) practice score was calculated. Associations between categorical variables were assessed using chi-square/Fisher's exact analysis (p < 0.05), with Cramér's V as effect size.

RESULTS

The survey yielded 35 responses (13.1%). Twenty (57.1%) respondents were female. Seventeen (48.6%) respondents were between the ages of 31 and 40 years. The mean knowledge score of respondents was 9.8 (2.6) (N = 34), with knowledge gaps on One Health and socioeconomic determinates of ABR. Ten (29.6%) respondents thought One Health discouraged multi-sector collaboration, and nineteen (55.9%) respondents thought ASP was the only strategic response to ABR. Sixteen (47.1%) respondents did not know that poor access to clean water accelerates ABR and seventeen (50.0%) did not know that poverty could be a determinant for antibiotic use. The mean respondent attitude score was 8.0 (1.7) (N = 28). Twenty-seven (96.4%) respondents agreed that ASP was necessary and agreed to participate in ASP respectively. All 28 (100.0%) respondents agreed to lead an ASP. The median (IQR) respondents' practice score was - 2.0 (IQR: -6.0-5.8) (N = 16). Respondents were inconsistently (never, sometimes, every time) participating in multi-disciplinary forums (6/16, 37.5%) and expressed a desire for training (11/13, 84.6%) on ASP through in-service (7/27, 25.9%). Respondents thought ASP training should include medical officers (12/29, 41.4%) and nurses (9/29, 31.8%). Knowledge score was associated with gender (p = 0.048; V = 0.416) and attitude score (p = 0.013; V = 0.556).

CONCLUSION

Our study found pharmacists had good knowledge and a positive attitude toward ASP implementation but poor ASP practices. A multi-disciplinary in-service training could address identified knowledge and practice gaps.

A qualitative study evaluating barriers and enablers to improving antimicrobial use for the management of bacteriuria in hospitalized adults

Objective

The objective of this study was to explore barriers and enablers to improving the management of bacteriuria in hospitalized adults.

Design

Qualitative study.

Setting

Nova Scotia, Canada.

Participants

Nurses, physicians, and pharmacists involved in the assessment, diagnosis, and treatment of bacteriuria in hospitalized patients.

Methods

Focus groups (FGs) were completed between May and July 2019. FG discussions were facilitated using an interview guide that consisted of open-ended questions coded to the theoretical domains framework (TDF) v2. Discussions were transcribed verbatim then independently coded to the TDFv2 by two members of the research team and compared. Thematic analysis was used to identify themes.

Results

Thirty-three healthcare providers from five hospitals participated (15 pharmacists, 11 nurses, and 7 physicians). The use of antibiotics for the treatment of asymptomatic bacteriuria (ASB) was the main issue identified. Subthemes that related to management of ASB included: "diagnostic uncertainty," difficulty "ignoring positive urine cultures," "organizational challenges," and "how people learn." Barriers and/or enablers to improving the management of bacteriuria were mapped to 12 theoretical domains within these subthemes. Barriers and enablers identified by participants that were most extensively discussed related to the domains of environmental context and resources, belief about capabilities, social/professional role and identity, and social influences.

Conclusions

Healthcare providers highlighted barriers and recognized enablers that may improve delivery of care to patients with bacteriuria. A wide range of barriers at the individual and organization level to address diagnostic challenges and improve workload should be considered to improve management of bacteriuria.

Long-Term Effects of a Stepwise, Multimodal, Non-Restrictive Antimicrobial Stewardship Programme for Reducing Broad-Spectrum Antibiotic Use in the ICU

Information on the long-term effects of non-restrictive antimicrobial stewardship (AMS) strategies is scarce. We assessed the effect of a stepwise, multimodal, non-restrictive AMS programme on broad-spectrum antibiotic use in the intensive care unit (ICU) over an 8-year period. Components of the AMS were progressively implemented. Appropriateness of antibiotic prescribing was also assessed by monthly point-prevalence surveys from 2013 onwards. A Poisson regression model was fitted to evaluate trends in the reduction of antibiotic use and in the appropriateness of their prescription. From 2011 to 2019, a total of 12,466 patients were admitted to the ICU. Antibiotic use fell from 185.4 to 141.9 DDD per 100 PD [absolute difference, -43.5 (23%), 95% CI -100.73 to 13.73; p = 0.13] and broad-spectrum antibiotic fell from 41.2 to 36.5 [absolute difference, -4.7 (11%), 95% CI -19.58 to 10.18; p = 0.5]. Appropriateness of antibiotic prescribing rose by 11% per year [IRR: 0.89, 95% CI 0.80 to 1.00; p = 0.048], while broad-spectrum antibiotic use showed a dual trend, rising by 22% until 2015 and then falling by 10% per year since 2016 [IRR: 0.90, 95% CI 0.81 to 0.99; p = 0.03]. This stepwise, multimodal, non-restrictive AMS achieved a sustained reduction in broad-spectrum antibiotic use in the ICU and significantly improved appropriateness of antibiotic prescribing.

How are Oral Antibiotics Being Used in Total Joint Arthroplasty? A Review of the Literature

While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.

Implementation of antimicrobial stewardship programs: A study of prescribers' perspective of facilitators and barriers

BACKGROUND

Despite promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs), there remains limited knowledge on how to implement ASPs in peculiar settings for a more elaborate impact. This study explored prescriber experiences and perceptions of the usefulness, and feasibility of strategies employed for the implementation of antimicrobial stewardship (AMS) interventions as well as challenges encountered.

METHODS

This is a cross-sectional mixed-method survey of prescribers' perspective of the facilitators and barriers of implementing ASP. The quantitative approach comprised of a semi-structured questionnaire and data collected were analyzed using SPSS version 26 while the qualitative approach used focus group discussions followed by content analysis.

RESULTS

Out of the thirty people that participated in the workshop, twenty-five completed the questionnaires which were analyzed. The respondents included 15 (60.0%) medical doctors and 10 (40.0%) pharmacists. The mean age of the respondents was 36.39±7.23 years with mean year of practice of 9.48±6.01 years. Majority of them (84.0%) were in a position to provide input on the implementation of AMS in their facilities, although their managements had the final decision. The pharmacists (100%) were more likely to agree that antibiotic resistance was a problem for their practice than the medical doctors (78.6%) while equal number (80.0%) of respondents (pharmacists and medical doctors) believed that inappropriate prescribing was a problem. Having a specialized and dedicated team with effective monitoring was recognized as crucial for effective ASP while inadequate personnel was identified as a major barrier. We identified stakeholder's engagement, policies and regulation, as well as education as themes for improving AMS in the country.

CONCLUSION

The results gave insight into the prescribers' perspective on the facilitators and barriers to antimicrobial stewardship; challenges and possible solutions to implementing ASPs in health facilities in Lagos State. We further identified pertinent contextual factors that need to be addressed when developing ASPs in healthcare facilities in a resource-poor setting.

Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Incidence of acute kidney injury (AKI) and its impact on patient outcomes among adult hospitalized patients with carbapenem-resistant Gram-negative infections who received targeted treatment with a newer β-lactam or β-lactam/β-lactamase inhibitor-, polymyxin- or aminoglycoside-containing regimen

BACKGROUND

Limited comparative data exist on acute kidney injury (AKI) risk and AKI-associated outcomes in hospitalized patients with carbapenem-resistant Gram-negative infections (CR-GNIs) treated with a newer β-lactam/β-lactam-β-lactamase inhibitor (BL/BL-BLI)-, polymyxin (PB)- or aminoglycoside (AG)-containing regimen. This study quantified the risk of AKI and AKI-related outcomes among patients with CR-GNIs treated with a newer BL/BL-BLI-, PB- or AG-containing regimen.

METHODS

A multicentre, retrospective, observational study was performed (2016-20). The study included adult hospitalized patients with (i) baseline estimated glomerular filtration rates ≥30 mL/min/1.73 m2; (ii) CR-GN pneumonia, complicated urinary tract infection or bloodstream infection; and (iii) receipt of newer BL/BL-BLI, PG or AG within 7 days of index CR-GN culture for ≥3 days. Outcomes included AKI, in-hospital mortality and hospital costs.

RESULTS

The study included 750 patients and most (48%) received a newer BL/BL-BLI. The median (IQR) treatment duration was 8 (5-11), 5 (4-8) and 7 (4-8) days in the newer BL/BL-BLI group, AG group and PB group, respectively. The PB group had the highest adjusted AKI incidence (95% CI) (PB: 25.1% (15.6%-34.6%) versus AG: 8.9% (5.7%-12.2%) versus newer BL/BL-BLI: 11.9% (8.1%-15.7%); P = 0.001). Patients with AKI had significantly higher in-hospital mortality (AKI: 18.5% versus 'No AKI': 5.6%; P = 0.001) and mean hospital costs (AKI: $49 192 versus 'No AKI': $38,763; P = 0.043).

CONCLUSIONS

The AKI incidence was highest among PB patients and patients with AKI had worse outcomes. Healthcare systems should consider minimizing the use of antibiotics that augment AKI risk as a measure to improve outcomes in patients with CR-GNIs.

Recent trends and risk factors associated with Clostridioides difficile infections in hospitalized patients with inflammatory bowel disease

BACKGROUND

Clostridioides difficile infections (CDIs) are common among patients with inflammatory bowel disease (IBD) and can mimic and exacerbate IBD flares, thus warranting appropriate testing during flares.

AIMS

To examine recent trends in rates of CDI and associated risk factors in hospitalized IBD patients, which may better inform targeted interventions to mitigate the risk of infection.

METHODS

This is a retrospective analysis using the Nationwide Readmissions Database from 2010 to 2020 of hospitalized individuals with Crohn's disease (CD) or ulcerative colitis (UC). Longitudinal changes in rates of CDI were evaluated using International Classification of Diseases codes. Multivariable logistic regression evaluated the association between patient- and hospital-related factors and CDI.

RESULTS

There were 2,521,935 individuals with IBD who were hospitalized at least once during the study period. Rates of CDI in IBD-related hospitalizations increased from 2010 to 2015 (CD: 1.64%-3.32%, p < 0.001; UC: 4.15%-5.81%, p < 0.001), followed by a steady decline from 2016 to 2020 (CD: 3.15%-2.27%, p < 0.001; UC: 5.04%-4.27%, p < 0.001). In multivariable models, CDI was associated with the Charlson-Deyo comorbidity index, public insurance, and hospital size. CDI was associated with increased mortality.

CONCLUSIONS

Rates of CDI among hospitalized patients with IBD had initially increased, but have declined since 2015. Increased comorbidity, large hospital size, public insurance, and urban teaching hospitals were associated with higher rates of CDI. CDI was associated with increased mortality in hospitalized patients with IBD. Continued vigilance, infection control, and treatment of CDI can help continue the trend of declining infection rates.

Conventional vs Short Duration of Antibiotics in Patients With Moderate or Severe Cholangitis: Noninferiority Randomized Trial

INTRODUCTION

Successful biliary drainage and antibiotics are the mainstays of therapy in management of patients with acute cholangitis. However, the duration of antibiotic therapy after successful biliary drainage has not been prospectively evaluated. We conducted a single-center, randomized, noninferiority trial to compare short duration of antibiotic therapy with conventional duration of antibiotic therapy in patients with moderate or severe cholangitis.

METHODS

Consecutive patients were screened for the inclusion criteria and randomized into either conventional duration (CD) group (8 days) or short duration (SD) group (4 days) of antibiotic therapy. The primary outcome was clinical cure (absence of recurrence of cholangitis at day 30 and >50% reduction of bilirubin at day 15). Secondary outcomes were total days of antibiotic therapy and hospitalization within 30 days, antibiotic-related adverse events, and all-cause mortality at day 30.

RESULTS

The study included 120 patients (the mean age was 55.85 ± 13.52 years, and 50% were male patients). Of them, 51.7% patients had malignant etiology and 76.7% patients had moderate cholangitis. Clinical cure was seen in 79.66% (95% confidence interval, 67.58%-88.12%) patients in the CD group and 77.97% (95% confidence interval, 65.74%-86.78%) patients in the SD group ( P = 0.822). On multivariate analysis, malignant etiology and hypotension at presentation were associated with lower clinical cure. Total duration of antibiotics required postintervention was lower in the SD group (8.58 ± 1.92 and 4.75 ± 2.32 days; P < 0.001). Duration of hospitalization and mortality were similar in both the groups.

DISCUSSION

Short duration of antibiotics is noninferior to conventional duration in patients with moderate-to-severe cholangitis in terms of clinical cure, recurrence of cholangitis, and overall mortality.

Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations

INTRODUCTION

The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions.

AREAS COVERED

Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges.

EXPERT OPINION

Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.

Shorter versus longer duration of antibiotic treatment in children with bacterial meningitis: a systematic review and meta-analysis

The optimal duration of antibiotic treatment for the most common bacterial meningitis etiologies in the pediatric population, namely Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, is not well-established in the literature. Therefore, we aimed to perform an updated meta-analysis comparing shorter versus longer antibiotic treatment in children with meningitis. PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials (RCTs) that compared shorter (up to 7 days) versus longer (10 days or double the days of the equivalent short course) duration of antibiotic treatment in children with meningitis and reported the outcomes of treatment failure, death, neurologic sequelae, non-neurologic complications, hearing impairment, nosocomial infection, and relapse. Heterogeneity was examined with I2 statistics. RevMan 5.4.1 was used for statistical analysis and RoB-2 (Cochrane) for risk of bias assessment. Of 684 search results, 6 RCTs were included, with a cohort of 1333 children ages 3 weeks to 15.5 years, of whom 49.51% underwent a short antibiotic course. All RCTs included monotherapy with ceftriaxone, except one, which added vancomycin as well. No differences were found comparing the short and long duration of therapy concerning treatment failure, relapse, mortality, and neurologic complications at discharge and at follow-up.  Conclusion: Because no statistically significant differences were found between groups for the analyzed outcomes, the results of this meta-analysis support shorter therapy. However, generalizing these results to complicated meningitis and infections caused by other pathogens should be made with caution. (PROSPERO identifier: CRD42022369843). What is Known: • Current recommendations on the duration of antibiotic therapy for bacterial meningitis are mostly based on clinical practice. • Defining an optimal duration of antibiotic therapy is essential for antimicrobial stewardship achievement, improving patient outcomes, and minimizing adverse effects. What is New: • There are no differences between shorter versus longer antibiotic treatment duration in regard to treatment failure, relapse, mortality, neurologic complications, and hearing impairment at discharge and at follow-up.

Development of machine learning algorithms for scaling-up antibiotic stewardship

BACKGROUND

Antibiotic stewardship programs (ASP) aim to reduce inappropriate use of antibiotics, but their labor-intensive nature impedes their wide adoption. The present study introduces explainable machine learning (ML) models designed to prioritize inpatients who would benefit most from stewardship interventions.

METHODS

A cohort of inpatients who received systemic antibiotics and were monitored by a multidisciplinary ASP team at a tertiary hospital in the Republic of Korea was assembled. Data encompassing over 130,000 patient-days and comprising more than 160 features from multiple domains, including prescription records, laboratory, microbiology results, and patient conditions was collected.Outcome labels were generated using medication administration history: discontinuation, switching from intravenous to oral medication (IV to PO), and early or late de-escalation. The models were trained using Extreme Gradient Boosting (XGB) and light Gradient Boosting Machine (LGBM), with SHapley Additive exPlanations (SHAP) analysis used to explain the model's predictions.

RESULTS

The models demonstrated strong discrimination when evaluated on a hold-out test set(AUROC - IV to PO: 0.81, Early de-escalation: 0.78, Late de-escalation: 0.72, Discontinue: 0.80). The models identified 41%, 16%, 22%, and 17% more cases requiring discontinuation, IV to PO, early and late de-escalation, respectively, compared to the conventional length of therapy strategy, given that the same number of patients were reviewed by the ASP team. The SHAP results explain how each model makes their predictions, highlighting a unique set of important features that are well-aligned with the clinical intuitions of the ASP team.

CONCLUSIONS

The models are expected to improve the efficiency of ASP activities by prioritizing cases that would benefit from different types of ASP interventions along with detailed explanations.