Use of electronic health records and clinical decision support systems for antimicrobial stewardship

Data Representation Structure to Support Clinical Decision-Making in the Pediatric Intensive Care Unit: Interview Study and Preliminary Decision Support Interface Design

BACKGROUND

Clinical decision-making is a complex cognitive process that relies on the interpretation of a large variety of data from different sources and involves the use of knowledge bases and scientific recommendations. The representation of clinical data plays a key role in the speed and efficiency of its interpretation. In addition, the increasing use of clinical decision support systems (CDSSs) provides assistance to clinicians in their practice, allowing them to improve patient outcomes. In the pediatric intensive care unit (PICU), clinicians must process high volumes of data and deal with ever-growing workloads. As they use multiple systems daily to assess patients' status and to adjust the health care plan, including electronic health records (EHR), clinical systems (eg, laboratory, imaging and pharmacy), and connected devices (eg, bedside monitors, mechanical ventilators, intravenous pumps, and syringes), clinicians rely mostly on their judgment and ability to trace relevant data for decision-making. In these circumstances, the lack of optimal data structure and adapted visual representation hinder clinician's cognitive processes and clinical decision-making skills.

OBJECTIVE

In this study, we designed a prototype to optimize the representation of clinical data collected from existing sources (eg, EHR, clinical systems, and devices) via a structure that supports the integration of a home-developed CDSS in the PICU. This study was based on analyzing end user needs and their clinical workflow.

METHODS

First, we observed clinical activities in a PICU to secure a better understanding of the workflow in terms of staff tasks and their use of EHR on a typical work shift. Second, we conducted interviews with 11 clinicians from different staff categories (eg, intensivists, fellows, nurses, and nurse practitioners) to compile their needs for decision support. Third, we structured the data to design a prototype that illustrates the proposed representation. We used a brain injury care scenario to validate the relevance of integrated data and the utility of main functionalities in a clinical context. Fourth, we held design meetings with 5 clinicians to present, revise, and adapt the prototype to meet their needs.

RESULTS

We created a structure with 3 levels of abstraction-unit level, patient level, and system level-to optimize clinical data representation and display for efficient patient assessment and to provide a flexible platform to host the internally developed CDSS. Subsequently, we designed a preliminary prototype based on this structure.

CONCLUSIONS

The data representation structure allows prioritizing patients via criticality indicators, assessing their conditions using a personalized dashboard, and monitoring their courses based on the evolution of clinical values. Further research is required to define and model the concepts of criticality, problem recognition, and evolution. Furthermore, feasibility tests will be conducted to ensure user satisfaction.

Principles and Practice of Antimicrobial Stewardship Program Resource Allocation

Antimicrobial Stewardship Programs (ASP) improve individual patient outcomes and clinical care processes while reducing antimicrobial-associated adverse events, optimizing operational priorities, and providing institutional cost savings. ASP composition, resources required, and priority focuses are influenced by myriad factors. Despite robust evidence and broad national support, individual ASPs still face challenges in obtaining appropriate resources. Though understanding the current landscape of ASP resource allocation, factors influencing staffing needs, and strategies required to obtain desired resources is important, acceptance of recommended staffing levels and appropriate ASP resource allocation are much needed to facilitate ASP sustainability and growth across the complex and diverse health care continuum.

Harnessing the power of clinical decision support systems: challenges and opportunities

Clinical decision support systems (CDSSs) are increasingly integrated into healthcare settings to improve patient outcomes, reduce medical errors and enhance clinical efficiency by providing clinicians with evidence-based recommendations at the point of care. However, the adoption and optimisation of these systems remain a challenge. This review aims to provide an overview of the current state of CDSS, discussing their development, implementation, benefits, limitations and future directions. We also explore the potential for enhancing their effectiveness and provide an outlook for future developments in this field. There are several challenges in CDSS implementation, including data privacy concerns, system integration and clinician acceptance. While CDSS have demonstrated significant potential, their adoption and optimisation remain a challenge.

Modelling antimicrobial resistance transmission to guide personalized antimicrobial stewardship interventions and infection control policies in healthcare setting: a pilot study

Infection control programs and antimicrobial stewardship have been proven effective in reducing the burden of diseases due to multidrug-resistant organisms, but quantifying the effect of each intervention is an open issue. For this aim, we propose a model to characterize the effect of interventions at single ward level. We adapted the Ross-Macdonald model to describe hospital cross-transmission dynamics of carbapenem resistant Klebsiella pneumoniae (CRKP), considering healthcare workers as the vectors transmitting susceptible and resistant pathogens among admitted patients. The model parameters were estimated from a literature review, further adjusted to reproduce observed clinical outcomes, and validated using real life data from a 2-year study in a university hospital. The model has been further explored through extensive sensitivity analysis, in order to assess the relevance of single interventions as well as their synergistic effects. Our model has been shown to be an effective tool to describe and predict the impact of interventions in reducing the prevalence of CRKP colonisation and infection, and can be extended to other specific hospital and pathological scenarios to produce tailored estimates of the most effective strategies.

Deficiencies of Rule-Based Technology-Generated Antibiograms for Specialized Care Units

The objective of this study was to compare the pathogens and susceptibilities of the current automated, rule-based technology (RBT) antibiogram with one manually collected through chart review with additional rules applied. This study was a two-year, retrospective cohort study and included all bacterial cultures within the first 30 days from patients admitted to a single Burn Center. The current RBT antibiogram served as the control, and new antibiogram versions were created using additional rules and compared to the control. Six-hundred fifty-seven patients were admitted (61% excluded for lack of cultures). 59% had at least one hospital-acquired risk factor, with over one-third having recent illicit drug use and one-third having a recent hospitalization. Of the 410 cultures included, 57% were Gram-negative, and half were from wound infections. Sensitivities were significantly different when comparing the manual and the RBT version after including factors such as days since admission, presence of hospital-acquired risk factors, or previous antibiotic courses. Recommended empiric Gram-negative antibiotics changed from double coverage to a single β-lactam with >90% susceptibility. The susceptibilities between the first and subsequent courses were dramatically different. Before developing an antibiogram or interpreting the output, it is important to consider which automated criteria are utilized, especially for units with extended lengths of stay.

Impact of a prospective audit and feedback antimicrobial stewardship programme on carbapenem consumption: a quasi-experimental study (IPANEMA study)

OBJECTIVES

To test the hypothesis that a prospective audit and feedback (PAF) intervention combined with electronic tools will reduce carbapenem use without negatively affecting patient outcomes.

METHODS

A quasi-experimental, pre-intervention and intervention study was performed conducted in the urology department of a university hospital. The intervention involved implementing a PAF within an antimicrobial stewardship programme with the aid of an electronic tool. The primary outcome was carbapenem use, assessed by DDD/100 patient-days (PD). Secondary outcomes included evaluating the effect of the intervention on overall antibiotic use measured by DDD/100 PD and days of therapy (DOT)/100 PD, as well as patient safety. The chi-squared test or t-test was used, and the Poisson model was employed to assess the association between the intervention and outcomes.

RESULTS

A 9% decrease in carbapenem DDD/100 PD was observed during the intervention period (IR = 0.91; 95% CI = 0.85-0.97, P = 0.007). The proportion of patients who received carbapenem treatment dropped from 17.8% to 16.5% [incidence ratio (IR) = 0.95; 95% CI = 0.86-2.05, P = 0.31]. Carbapenem DOT/100 PD decreased from 12.4 to 11.0 (IR = 0.89; 95% CI = 0.83-0.94, P < 0.001). Overall antibiotic DDD/100 PD decreased by 3% (IR = 0.97; 95% CI = 0.94-0.99, P = 0.001) and DOT/100 PD by 7% (IR = 0.93; 95% CI = 0.91-0.95, P < 0.001). The incidence of infections caused by carbapenemase-producing microorganisms, Enterococcus faecium bacteraemia and Clostridioides difficile-associated diarrhoea episodes was similar in the pre-intervention and intervention periods. ESBL incidence rate decreased, but the differences were not statistically significant (3.94/1000 PD versus 2.88/1000 PD, P = 0.111). Length of hospital stay, in-hospital all-cause mortality, and 30 day readmission incidence remained unchanged.

CONCLUSIONS

The implementation of PAF combined with an electronic tool was an effective and safe intervention for reducing carbapenem use.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

What's New in Antibiograms? Updating CLSI M39 Guidance with Current Trends

A vast amount of antimicrobial susceptibility test (AST) data is generated from routine testing in diagnostic laboratories for the primary purpose of guiding clinicians in antimicrobial therapy decisions for their patients. However, there is additional value for these data when they are compiled at the local, regional, national, and global levels. Cumulative AST data can be used to prepare antibiograms at the individual health care facility level. These reports can be used to gain insight into appropriate empirical therapy options prior to the availability of AST results on an individual patient's isolate. Different types of cumulative AST data reports can also be compiled at the regional, national, and global levels to estimate susceptibility rates in geographic regions, document trends in evolving microbial populations, and recognize the appearance and spread of emerging antimicrobial resistance threats. The first CLSI M39 Guideline for Analysis and Presentation of Cumulative AST Data was published in 2000. Since that time, there have been changes to AST and reporting recommendations as well as the introduction of advanced informatics technologies to analyze and present data. The 5th edition of M39 has taken into consideration these changes to assist those who analyze, present, and utilize routine antibiograms and other types of cumulative AST data reports as well as those who design information systems for the capturing and analyzing of AST data. Furthermore, antimicrobial stewardship programs (ASPs) have expanded considerably, and uses of the antibiogram by ASPs have been addressed. This minireview will remind users of the basic recommendations for analysis and presentation of antibiograms and provide new suggestions to enhance these reports.

Get2PrEP: An Electronic Medical Record Laboratory Comment Increased Safe Sex Counseling But Not Preexposure Prophylaxis Services at a Large Urban Academic Medical Center in Northern Manhattan

BACKGROUND

HIV preexposure prophylaxis (PrEP) remains underutilized despite its efficacy and potential population impact. Achieving PrEP's full potential depends on providers who are knowledgeable and comfortable prescribing it to individuals at risk of acquiring HIV. Previous educational interventions targeting provider-related uptake barriers have had limited success. We designed and tested an electronic medical record (EMR) interpretative comment to improve the delivery of PrEP.

METHODS

An EMR comment provided information on PrEP eligibility and referral resources to providers delivering positive chlamydia and gonorrhea results. Positive test results for bacterial sexually transmitted infections before intervention (January 1, 2019-August 23, 2019) and after intervention (August 24, 2019-December 31, 2019) were identified. A retrospective chart review was conducted to ascertain provider documentation of PrEP discussions or provision, HIV prevention discussions, and HIV screening. Pretest-posttest analysis was performed to compare the provision of PrEP and HIV prevention services.

RESULTS

We reviewed 856 preintervention encounters spanning 8 months and 461 postencounters spanning 4 months. Patient demographics were comparable. We observed an increase in provider documentation of safe sex and condom counseling (odds ratios [ORs], 1.2 [95% confidence interval {CI}, 1.07-1.18] and 1.11 [95% CI, 1.05-1.17], respectively), and the absence of any HIV prevention discussion decreased (OR, 0.85; 95% CI, 0.80-0.90), but not HIV screening or PrEP documentation.

CONCLUSIONS

We demonstrated that an EMR laboratory comment had a modest effect on increasing risk reduction counseling, although not HIV screening or PrEP prescriptions. Future strategies to encourage provider delivery of sexual health services may benefit from more targeted strategies that combine behavioral and information technology approaches.

Pharmacists’ Perspectives of Their Roles in Antimicrobial Stewardship: A Qualitative Study among Hospital Pharmacists in Malaysia

Antimicrobial resistance has negatively impacted patient outcomes and increased healthcare costs. Antimicrobial stewardship (AMS) includes all activities and policies to promote the judicious use of antimicrobials. Pharmacists are key players in AMS models worldwide. However, there is a research gap in the role of pharmacists as antimicrobial stewards in Malaysia. This study aimed to explore hospital pharmacists’ perspectives on their roles in, and barriers and facilitators to the implementation of AMS strategies. Individual, semi-structured interviews were conducted with 16 hospital pharmacists involved in AMS activities from 13 public hospitals in Kuala Lumpur and Selangor. Audio-taped interviews were transcribed verbatim and imported into NVivo software version 10.0 (QSR). A thematic analysis method was used to identify themes from the qualitative data until theme saturation was reached. Respondents perceived pharmacists as having important roles in the implementation of AMS strategies, in view of the multiple tasks they were entrusted with. They described their functions as antimicrobial advisors, antimicrobial guardians and liaison personnel. The lack of resources in terms of training, manpower and facilities, as well as attitudinal challenges, were some barriers identified by the respondents. Administrative support, commitment and perseverance were found to be facilitators to the role of pharmacists in AMS. In conclusion, pharmacists in public hospitals play important roles in AMS teams. This study has provided insights into the support that AMS pharmacists in public hospitals require to overcome the barriers they face and to enhance their roles in the implementation of AMS strategies.

Leveraging antimicrobial stewardship programs in response to the coronavirus disease 2019 (COVID-19) public health emergency

The coronavirus disease 2019 (COVID-19) pandemic has strained antimicrobial stewardship programs (ASPs) but offered new opportunities. This review summarizes the impact of the COVID-19 pandemic on ASPs, review the contributions ASPs have made in the pandemic response, and highlight the potential role of ASPs in future pandemics.

Big Data for Treatment Planning: Pathways and Possibilities for Smart Healthcare Systems

BACKGROUND

Treatment planning is one of the crucial stages of healthcare assessment and delivery. Moreover, it also has a significant impact on patient outcomes and system efficiency. With the evolution of transformative healthcare technologies, most areas of healthcare have started collecting data at different levels, as a result of which there is a splurge in the size and complexity of health data being generated every minute.

INTRODUCTION

This paper explores the different characteristics of health data with respect to big data. Besides this, it also classifies research efforts in treatment planning on the basis of the informatics domain being used, which includes medical informatics, imaging informatics and translational bioinformatics.

METHODS

This is a survey paper that reviews existing literature on the use of big data technologies for treatment planning in the healthcare ecosystem. Therefore, a qualitative research methodology was adopted for this work.

RESULTS

Review of existing literature has been analyzed to identify potential gaps in research, identifying and providing insights into high prospect areas for potential future research.

CONCLUSION

The use of big data for treatment planning is rapidly evolving, and findings of this research can head start and streamline specific research pathways in the field.

A systems thinking approach for antimicrobial stewardship in primary care

INTRODUCTION

The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care.

AREAS COVERED

The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries.

EXPERT OPINION

The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care.

Hospital Pharmacists and Antimicrobial Stewardship: A Qualitative Analysis

Antimicrobial stewardship programmes (ASPs) in hospitals are predominantly led by specific ASP physicians and pharmacists. Limited studies have been conducted to appreciate non-ASP-trained hospital pharmacists' perspectives on their roles in antimicrobial stewardship. Focus group discussions (FGDs) were conducted with 74 pharmacists, purposively sampled from the 3 largest acute-care public hospitals in Singapore, to explore facilitators and barriers faced by them in antimicrobial stewardship. Applied thematic analysis was conducted and codes were categorised using the social-ecological model (SEM). At the intrapersonal level, pharmacists identified themselves as reviewers for drug safety before dispensing, confining to a restricted advisory role due to lack of clinical knowledge, experience, and empowerment to contribute actively to physicians' prescribing decisions. At the interpersonal level, pharmacists expressed difficulties conveying their opinions and recommendations on antibiotic therapy to physicians despite frequent communications, but they assumed critical roles as educators for patients and their caregivers on proper antibiotic use. At the organisational level, in-house antibiotic guidelines supported pharmacists' antibiotic interventions and recommendations. At the community level, pharmacists were motivated to improve low public awareness and knowledge on antibiotic use and antimicrobial resistance. These findings provide important insights into the gaps to be addressed in order to harness the untapped potential of hospital pharmacists and fully engage them in antimicrobial stewardship.

Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention

Objective

To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI).

Design

We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention.

Setting

An academic healthcare system with 4 hospitals.

Patients

All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients.

Intervention

Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing.

Results

Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01).

Conclusions

Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.

Use of the Electronic Health Record to Optimize Antimicrobial Prescribing

PURPOSE

This review summarizes how interventions in the electronic health record (EHR) can optimize antimicrobial stewardship across the continuum of antimicrobial decision making, from diagnosis of infection to discontinuation of therapy. In addition, opportunities to optimize provider communication and patient education are identified.

METHODS

A narrative review was conducted to identify how interventions in the EHR can influence antimicrobial prescribing behavior. Examples from pediatrics were specifically identified. Interventions were then categorized into high-impact/low-effort, high-impact/high-effort, and low-impact/low-effort groupings based on historical experience.

FINDINGS

EHR-based interventions can be used for stratifying patients at risk for infection and are useful in identifying patients with new-onset infections. Additional tools include automatically updated antibiograms tailored to specific patient populations, timely authorization of restricted antimicrobials, and more accurate allergy labeling. Medical errors can be reduced and communication between providers can be improved by standardized data fields. Clinical decision support tools can guide appropriate selection of therapy, and visual prompts can reduce unnecessarily prolonged therapy. Benchmarking of antimicrobial use, tailored patient education, and improved communication during transitions of care are enhanced through EHR-based interventions.

IMPLICATIONS

Prescribing behavior can be modified through a range of interventions in the EHR, including tailored education, alerts, prompts, and restrictions on provider behavior. Further studies are needed to compare the effectiveness of various strategies.

Computer Informatics for Infection Control

Computer informatics have the potential to improve infection control outcomes in surveillance, prevention, and public health. Surveillance activities include surveillance of infections, device use, and facility/ward outbreak detection and investigation. Prevention activities include awareness of multidrug-resistant organism carriage on admission, identification of high-risk individuals or populations, reducing device use, and antimicrobial stewardship. Enhanced communication with public health and other health care facilities across networks includes automated electronic communicable disease reporting, syndromic surveillance, and regional outbreak detection. Computerized public health networks may represent the next major evolution in infection control. This article reviews the use of informatics for infection control.

Appropriateness of antibiotic selection for pneumonia in the emergency department: pre- and post-order set changes

OBJECTIVES

Emergency department (ED) providers face pressure to meet sepsis mandates such as prompt administration of antibiotic therapy, which can lead to the overuse of broad-spectrum antibiotics. In recent years, there has also been a push to adhere to institutional antibiotic stewardship goals including decreasing inappropriate antibiotic therapy and limiting duration of therapy. Previous literature has demonstrated that the incorporation of clinical decision support (CDS) tools in electronic medical records can aid in guiding appropriate antibiotic prescribing. Therefore, the objective of this study was to determine whether the implementation of a CDS tool could improve antibiotic selection for pneumonia management in the ED.

METHODS

This was a retrospective single-centre observational study conducted in patients that presented to the ED with pneumonia. In November 2018, a CDS tool was incorporated into the ED sepsis order set to guide practitioners in selecting appropriate antibiotics for pneumonia. Antibiotic prescribing patterns were assessed pre-CDS (January-February 2018) and post-CDS (January-February 2019) implementation. Patients were included if they were 18 years of age or older, had an ED visit with ICD10 code reflective of pneumonia, and had at least one antibiotic ordered from the ED sepsis order set. The primary endpoint was the percentage of patients prescribed appropriate antibiotic therapy for pneumonia based on patient risk factors pre- and post-CDS implementation.

KEY FINDINGS

There were 161 patients in the pre-CDS group and 119 patients in the post-CDS group included in the study. There was a significant improvement in the selection of appropriate antibiotics in the post-CDS group (31.9% versus 65.3%, P < 0.0001) with no significant differences in duration of antibiotics, intubation rates, vasopressor initiation, length of stay, mortality or 30-day readmission.

CONCLUSION

The implementation of a CDS tool for empiric management of pneumonia in the ED significantly improved the selection of appropriate antibiotics.

Chronic patient remote monitoring through the application of big data and internet of things

Chronic patients could benefit from the technological advances, but the clinical approaches for this kind of patients are still limited. This paper describes a system for chronic patients monitoring both, in home and external environments. For this purpose, we used novel technologies as big data, cloud computing and internet of things (IoT). Additionally, the system has been validated for three use cases: cardiovascular disease (CVD), hypertension (HPN) and chronic obstructive pulmonary disease (COPD), which were selected for their incidence in the population. This system is innovative within e-health, mainly due to the use of a big data architecture based on open-source components, also it provides a scalable and distributed environment for storage and processing of biomedical sensor data. The proposed system enables the incorporation of non-medical data sources in order to improve the self-management of chronic diseases and to develop better strategies for health interventions for chronic and dependents patients.

Can evidence-based decision support tools transform antibiotic management? A systematic review and meta-analyses

OBJECTIVES

To assess the effectiveness of clinical decision support systems (CDSSs) at reducing unnecessary and suboptimal antibiotic prescribing within different healthcare settings.

METHODS

A systematic review of published studies was undertaken with seven databases from database inception to November 2018. A protocol was developed using the PRISMA-P checklist and study selection criteria were determined prior to performing the search. Critical appraisal of studies was undertaken using relevant tools. Meta-analyses were performed using a random-effects model to determine whether CDSS use affected optimal antibiotic management.

RESULTS

Fifty-seven studies were identified that reported on CDSS effectiveness. Most were non-randomized studies with low methodological quality. However, randomized controlled trials of moderate methodological quality were available and assessed separately. The meta-analyses indicated that appropriate antibiotic therapy was twice as likely to occur following the implementation of CDSSs (OR 2.28, 95% CI 1.82-2.86, k = 20). The use of CDSSs was also associated with a relative decrease (18%) in mortality (OR 0.82, 95% CI 0.73-0.91, k = 18). CDSS implementation also decreased the overall volume of antibiotic use, length of hospital stay, duration and cost of therapy. The magnitude of the effect did vary by study design, but the direction of the effect was consistent in favouring CDSSs.

CONCLUSIONS

Decision support tools can be effective to improve antibiotic prescribing, although there is limited evidence available on use in primary care. Our findings suggest that a focus on system requirements and implementation processes would improve CDSS uptake and provide more definitive benefits for antibiotic stewardship.

Development of an Electronic Algorithm to Identify in Real Time Adults Hospitalized With Suspected Community-Acquired Pneumonia

Background

Community-acquired pneumonia (CAP) is a major driver of hospital antibiotic use. Efficient methods to identify patients treated for CAP in real time using the electronic health record (EHR) are needed. Automated identification of these patients could facilitate systematic tracking, intervention, and feedback on CAP-specific metrics such as appropriate antibiotic choice and duration.

Methods

Using retrospective data, we identified suspected CAP cases by searching for patients who received CAP antibiotics AND had an admitting International Classification of Diseases, Tenth Revision (ICD-10) code for pneumonia OR chest imaging within 24 hours OR bacterial urinary antigen testing within 48 hours of admission (denominator query). We subsequently explored different structured and natural language processing (NLP)–derived data from the EHR to identify CAP cases. We evaluated combinations of these electronic variables through receiver operating characteristic (ROC) curves to assess which best identified CAP cases compared to cases identified by manual chart review. Exclusion criteria were age <18 years, absolute neutrophil count <500 cells/mm³, and admission to an oncology unit.

Results

Compared to the gold standard of chart review, the area under the ROC curve to detect CAP was 0.63 (95% confidence interval [CI], .55–.72; P < .01) using structured data (ie, laboratory and vital signs) and 0.83 (95% CI, .77–.90; P < .01) when NLP-derived data from radiographic reports were included. The sensitivity and specificity of the latter model were 80% and 81%, respectively.

Conclusions

Creating an electronic tool that effectively identifies CAP cases in real time is possible, but its accuracy is dependent on NLP-derived radiographic data.

Short-Duration Electronic Health Record Option Buttons to Reduce Prolonged Length of Antibiotic Therapy in Outpatients

BACKGROUND

Prolonged antibiotic therapy may be associated with increased adverse events and antibiotic resistance. We deployed an intervention in the electronic health record (EHR) to reduce antibiotic duration for pediatric outpatients.

METHODS

A preintervention and postintervention interrupted time series analysis of antibiotic duration for 7 antibiotics was performed for patients discharged from the ED and clinics of a children's hospital network from 2012 to 2018. In February 2015, clickable 5- and 7-day duration option buttons were deployed in the EHR for clindamycin, cephalexin, ciprofloxacin and levofloxacin, trimethoprim-sulfamethoxazole, amoxicillin, and cefdinir, with an additional 10-day option for the latter 2. Prescribers were able to enter a free-text duration. The option buttons were not announced, and were not linked to a specific diagnosis or quality improvement initiative. The primary outcome was proportion of prescriptions per month with duration of 10 days. Balancing secondary outcomes were reorders of the same agent, return to clinic, and inpatient admissions within 30 days.

RESULTS

There were 54 315 prescriptions for the 7 antibiotics associated with 39 894 patients, 18 683 clinic visits, and 35 632 ED visits. Overall, a -5.1% (95% confidence interval [CI], -8.3% to -2.0%) change in the proportion of prescriptions with a 10-day duration was attributable to the intervention, with larger effects noted for clindamycin (-20.8% [95% CI, -26.9% to -14.7%]) and cephalexin (-9.9% [95% CI, -14.3% to -5.4%]). There was no increase in the reorders of the same agent, return clinical encounters, or inpatient admissions within 30 days.

CONCLUSIONS

A simple intervention in the EHR can safely reduce duration of antibiotic therapy.

Development of an antimicrobial stewardship module in an electronic health record: Options to enhance daily antimicrobial stewardship activities

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

The purpose of this manuscript is to describe our experience developing an antimicrobial stewardship (AS) module as a clinical decision support tool in the Epic electronic health record (EHR).

Summary

Clinical decision support systems within the EHR can be used to decrease use of broad-spectrum antibiotics, improve antibiotic selection and dosing, decrease adverse effects, reduce antibiotic costs, and reduce the development of antibiotic resistance. The Johns Hopkins Hospital constructed an AS module within Epic. Customized stewardship alerts and scoring systems were developed to triage patients requiring stewardship intervention. This required a multidisciplinary approach with a team comprising AS physicians and pharmacists and Epic information technology personnel, with assistance from clinical microbiology and infection control when necessary. In addition, an intervention database was enhanced with stewardship-specific interventions, and workbench reports were developed specific to AS needs. We herein review the process, advantages, and challenges associated with the development of the Epic AS module.

Conclusion

Customizing an AS module in an EHR requires significant time and expertise in antimicrobials; however, AS modules have the potential to improve the efficiency of AS personnel in performing daily stewardship activities and reporting through a single system.

The Genotype-to-Phenotype Dilemma: How Should Laboratories Approach Discordant Susceptibility Results?

Traditional culture-based methods for identification and antimicrobial susceptibility testing (AST) of bacteria take 2 to 3 days on average. Syndromic molecular diagnostic panels have revolutionized clinical microbiology laboratories as they can simultaneously identify an organism and detect some of the most significant antimicrobial resistance (AMR) genes directly from positive blood culture broth or from various specimen types (e.g., whole blood, cerebrospinal fluid, and respiratory specimens). The presence or absence of an AMR marker associated with a particular organism can be used to predict the phenotypic AST results to more rapidly guide therapy. Numerous studies have shown that genotypic susceptibility predictions by syndromic panels can improve patient outcomes. However, an important limitation of AMR marker detection to predict phenotype is the potential discrepancies that may arise upon performing phenotypic AST of the recovered organism in culture. The focus of this minireview is to address how clinical laboratories should interpret rapid molecular results from commercial platforms in relation to phenotypic AST. Stepwise approaches and solutions are provided to resolve discordant results between genotypic and phenotypic susceptibility results.

Impact of a Best Practice Advisory for Pediatric Patients With Staphylococcus aureus Bacteremia

BACKGROUND

Infectious diseases (ID) consultation and optimal antibiotic therapy improve outcomes in Staphylococcus aureus bacteremia (SAB). Data on strategies to improve adherence to these practices in children are limited.

METHODS

This was a quasi-experimental study evaluating the impact of an electronic medical record (EMR)-based best practice advisory (BPA) for SAB, recommending ID consult and optimal antibiotic therapy based on rapid mecA gene detection. Inpatients < 21 years old with SAB before (January 2015-July 2017) and after (August 2017-December 2018) BPA implementation were included. Primary outcome was receipt of ID consult. Secondary outcomes included receipt of optimal therapy, time to ID consult and optimal therapy, recurrent SAB, and 30-day all-cause mortality. ID consultation rates pre- and postimplementation were compared using interrupted time series (ITS) analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) for time to optimal therapy were calculated using Cox regression.

RESULTS

We included 99 SAB episodes (70 preintervention, 29 postintervention). Preintervention, 48 (68.6%) patients received an ID consult compared to 27 (93.1%) postintervention, but this was not statistically significant on ITS analysis due to a preexisting trend of increasing consultation. Median hours to optimal therapy decreased from 26.1 to 5.5 (P = .03), most notably in patients with methicillin-sensitive S. aureus (MSSA) (42.2 to 10.8; P < .01). On Cox regression, BPA implementation was associated with faster time to optimal therapy (HR, 3.22 [95% CI, 1.04-10.01]).

CONCLUSIONS

Implementation of an EMR-based BPA for SAB resulted in faster time to optimal antibiotic therapy, particularly for patients with MSSA. ID consultation increased throughout the study period and was not significantly impacted by the BPA.

Factors That Impact the Adoption of Clinical Decision Support Systems (CDSS) for Antibiotic Management

The study evaluated individual and setting-specific factors that moderate clinicians’ perception regarding use of clinical decision support systems (CDSS) for antibiotic management. A cross-sectional online survey examined clinicians’ perceptions about CDSS implementation for antibiotic management in Australia. Multivariable logistic regression determined the association between drivers of CDSS adoption and different moderators. Clinical experience, CDSS use and care setting were important predictors of clinicians’ perception concerning CDSS adoption. Compared to nonusers, CDSS users were less likely to lack confidence in CDSS (OR = 0.63, 95%, CI = 0.32, 0.94) and consider it a threat to professional autonomy (OR = 0.47, 95%, CI = 0.08, 0.83). Conversely, there was higher likelihood in experienced clinicians (>20 years) to distrust CDSS (OR = 1.58, 95%, CI = 1.08, 2.23) due to fear of comprising their clinical judgement (OR = 1.68, 95%, CI = 1.27, 2.85). In primary care, clinicians were more likely to perceive time constraints (OR = 1.96, 95%, CI = 1.04, 3.70) and patient preference (OR = 1.84, 95%, CI = 1.19, 2.78) as barriers to CDSS adoption for antibiotic prescribing. Our findings provide differentiated understanding of the CDSS implementation landscape by identifying different individual, organisational and system-level factors that influence system adoption. The individual and setting characteristics can help understand the variability in CDSS adoption for antibiotic management in different clinicians.

A Mobile App to Support Clinical Diagnosis of Upper Respiratory Problems (eHealthResp): Co-Design Approach

BACKGROUND

The misuse of antibiotics is a global public health issue that fosters bacterial resistance and jeopardizes generational health. The development of validated tools such as web-based courses and mobile apps to enhance clinical decisions in upper respiratory infections is of great importance in reducing the incorrect use of antibiotics in these situations.

OBJECTIVE

The aim of this study was to design and prevalidate the interface of a mobile app to assist and provide clinical support in the diagnosis of upper respiratory problems. We aimed to assess the adequacy and usability of the interface of the tool in the belief that it could be beneficial to health care delivery in the clinical decision setting.

METHODS

Using a co-design approach that brought together professionals in interface design and experts in pharmacology and pharmacoepidemiology, the mobile app interface was evaluated through peer review sessions held by interface design professionals on a heuristic survey. The reviewers accessed a high-fidelity interactive mock-up of the interface and filled in a questionnaire to assess the dimensions of layout and visual design and navigation and tasks. The resulting feedback of this evaluation supported the redesign of the primary interface, which was assessed for the second time by 2 of the previously mentioned reviewers.

RESULTS

With 4 as the highest score, the interface scored a mean of 3.16 (SD 0.45; median of the means 3.2) for layout and visual design and a mean of 3.43 (SD 0.33; median of the means 3.51) for navigation and tasks, reflecting an overall positive evaluation. The open-ended commentaries allowed us to better understand specific recommendations of the reviewers. Throughout this section, approximately 0.98 comments per parameter were registered, reflecting a high level of effectiveness of the chosen parameters in identifying potential problems. The resultant beta version of the interface, addressing the majority of the detected problems, was further assessed by 2 of the previous reviewers, validating the new design. Future tests with physicians and pharmacists will help assess credibility and user experience dimensions.

CONCLUSIONS

Our study revealed that the designed interface is easy to interpret and use. Peer reviewers raised important issues that could be easily fixed and positively reassessed. As a result, the study enabled us to produce a new tool for interface usability assessment and a set of recommendations for developing mobile interfaces for clinical decision support systems in the scope of upper respiratory problems.

Urinary tract infection stewardship: A urinary antibiogram and electronic medical record alert nudging narrower-spectrum antibiotics for urinary tract infections

An antimicrobial stewardship intervention consisting of a urinary antibiogram and an electronic health record best-practice advisory promoted narrower-spectrum antibiotics for uncomplicated urinary tract infections in hospitalized patients. Over 20 months, the intervention significantly reduced ceftriaxone orders by 48% (P < .001) and increased cefazolin use 19 times from baseline (P < .001).

Using the clinical information system and self-supervision to rationalize the need for antibiotic stewardship: An interventional study in a 2000-bed university hospital

OBJECTIVES

To describe the usefulness of electronic medical records (EMRs) and a computerized physician order entry (CPOE) system to support and assess an antimicrobial stewardship programme (ASP).

METHODS

At the study hospital, infectious diseases specialists supervise antimicrobial prescription when solicited by physicians in charge of patients. From January to October 2015, treatment days of antibiotic prescription, supervised or unsupervised by infectious disease specialists (SAP or UAP, respectively) in all wards, except intensive care units emergency department, bone marrow transplantation units, and paediatric units, were calculated. Embedding recommendations on carbapenem indications as a checklist into the CPOE system, a self-administered ASP was implemented in 2017. EMRs were reviewed to determine global compliance with carbapenem prescription guidelines (combining introduction of therapy and 72-h assessment) before and after implementation of a self-administered ASP in departments with a low SAP rate for these antibiotics.

RESULTS

Among 16 090 prescriptions extracted, 19.9% were SAPs. Three patterns of prescription were identified. The first pattern (amoxicillin-clavulanate, ceftriaxone) was characterized by a high UAP rate in every department, the second pattern (cloxacillin, rifampin) was characterized by a high SAP rate in every department, and the third pattern (broad-spectrum beta-lactams) was characterized by heterogeneous distribution of SAP/UAP among departments. Carbapenem prescription was reviewed in five departments with a low SAP rate for carbapenems over 6 months: 94 before and 107 after implementation of the self-administered ASP. Global compliance with guidelines increased significantly from 22% to 37% (risk difference 15%, 95% confidence interval 2.3-28.5%; P=0.02).

CONCLUSION

A clinical information system may help to rationalize antibiotic stewardship in a context of scarce medical resources. Mapping of antibiotic prescriptions and self-supervision are efficient, complementary and easy-to-implement tools.

India Antimicrobial Stewardship and Resistance (INTEREST) 2018: A needs assessment survey

Antimicrobial resistance is a major problem in India with limited understanding of whether this issue is related to systems, prescriber characteristics, patient characteristics, or diagnostic technologies. In our survey, most of the issues lie in the easy availability of antimicrobials and the lack of electronic storage of medical and microbiological records.

Antimicrobial Stewardship: What the Clinical Laboratory Needs to Know

Misuse of antibiotics, including unnecessary use or inappropriate selection, may result in side effects and poor outcome in individual patients, as well as contribute to the spread of antimicrobial resistance. Antimicrobial stewardship programs exist to reduce such misuse of antibiotics and ill effect in order to promote patient outcome. The importance of diagnostics, antibiogram data, possible interventions, and impact are reviewed. It is essential for clinical microbiologists and other health care members to understand the field and scope of antimicrobial stewardship, actively participate in, and understand the value they bring to supporting their institution's efforts.

Clinimetric properties and suitability of selected quality indicators for assessing antibiotic use in hospitalized adults: a multicentre point prevalence study in 24 hospitals in Germany

OBJECTIVES

The capability to measure and monitor the quality of antibiotic prescribing is an important component of antibiotic stewardship (ABS) programmes. Several catalogues of consensus-based structure and process-of-care quality indicators (QIs) have been proposed, but only a few studies have tested and validated ABS QIs in practice tests. This multicentre study determined the clinimetric properties and suitability of a set of 33 process QIs for ABS that had earlier been developed and in part recommended in a German-Austrian hospital ABS practice guideline.

METHODS

Two point prevalence surveys were conducted in a convenience sample of 24 acute care hospitals throughout Germany, and data of all screened adult inpatients with prescription of a systemic antibiotic at a given day (n=4310) were included in the study. For each QI, the following clinimetric properties were assessed: applicability, feasibility, performance, case mix stability and interobserver reliability.

RESULTS

Eighteen QIs were considered sufficiently feasible, applicable and reliable, and had adequate room for improvement. The finally selected QIs primarily cover antibiotic therapy of common infections (bloodstream infection, pneumonia and urinary tract infection), while two of the QIs each address surgical prophylaxis and general aspects of antibiotic administration.

CONCLUSIONS

Practice tests may be important to test the suitability of consensus process-of-care QIs in the field of hospital ABS. The 18 selected QIs considered suitable enough for hospital ABS in this study should be regarded as priority QIs useful for internal quality control and assurance. More research and additional practice tests may be needed to confirm their suitability for external quality assessment schemes.

Effectiveness of Electronic Guidelines (GERH®) to Improve the Clinical Use of Antibiotics in An Intensive Care Unit

The objective of the study was to evaluate the capacity of GERH^®-derived local resistance maps (LRMs) to predict antibiotic susceptibility profiles and recommend the appropriate empirical treatment for ICU patients with nosocomial infection. Data gathered between 2007 and 2016 were retrospectively studied to compare susceptibility information from antibiograms of microorganisms isolated in blood cultures, lower respiratory tract samples, and urine samples from all ICU patients meeting clinical criteria for infection with the susceptibility mapped by LRMs for these bacterial species. Susceptibility described by LRMs was concordant with in vitro study results in 73.9% of cases. The LRM-predicted outcome agreed with the antibiogram result in >90% of cases infected with the bacteria for which GERH^® offers data on susceptibility to daptomycin, vancomycin, teicoplanin, linezolid, and rifampicin. Full adherence to LRM recommendations would have improved the percentage adequacy of empirical prescriptions by 2.2% for lower respiratory tract infections (p = 0.018), 3.1% for bacteremia (p = 0.07), and 5.3% for urinary tract infections (p = 0.142). LRMs may moderately improve the adequacy of empirical antibiotic therapy, especially for lower respiratory tract infections. LRMs recommend appropriate prescriptions in approximately 50% of cases but are less useful in patients with bacteremia or urinary tract infection.

Antimicrobial Stewardship by Leveraging Electronic Medical Records

This paper describes how an antimicrobial stewardship program was successfully developed and integrated into a university medical center's electronic healthcare records and improved antibiotic selection.

A survey of Chinese pharmacists participating in anti-infective therapy and its related information technology support

WHAT IS KNOWN AND OBJECTIVE

Anti-infective therapy is the major daily work for most clinical pharmacists in China, and information technology (IT) support for them is very important. However, the current situation of pharmacists' roles in anti-infective therapy and related IT support are seldom reported. The aim of the study was to investigate the current situation of pharmacists participating in anti-infective therapy and the corresponding hospital IT support, which may help identify and solve related problems and facilitate pharmacists to play better roles.

METHODS

A 15-item questionnaire was distributed online to clinical pharmacists from Chinese hospitals. Pharmacists answered the questions on the WeChat platform. Data were analysed using descriptive statistics.

RESULTS AND DISCUSSION

A total of 272 valid questionnaires were returned, and the respondents were from 27 provinces (or autonomous regions or municipalities) of China covering over 15 specialties. Most of the respondents (76.1%) were from tertiary hospitals and 72.4% of all the respondents participated in anti-infective therapy. They mainly performed drug selection (95.4%), dose adjustment (88.8%) and adverse drug reaction monitoring (84.8%) for anti-infective therapy, in ways such as consultation (71.1%), drug consult (86.3%) and prescription evaluation (88.8%). Most pharmacists (93.0%) thought that the modules of anti-infective therapy in hospital IT system needed to be advanced, in the aspects of doctor-pharmacist interaction, convenience for pharmacists to control drug expenses and integration of multi-functions for anti-infective therapy.

WHAT IS NEW AND CONCLUSION

The roles of Chinese clinical pharmacists in anti-infective therapy are becoming increasingly clear, and establishing smart, pharmacist-friendly and highly-integrated electronic interfaces will facilitate the establishment of pharmacist-driven anti-infective therapy team, thus improving work efficiency and user experience.

Collaborative Antimicrobial Stewardship: Working with Information Technology

Information technology (IT) is vitally important to making antimicrobial stewardship a scalable endeavor in modern health care systems. Without IT, many antimicrobial interventions in patient care would be missed. Clinical decision support systems and smartphone apps, either stand-alone or integrated into electronic health records, can all be effective tools to help augment the work of antimicrobial stewardship programs and support the management of infectious diseases in any health care setting.

Development of Patient Databases for Endocrinological Clinical and Pharmaceutical Trials: A Survey

BACKGROUND

According to European legislation, a clinical trial is a research involving patients, which also includes a research end-product. The main objective of the clinical trial is to prove that the research product, i.e. a proposed medication or treatment, is effective and safe for patients. The implementation, development, and operation of a patient database, which will function as a matrix of samples with the appropriate parameterization, may provide appropriate tools to generate samples for clinical trials.

AIMS

The aim of the present work is to review the literature with respect to the up-to-date progress on the development of databases for clinical trials and patient recruitment using free and open-source software in the field of endocrinology.

METHODS

An electronic literature search was conducted by the authors from 1984 to June 2019. Original articles and systematic reviews selected, and the titles and abstracts of papers screened to determine whether they met the eligibility criteria, and full texts of the selected articles were retrieved.

RESULTS

The present review has indicated that the electronic health records are related with both the patient recruitment and the decision support systems in the domain of endocrinology. The free and open-source software provides integrated solutions concerning electronic health records, patient recruitment, and the decision support systems.

CONCLUSION

The patient recruitment relates closely to the electronic health record. There is maturity at the academic and research level, which may lead to good practices for the deployment of the electronic health record in selecting the right patients for clinical trials.

Implementation of a Clinical Decision Support Tool to Improve Antibiotic IV-to-Oral Conversion Rates at a Community Academic Hospital

BACKGROUND

Antibiotic IV-to-oral (IV-PO) conversion is a key initiative of antimicrobial stewardship programs. Guidelines and education are commonly described interventions to promote IV-PO conversion; however, technological interventions may be more effective in changing practice.

OBJECTIVE

To determine the impact of a clinical decision support (CDS) tool on the adoption and sustainability of an antibiotic IV-PO conversion program at a community academic hospital.

METHODS

A quasi-experimental study consisting of 3 phases was conducted. During phase 1, the pre-intervention antibiotic IV-PO conversion rate was determined. During phase 2, the IV-PO conversion policy was updated, education was provided to pharmacists and physicians, and a post-intervention evaluation was conducted. During phase 3, a CDS tool was developed to generate real-time electronic alerts prompting pharmacists to assess antibiotic therapy, and post-intervention audits were performed 1 month, 3 months, and 15 months after implementation of the tool. Pantoprazole IV-PO conversion was assessed during each phase as a non-equivalent dependent variable. The primary outcome was the proportion of patients eligible for IV-PO conversion who were switched to oral therapy.

RESULTS

Of 332 patients receiving targeted IV antibiotic therapy during the overall study period, 122 (37%) met the criteria for IV-PO conversion. The phase 2 IV-PO conversion rate of 35% (9/26) was comparable to the pre-intervention rate of 29% (10/35) (p = 0.61). Implementation of the CDS tool significantly increased the conversion rate to 78% (14/18), an increase that was sustained at 3 months (71% [17/24]) and 15 months (74% [14/19]) after implementation (p < 0.05 for all comparisons with phases 1 and 2). Pantoprazole conversion rates were similar across all phases.

CONCLUSIONS

Implementation of the CDS tool was effective in improving and sustaining antibiotic IV-PO conversion rates and enhancing policy compliance beyond the effects of policy revision and education. Refinement of both the policy and the tool is warranted to maximize adoption of the IV-PO conversion program.

Customizing an Electronic Medical Record to Automate the Workflow and Tracking of an Antimicrobial Stewardship Program

Background

Documenting the actions and effects of an antimicrobial stewardship program (ASP) is essential for quality improvement and support by hospital leadership. Thus, our ASP tallies the number of charts reviewed, types of recommendations, how and to whom they were communicated, whether they were followed, and any effects on antimicrobial days of therapy. Here we describe how we customized the electronic medical record at our institution to facilitate our workflow and data analysis, while highlighting principles that should be adaptable to other ASPs.

Methods

The documentation system involves the creation of a novel and intuitive ASP form in each chart reviewed and 2 mutually exclusive tracking systems: 1 for active forms to facilitate the daily ASP workflow and 1 for finalized forms to generate cumulative reports. The ASP form is created by the ASP pharmacist, edited by the ASP physician, reopened by the pharmacist to assess whether the recommendation was followed and to quantify any antimicrobial days avoided or added, then reviewed and finalized by the ASP physician. Active forms are visible on a real-time “MPage,” whereas all finalized forms are compiled nightly into 65 informative tables and associated graphs.

Results and Conclusions

This system and its underlying principles have automated much of the documentation, facilitated follow-up of interventions, improved the completeness and validity of recorded data and analysis, enabled our ASP to expand its activities, and been associated with decreased antimicrobial usage, drug resistance, and Clostridioides difficile infections.

The Role of Antibiotic Stewardship in Promoting Appropriate Antibiotic Use

Antibiotics are one of the most significant medical discoveries in human history. The widespread use of antibiotics has resulted in the emergence of antibiotic-resistant pathogens. This fact, coupled with the paucity of new antibiotic developments, has spurred efforts to combat antibiotic resistance. One of the most critical components of these efforts is antibiotic stewardship, a multidisciplinary endeavor, employing a collection of interventions in a variety of health care settings with the aim of promoting appropriate utilization of antibiotics. This article describes antibiotic stewardship programs and key practices used to minimize the development and spread of antibiotic-resistant pathogens including the optimization of antibiotic pharmacokinetics and pharmacodynamics, the application of rapid diagnostic tools, and the use of computerized provider order entry tools.

Antimicrobial stewardship during a time of rapid antimicrobial development: Potential impact on industry for future investment

In response to the antimicrobial resistance crisis, pharmaceutical industry reinvested in and produced new antibiotics. Antimicrobial stewardship programs influence optimal antimicrobial use, which often places them at the cross-roads of resistance and treatments. We surveyed a clinical administration database of US medical centers between 2014 and 2018 for index antimicrobial utilization date of six Qualified Infectious Diseases Products (QIDP). Among 132 hospitals identified, the median time to use any agent was 398 days (range 13 to >1478 days). QIDP antibiotic use was more likely among academic medical centers (range 34%-88%) and hospitals >400 beds (range 39%-86%) compared to non-academic medical center (3-51%) and smaller and hospitals (range 0-61%). The South was quickest to use all QIDP (median 733 days), while the Northeast was longest at 1370 days. New antimicrobials have limited clinical use, which impacts manufacturers' ability to stay in the antimicrobial market and further risking a depleted antimicrobial pipeline.