Antimicrobial stewardship programs: how to start and steer a successful program

Impact evaluation of guidelines on antibiotic utilisation & appropriateness in Malaysian public primary care: an interrupted time series analysis

Background

The National Antimicrobial Guidelines (NAG) 2014 and NAG2019 in Malaysia targeted rational and judicious use of antimicrobials. In this study, we assessed the change in antibiotic utilisation and appropriateness due to the guidelines that were implemented from 2011 to 2019.

Methods

Interrupted time series analyses on rates of antibiotic appropriateness and utilisation were performed using prescription data from public primary care clinics in Malaysia between January 2011 and December 2019. Rates of antibiotic utilisation, reported as Defined Daily Dose (DDD) per 1000 patients per day, were stratified by antibiotic classes.

Results

Of the 16,081,492 prescriptions recorded during the study period, 4.98% (n = 800,899) contained antibiotics. NAG2014 resulted in a significant increase in antibiotic utilisation trend by 0.029 (p < 0.0001) while NAG2019 had a substantial impact on antibiotic utilisation, decreasing DDD by 1778 and increasing appropriateness by 54.6% (p < 0.0001). Variation in the number of antibiotic molecules being prescribed also decreased after NAG2019.

Conclusion

Our findings indicate that the introduction of NAG2019 led to a substantial improvement in antibiotic appropriateness. At the same time, antibiotic utilisation decreased. Further research is needed to ascertain and ensure the sustainability of these changes and to establish targeted improvement strategies focusing on reducing inappropriate and unnecessary prescribing.

Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey

BACKGROUND

Recent evidence highlights the need for an interdisciplinary approach to antimicrobial stewardship (AMS). Nursing involvement in optimising antimicrobials in the intensive care unit (ICU) remains understudied.

OBJECTIVE

The objective of this study was to explore nurses' perceptions and experiences of antimicrobial optimisation or stewardship in ICUs in Australia.

METHODS

An anonymous web-based survey was deployed nationally in early 2021 through two ICU nursing networks. Associations between survey responses were analysed descriptively and by using nonparametric tests (with statistical significance established at p ≤ 0.05). Free-text survey responses underwent qualitative thematic analysis. Interpretation and reporting of quantitative and qualitative data were integrated.

RESULTS

A total of 226 ICU nurses completed the survey. The majority (197/226; 87%) responded that lack of education limits engagement in AMS. Only 13% (30/226) reported the presence of AMS education and training for nurses in their ICUs. Only about half (108/226; 48%) of the nurses were confident to question prescribers when they considered that the antimicrobial prescribed was unnecessary, with nurses in senior roles more likely to do so than nurses providing bedside care (p < 0.05). Gaps in education (including unfamiliarity with AMS roles), noninclusive antimicrobial discussions, moral distress, and potential workload burden were seen as potential barriers/challenges to engagement.

CONCLUSION

The multifactorial barriers identified that inhibit nurses from performing AMS tasks could be addressed by strengthening interprofessional education at all levels and by applying practical AMS interventions that are inclusive for nursing participation. A purposeful culture change that fosters psychological safety and collaborative practice is paramount to supporting nurses in these roles.

Antifungal stewardship: What we need to know

Antimicrobial stewardship refers to a well-coordinated program which promotes the scientific and rational use of antimicrobials, reduces the chances of drug resistance and improves patient outcomes. A comprehensive English language literature search was done across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for the period 1990-2022, revealing a large volume of reports of growing resistance to established antifungal therapies, against a backdrop of irrational and unscientific prescriptions. As a result of this, antifungal stewardship, a new kid on the block, has recently garnered attention. This review article is an attempt to summarise the basic concept of stewardship programs, highlighting the dire need to implement the same in the present situation of antifungal resistance and treatment failure.

Point-prevalence surveys of antimicrobial consumption and resistance at a paediatric and an adult tertiary referral hospital in Yangon, Myanmar

BACKGROUND

Antimicrobial resistance is increasingly prevalent worldwide. The inappropriate use of antimicrobials, including in the hospital setting, is considered a major driver of antimicrobial resistance.

AIM

To inform improvements in antimicrobial stewardship, we undertook point prevalence surveys of antimicrobial prescribing at Yangon Children's Hospital and Yangon General Hospital in Yangon, Myanmar.

METHODS

We conducted our surveys using the Global Point-Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) method. All inpatients who were prescribed an antimicrobial on the day of the survey were included in the analysis.

FINDINGS

We evaluated a total of 1,980 patients admitted to two hospitals during December 2019. Of these, 1,255 (63.4%) patients were prescribed a total of 2,108 antimicrobials. Among antimicrobials prescribed, 722 (34.3%) were third-generation cephalosporins, the most commonly prescribed antimicrobial class. A total of 940 (44.6%) antimicrobials were prescribed for community-acquired infection, and 724 (34.3%) for surgical prophylaxis. Of 2,108 antimicrobials, 317 (15.0%) were prescribed for gastrointestinal tract prophylaxis, 305 (14.5%) for skin, soft tissue, bone and joint prophylaxis, and 303 (14.4%) for pneumonia treatment. A stop or review date was documented for 350 (16.6%) antimicrobial prescriptions, 673 (31.9%) antimicrobial prescriptions were guideline compliant, and 1,335 (63.3%) antimicrobials were administered via the parenteral route. Of 1,083 antimicrobials prescribed for a therapeutic use, 221 (20.4%) were targeted therapy.

CONCLUSION

Our findings underscore the need to update and expand evidence-based guidelines for antimicrobial use, promote the benefits of targeted antimicrobial therapy, and support the implementation of hospital-based antimicrobial stewardship programmes at the hospitals surveyed.

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.

Cross-sectional study on the drug utilization and evaluation indicator of antibiotics used in pediatric population

Background

The lack of medication standards is a serious problem in paediatrics mainly because of age-related differences in organ development and physiological functions in children. Consequently, dosage measurement becomes inaccurate. For this reason, methods for evaluating and monitoring rational paediatric medications should be developed. Drug use indicators, such as those similar to the drug utilisation index (DUI) based on the Anatomical Therapeutic Chemical/Defined Daily Dose (DDD) and widely used for the assessment of appropriate dosage in adults, should be explored in terms of their applicability to children.

Methods

A total of 5,538 prescriptions of antibiotics selected from a general teaching hospital were included. Drug, dose, frequency and treatment duration were obtained from each prescription. The prescription daily dose (PDD) of each antibiotic drug was calculated as the average of the daily doses. Underdose and overdose were determined in terms of the PDD/DDD ratio for each prescription. Children’s DUI (cDUI) was explored in terms of the appropriate dosage for children as follows: the meaning of children’s DDD (cDDD) and the evaluation of paediatric drug dosage.

Results

The top five antibiotics and their utilisation rates were as follows: cefmetazole sodium injection (18.47 %), erythromycin lactobionate injection (15.07 %), amoxicillin/clavulanate potassium injection (10.72 %), ceftriaxone sodium injection (9.50 %) and azithromycin dry suspension (8.02 %). The ratio of cDUI and PDD/cDDD was mostly not close to 1.

Conclusions

The establishment of a cDUI system is an effective means of paediatric dosage evaluation. In addition to DDDs, cDUI and PDD/cDDD should be used to analyse the utilisation of antibiotics in children.

Core Elements for Successful Implementation of Antimicrobial Stewardship Programs

Antimicrobial resistance has emerged as a serious global public health threat. One of the countermeasures to increased antibiotic-resistant bacterial infections is the use of an integrative intervention strategy for the selection and administration of appropriate antibiotics and for the monitoring of antibiotic use, collectively known as "Antimicrobial Stewardship Programs" (ASPs). However, since the medical environment and policies vary by country and medical facilities, ASPs also need to be applied to each facility and condition accordingly. The United States Centers for Disease Control and Prevention announced the core elements for hospital ASPs, which outlines the specific structural and procedural components required to implement ASPs in 2014. As multidrug-resistant bacterial infections and use of broad-spectrum antibiotics in Korea are on the rise, ASPs must be urgently applied to medical facilities for appropriate management of antibiotic use. However, there is an ongoing limitation to the immediate adoption and application of ASPs in Korean medical facilities due to the lack of medical workforce and related financial resources. To address this issue, efforts of medical professionals and government are required, and core elements that match the characteristics and circumstances of Korean medical facilities must be urgently developed.

The Role of PK/PD Analysis in the Development and Evaluation of Antimicrobials

Pharmacokinetic/pharmacodynamic (PK/PD) analysis has proved to be very useful to establish rational dosage regimens of antimicrobial agents in human and veterinary medicine. Actually, PK/PD studies are included in the European Medicines Agency (EMA) guidelines for the evaluation of medicinal products. The PK/PD approach implies the use of in vitro, ex vivo, and in vivo models, as well as mathematical models to describe the relationship between the kinetics and the dynamic to determine the optimal dosing regimens of antimicrobials, but also to establish susceptibility breakpoints, and prevention of resistance. The final goal is to optimize therapy in order to maximize efficacy and minimize side effects and emergence of resistance. In this review, we revise the PK/PD principles and the models to investigate the relationship between the PK and the PD of antibiotics. Additionally, we highlight the outstanding role of the PK/PD analysis at different levels, from the development and evaluation of new antibiotics to the optimization of the dosage regimens of currently available drugs, both for human and animal use.

Perception and practices of community pharmacists towards antimicrobial stewardship in Lahore, Pakistan

OBJECTIVES

Antimicrobial resistance is a major health concern worldwide. Community pharmacists can play an important role in rational antibiotic use. This study aimed to evaluate the perception and practices of community pharmacists regarding antimicrobial stewardship (AMS) in Lahore, Pakistan.

METHODS

A descriptive cross-sectional study was conducted among community pharmacists in Lahore from 1 November 2017 to 31 December 2017. A self-administered questionnaire was used for data collection. Non-probability convenience sampling was performed to select community pharmacists. Descriptive statistics were applied and Mann-Whitney U-tests and Kruskal-Wallis tests were performed to compare independent groups using SPSS v.20.0. A P-value of <0.05 was considered statistically significant. Perception and practice scores were determined to access community pharmacist knowledge regarding AMS. A score of 0.5-1 was considered to be very good.

RESULTS

The overall response rate was 70.9%. Sex, age, work experience and education level did not significantly influence the perception and practices of community pharmacists. Experienced pharmacists showed a better response to AMS. The majority of pharmacists strongly agreed that they educate patients on the use of antimicrobials and resistance-related issues.

CONCLUSION

It was concluded that community pharmacists in Lahore have good perception regarding AMS and they are practicing it well. But there are several gaps in their practices that must be filled, such as dispensing without a prescription and dispensing for a longer duration than prescribed. Additionally, there should be strict implementation of guidelines for dispensing antibiotics in order to rationalise antibiotic use and decrease antimicrobial resistance.

The tripartite insurance model (TIM): a financial incentive to prevent outbreaks of infections due to multidrug-resistant microorganisms in hospitals

Healthcare-associated infections caused by multidrug-resistant organisms (MDROs) constitute a major challenge worldwide, but care providers are often not sufficiently incentivized to implement recommended infection prevention measures to prevent the spread of such infections. We propose a new approach which creates incentives for hospitals, external laboratories and insurers to collaborate on preventing MDRO outbreaks by testing more and implementing infection prevention measures. This tripartite insurance model (TIM) redistributes the costs of preventing and combating MDRO outbreaks in a way that all parties benefit from reducing the number of outbreaks.

Evaluating the appropriateness of carbapenem and piperacillin-tazobactam prescribing in a tertiary care hospital in Saudi Arabia

Background

Antimicrobial resistance (AMR) is presently considered an emergent major global public health concern and excessive and/or inappropriate use of broad-spectrum antimicrobials contribute to the development of AMR.

Objective

To evaluate the appropriateness of carbapenems and piperacillin-tazobactam use in a tertiary care hospital.

Methods

A retrospective, observational, cross-sectional, drug-utilization study was conducted. The study included all adult hospitalized patients who had received at least one dose of the antimicrobials during their admission for the period between 1 January 2016 and 31 December 2017. The appropriateness of antimicrobial therapy was evaluated according to the Infectious Diseases Society of America (IDSA) guidelines with the consideration of the institutional antibiogram.

Results

Overall, 2731 patients received 5005 courses with one of the antimicrobials, for a total of 5045.9 defined daily doses (DDD) of imipenem-cilastatin, 6492.3 of meropenem and 15,595 of piperacillin-tazobactam (4.93, 6.34 and 15.24 DDD/100 bed days, respectively). The mean age of the patients who received either antimicrobial was 55.5 ± 20.3 years, with a 14-day average length of hospital stay. About half (52%) of the prescriptions were written for patients treated in the medical ward. Pneumonia (26.6%) and sepsis (24.9%) were the most common indication for the initiation of antimicrobial therapy. Of the assessed prescriptions, only 2787 (56.5%) were prescribed appropriately, with 2142 (43.5%) deemed inappropriate. The three most common reasons for inappropriate prescription were: the spectrum of activity was too broad (44.6%), followed by antimicrobial use without culture request (32.4%), and failure of suitable antimicrobial de-escalation (19.9%).

Conclusions

The study indicates that the overall rate of inappropriateness was high, emphasizing the need to develop initiatives to effectively improve broad-spectrum antimicrobial prescribing.

Empowerment of nurses in antibiotic stewardship: a social ecological qualitative analysis

BACKGROUND

Inappropriate antibiotics use and antimicrobial resistance (AMR) are increasingly becoming global health issues of great concern. Despite the established antibiotic stewardship programmes (ASPs) in many countries, limited efforts have been made to engage nurses and clearly define their roles in ASPs.

AIM

An exploratory qualitative study was conducted to understand the facilitators and barriers that impact nurses' involvement and empowerment in antibiotic stewardship.

METHODS

Focus group discussions (FGDs) were conducted with purposively sampled nurses from three major public hospitals in Singapore. FGDs were audio-recorded and transcribed verbatim. Data were analysed using Applied Thematic Analysis and interpreted using the Social Ecological Model.

FINDINGS

At the intrapersonal level, nurses felt empowered in carrying out their roles in antibiotic administration. They saw themselves as gatekeepers to ensure that the prescribed antibiotics were administered appropriately. However, nurses felt they lacked the knowledge and expertise in antibiotic use and AMR prevention. At the interpersonal level, this deficit in knowledge and expertise in antibiotic use impacted how they were perceived by patients and caregivers as well as their interactions with the primary care team when voicing outpatient safety concerns and antibiotic administration suggestions. At the organizational level, nurses relied on drug administration guidelines to ensure appropriate antibiotic administration and as a safety net when physicians questioned their clinical practice. At the community level, nurses felt there was a lack of awareness and knowledge on antibiotic use among the general population.

CONCLUSION

These findings provide important insights to harness the contributions of nurses, and to formally acknowledge and enlarge their roles in ASPs.

Surgeons Do Not Listen: Evaluation of Compliance with Antimicrobial Stewardship Program Recommendations

The purpose of this study was to determine if there are differences in interventions (int) required and compliance (comp) to recommendations (rec) by medical and surgical services as determined by an antimicrobial stewardship program (ASP). Concurrently collected ASP data from January 2008 through May 2011 were evaluated to determine number of int required and response to int. Results for medical (med) and surgical (surg) services were compared. There were 2322 int, of which 1108 were for med and 1214 were for surg. Recs were as follows: 242 appropriate coverage (AC) med versus 212 AC surg and 866 selective pressure (SP) med and 1002 SP surg. Comp with recs was higher for med: AC: 90.5 per cent (219 of 242) med versus 82.1 per cent (174 of 212) surg ( P = 0.0086) and SP: 81.1 per cent (702 of 866) med versus 69.5 per cent (696 of 1002) surg ( P < 0.0001). Overall surgical comp with ASP recs was better for AC than for SP. Moreover, less than half (seven of 15) of the surgical subspecialties demonstrated a comp of 75 per cent or greater with SP recs with only one-fifth having a comp over 80 per cent. Surgical services demonstrate poor compliance with ASP recommendations; this is especially true for interventions targeting selective pressure. By identifying services that are less compliant, programs can target their educational efforts to improve outcomes.

Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program

Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.

Economic Burden Of Inappropriate Empiric Antibiotic Therapy: A Report From Southern Iran

Introduction

Widespread inappropriate antibiotic prescribing by healthcare professionals in the hospital setting is a great concern that may cause many undesirable consequences. Adherences to antibiotic guidelines have proven to be a simple and effective intervention to guide the choice of appropriate empiric antibiotic regimens and reduce the unnecessary variations in the practice among practitioners. The objective of this study was to evaluate the prescription patterns of empiric antibiotic therapy in relation to treatment guidelines and the economic burden of discordance with guidelines in a major referral Iranian university hospital.

Method

Hospital records of hospitalized patients with empiric antibiotic prescription, from September 2016 to February 2017 were reviewed. The process consisted of comparing empiric antimicrobial administration with institutional guidelines for each patient by a clinical pharmacist and an infectious disease specialist to evaluate the appropriate utilization of antibiotics. Adherence to guideline, the cost of antibiotics usage for each patient and the excess cost consequent from discordance with guideline was calculated.

Results

The most inappropriate prescribed antibiotics were carbapenems and aminoglycosides. Overall guideline adherence was 27.8%. Frequency of antibiotic usage incompatibility with the guidelines on the basis of dosing interval, duration of therapy and drug indication were 31.46%, 29.44% and 19.36%, respectively. General surgery and internal medicine wards had the least and the most inappropriate antibiotic administration, respectively. Totally antibiotic usage cost was 578,959.39 USD (24,316,294,800 Iranian Rials, IRR) for 6 months, which the excess costs of inappropriate antibiotic prescribing, was 471,319.69 USD (19,795,427,225 IRR). The estimated annual excess cost is 942,639.38 USD (39,590,854,450 IRR).

Conclusion

In this research, physicians’ adherence with guidelines for empiric antibiotic therapy was low which was led to 471,319.69 USD excess costs. These results urge institution policy makers to develop guidelines to ensure active dissemination and implementation of them to decrease inappropriate antibiotic usage.

Structure of Antimicrobial Stewardship Programs in Leading US Hospitals: Findings of a Nationwide Survey

Background

To examine antibiotic stewardship program (ASP) structure among high-performing hospitals and determine which components of the 2016 Infectious Diseases Society of America (IDSA)/Society for Hospital Epidemiology of America (SHEA) ASP guidelines are implemented at each site.

Methods

A survey of the highest-ranking hospitals, compiled from the 2015–2016 US News and World Report’s Best Hospital Rankings, was conducted from August to December 2016. This corresponded to 138 adult and 62 pediatric unique hospitals. We inquired as to which components of the 2016 IDSA/SHEA ASP guidelines were implemented at each site. Appropriate persons at each hospital were emailed surveys after telephone or email conversations confirmed that they belonged to that hospital’s ASP.

Results

Overall, 101 of 200 hospitals responded (51%). Of these, 82% (n = 83/101) had an active ASP, and 59% (n = 47/80) were active for more than 5 years. Most report to a committee rather than to an individual (n = 68/80, 85%), do not have their own budget (n = 42/80, 53%), and selectively implement IDSA/SHEA recommendations. Additionally, the majority of ASPs in top hospitals follow aspects of The Joint Commission Standards for Antimicrobial Stewardship, which were released after the survey was administered.

Conclusions

Of leading US hospitals responding to our survey, >80% had an ASP, and most implemented the majority of commitments, interventions, and optimization strategies suggested by IDSA/SHEA. Understanding the structure of ASPs in these hospitals will assist other hospitals in program implementation.

Knowledge and Practice of Pharmacists toward Antimicrobial Stewardship in Pakistan

Background: The irrational use, “over the counter supply”, and unregulated supply chains of antimicrobials are contributing toward antimicrobial resistance. Antimicrobial stewardship programs regulate antimicrobials usage to prevent resistance and reduce health care burden. Objective: To assess the knowledge and practice of pharmacists’ working in various healthcare settings toward antimicrobial stewardship in Pakistan. Method: A cross-sectional study was conducted among pharmacists working in different sectors between March to June 2017. Results: A total of 181 pharmacists participated, of whom (n = 145, 80.1%) were males. The majority of participants were in the 20–30 age group (n = 147, 81.2%) and hold Doctor of Pharmacy degrees. More than 80% of pharmacists agreed that “antimicrobial stewardship is essential to improve patient care”; while (n = 159, 87.8%) pharmacists agreed that “pharmacist should be trained on the use of antimicrobial”. Close to 90% of pharmacists agreed that “adequate training should be provided to pharmacists on antimicrobial use”. Regarding the practice of antimicrobial stewardship, (n = 72, 39.8%) pharmacists often/always “make efforts to prevent or reduce the transmission of infections within the community”; (n = 58, 32%) pharmacists never “dispense antimicrobials without a prescription”; and (n = 60, 32%) pharmacist often/always “communicate with prescribers if unsure about the appropriateness of an antibiotic prescription”. Conclusions: Increased antimicrobial stewardship efforts can both optimize the treatment of infections and reduce adverse events associated with antibiotic use. Pharmacists in Pakistan have good knowledge and adopt positive practices toward antimicrobial stewardship. Pharmacist and other health care professionals should collaborate within multi-disciplinary teams to reduce the problem of antimicrobial resistance and improve the quality of life of patients.

The social biography of antibiotic use in smallholder dairy farms in India

Background

Antimicrobial resistance (AMR) has been identified as one of the major threats to global health, food security and development today. While there has been considerable attention about the use and misuse of antibiotics amongst human populations in both research and policy environments, there is no definitive estimate of the extent of misuse of antibiotics in the veterinary sector and its contribution to AMR in humans. In this study, we explored the drivers ofirrational usage of verterinary antibiotics in the dairy farming sector in peri-urban India.

Methods and materials

The study was conducted in the peri-urban belts of Ludhiana, Guwahati and Bangalore. A total of 54 interviews (formal and non-formal) were carried out across these three sites. Theme guides were developed to explore different drivers of veterinary antimicrobial use. Data was audio recorded and transcribed. Analysis of the coded data set was carried out using AtlasTi. Version 7. Themes emerged inductively from the set of codes.

Results

Findings were presented based on concept of 'levels of analyses'. Emergent themes were categorised as individual, health systems, and policy level drivers. Low level of knowledge related to antibiotics among farmers, active informal service providers, direct marketing of drugs to the farmers and easily available antibiotics, dispensed without appropriate prescriptions contributed to easy access to antibiotics, and were identified to be the possible drivers contributing to the non-prescribed and self-administered use of antibiotics in the dairy farms.

Conclusions

Smallholding dairy farmers operated within very small margins of profits. The paucity of formal veterinary services at the community level, coupled with easy availability of antibiotics and the need to ensure profits and minimise losses, promoted non-prescribed antibiotic consumption. It is essential that these local drivers of irrational antibiotic use are understood in order to develop interventions and policies that seek to reduce antibiotic misuse.

Antibiotic use among older adults on an acute care general surgery service

BACKGROUND

Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital.

METHODS

Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines.

RESULTS

During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses.

CONCLUSION

Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment.

Reducing Antibiotic Use in Respiratory Syncytial Virus-A Quality Improvement Approach to Antimicrobial Stewardship

Supplemental Digital Content is available in the text.

Objective:

The increased incidence of multidrug-resistant organisms is associated with increased morbidity, mortality, hospital length of stay, and cost. Estimates show that up to 50% of antimicrobial use is inappropriate. This initiative focuses on inappropriate use of antibiotics in respiratory syncytial virus (RSV) infections. This virus is the most common cause of bronchiolitis during childhood.

Methods:

Baseline data from the 2011–2012 RSV season showed that 56.2% of our RSV-positive patients received antibiotics. To decrease inappropriate antibiotic use in RSV infections, we established an antimicrobial stewardship program (ASP). This process improvement initiative aimed to decrease exposure to antibiotics and days of antibiotic therapy per 1,000 patient days (DOT/1000PD) in hospitalized RSV-positive patients by 25%. Key drivers included building health-care knowledge, proactive interventions using prospective audit and feedback, emergency department engagement, and performance dashboards.

Results:

We included a total of 290 children in the final analysis. After full implementation of the ASP, there was a significant reduction of antibiotic exposure from 56.2% to 30.9% (P < 0.001), an absolute reduction of 25% and a relative reduction of 45%. There was also a significant decrease in DOT/1000PD from 432.7 to 268.1 days (P = 0.017). This change represents a reduction of 164.6 DOT/1000PD from baseline after full ASP implementation.

Conclusion:

Despite the lack of a unified hospitalist group in our institution, we were successful in reducing inappropriate antibiotic use by focusing on standardizing care among different private pediatricians in the community. A multifaceted strategy and well-designed quality improvement methodology led to a sustained reduction in antibiotic use.

Navigating the New Antimicrobial Stewardship Regulations

Purpose: Many health care facilities are navigating their way through the new antimicrobial stewardship standards and guidelines. The purpose of this article is to provide information for health care facilities to improve patient care. Summary: New regulations and guidelines surrounding antimicrobial stewardship have prompted facilities to review their process related to antimicrobial stewardship. In setting up a program, there are many factors to consider including involving key personnel, obtaining leadership support, identifying an infectious disease physician to chair or cochair the committee, and meeting agenda, metrics, and educational needs. Conclusion: Antimicrobial stewardship plays a vital role in both our hospital and community setting. Pharmacists are uniquely positioned to improve optimal patient care through rounding, review of patients' chart, and contribute to the improvement of antimicrobial stewardship by working with a multidisciplinary team. These efforts may improve the utilization of antimicrobial agents.

Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study

Importance

Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs.

Objective

To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals.

Design, Setting, and Participants

The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study.

Interventions

We offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing.

Main Outcomes and Measures

Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time.

Results

A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found.

Conclusions and Relevance

Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.

EPICO 4.0. 'Total quality' in the management of invasive candidiasis in critically ill patients by analysing the integrated process

BACKGROUND

A high quality integrated process in the clinical setting of non-neutropenic critically ill patients at risk for invasive candidiasis is a necessary tool to improve the management of these patients.

AIMS

To identify the key points on invasive candidiasis in order to develop a set of recommendations with a high level of consensus required for the creation of a total quality integrated process for the management of non-neutropenic critically ill patients at risk of invasive candidiasis.

METHODS

After a thorough review of the literature of the previous five years, a Spanish prospective questionnaire, which measured consensus by the Delphi technique, was anonymously conducted by e-mail, including 31 national multidisciplinary experts with extensive experience in invasive fungal infections, from six national scientific societies. The experts included a specialist in intensive care medicine, anesthetists, microbiologists, pharmacologists, and specialists in infectious diseases that responded 27 questions prepared by the coordination group. The educational objectives considered six processes that included knowledge of the local epidemiology, the creation and development of multidisciplinary teams, the definitions of the process, protocols, and indicators (KPI), an educational phase, hospital implementation, and the measurement of outcomes. The level of agreement among experts in each category to be selected should exceed 70%. In a second phase, after drawing up the recommendations of the selected processes, a face to face meeting with more than 60 specialists was held. The specialists were asked to validate the pre-selected recommendations.

MEASURES AND MAIN OUTCOMES

Firstly, 20 recommendations from all the sections were pre-selected: Knowledge of local epidemiology (3 recommendations), creation and development of multidisciplinary teams (3), definition of the process, protocols and indicators (1), educational phase (3), hospital implementation (3), and measurement of outcomes (7). After the second phase, 18 recommendations were validated, and it was concluded that the minimum team or core necessary for the development of an efficient program in the use of antifungal drugs in non-neutropenic critically ill patients must consist of a specialist in infectious diseases, a clinical pharmacist, a microbiologist, a specialist in intensive care medicine, a specialist in anesthesia and recovery, and an administrator or member of the medical management team, and, in order to be cost-effective, it should be implemented in hospitals with over 200 beds. In addition, it is recommended to apply a consensual check list for the evaluation of the diagnostic process and treatment of invasive candidiasis in patients that have started an antifungal treatment. The management of external knowledge and individual learning stand out as active educational strategies. The main strategies for measuring patient safety outcomes are the analysis of the results achieved, and learning activities; assess, review and refine the deployment of the processes; quality control; epidemiological surveillance and applied research; benchmarking; and basic research. The results of the integrated process should be annually disseminated outside the hospital.

CONCLUSIONS

Optimizing the management of invasive candidiasis requires the application of the knowledge and skills detailed in our recommendations. These recommendations, based on the Delphi methodology, facilitate the creation of a total quality integrated process in critically-ill patients at risk for invasive candidiasis.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases

Introduction

In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.

Materials and methods

A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.

Conclusion

The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Antibiotic stewardship: the lower-extremity physician's prescription for effectively treating infection

The discovery of antibiotic drugs was one of the most significant medical achievements of the 20th century. The improper use of antibiotic drugs to prevent and treat infections has resulted in the emergence of resistance. Antimicrobic stewardship programs are becoming a mainstay in the fight against multidrug-resistant organisms. Individual clinicians should be encouraged to adopt the principles of antibiotic stewardship when treating lower-extremity infections in their scope of practice. First, a review of the available literature outlining the concept and practice of antibiotic stewardship is offered. Second, a discussion describing how to adopt and apply these principles to the individual clinician's practice as it applies to lower-extremity infections is offered. Finally, specific antimicrobial pharmacologic spectra and antibiogram information are offered.

A single center observational study on emergency department clinician non-adherence to clinical practice guidelines for treatment of uncomplicated urinary tract infections

Background

The Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidence-based guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG).

Methods

A single center, prospective, observational study of patients with uncomplicated UTI presenting to an urban ED between September 2012 and February 2014 that examined ED physician adherence to ICPG when treating uncomplicated UTIs. Clinician-directed antibiotic treatment was compared to the ICPG using a standardized case definition for non-adherence. Binomial confidence intervals and student’s t-tests were performed to evaluate differences in demographic characteristics and management between patients with pyelonephritis versus cystitis. Regression models were used to analyze the significance of various predictors to non-adherent treatment.

Results

103 cases met the inclusion and exclusion criteria, with 63.1 % receiving non-adherent treatment, most commonly use of a fluoroquinolone (FQ) in cases with cystitis (97.6 %). In cases with pyelonephritis, inappropriate antibiotic choice (39.1 %) and no initial IV antibiotic for pyelonephritis (39.1 %) where recommended were the most common characterizations of non-adherence. Overall, cases of cystitis were no more/less likely to receive non-adherent treatment than cases of pyelonephritis (OR 0.9, 95 % confidence interval 0.4–2.2, P = 0.90). In multivariable analysis, patients more likely to receive non-adherent treatment included those without a recent history of a UTI (OR 3.8, 95 % CI 1.3–11.4, P = 0.02) and cystitis cases with back or abdominal pain only (OR 11.4, 95 % CI 2.1–63.0, P = 0.01).

Conclusions

Patients with cystitis with back or abdominal pain only were most likely to receive non-adherent treatment, potentially suggesting diagnostic inaccuracy. Physician education on evidence-based guidelines regarding the treatment of uncomplicated UTI will decrease broad-spectrum use and drug resistance in uropathogens.

Antimicrobial drug prescribing patterns for community-acquired pneumonia in hospitalized patients: A retrospective pilot study from New Delhi, India

OBJECTIVE

The objective of this study was to determine patterns and frequency of antimicrobial drug use among hospitalized patients with community-acquired pneumonia (CAP).

METHODOLOGY

A retrospective 5 years (April 2007-March 2012) detailed medical record review of patients diagnosed with CAP and discharged to home from Non-Intensive Care Unit respiratory medicine wards of two public hospitals in Delhi.

RESULTS

A total of 261 medical records were analyzed. Over the 5 years, 82.0% (2007-08), 78.6% (2008-09), 59.5% (2009-10), 64.7% (2010-11), and 67.8% (2011-12) patients were prescribed two antimicrobials. In the last two study years, the proportion of patients receiving three antimicrobials increased (from 2.0% to 26.5% and 28.8%), while the proportion receiving monotherapy decreased (from 16.0% to 8.8% and 3.4%). In accordance with guidelines, beta-lactams and macrolides were the two most frequently prescribed antimicrobials (34.1%). However, newer generation beta-lactams were prescribed. A total of 37 patients were prescribed beta-lactam-tazobactam combination preparations. Overall, beta-lactams constituted more than 40% of prescriptions while macrolides were the second most prescribed class. Cephalosporin prescriptions significantly increased (P < 0.01) and penicillin prescriptions significantly decreased over study periods. The prescription of fluoroquinolones also decreased (21.5-6.0%, P < 0.01) and aminoglycoside prescription ranged from 9.7% to 16.4%, over 5 years. Reasons for prescribing three antimicrobials, use of aminoglycosides, or higher-end/reserve antibiotics were not mentioned in the medical records. There were no hospital-specific guidelines for doctors to follow in the treatment of CAP.

CONCLUSIONS

These findings suggest the need for implementing antimicrobial treatment guidelines. Adequate documentation and monitoring of antibiotic use for feedback are also lacking. An antimicrobial stewardship program may offer the most comprehensive solution for appropriate use of antimicrobials.

Breaking the Spell: Combating Multidrug Resistant 'Superbugs'

Multidrug-resistant (MDR) bacteria have become a severe threat to community wellbeing. Conventional antibiotics are getting progressively more ineffective as a consequence of resistance, making it imperative to realize improved antimicrobial options. In this review we emphasized the microorganisms primarily reported of being resistance, referred as ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa, and Enterobacteriaceae) accentuating their capacity to "escape" from routine antimicrobial regimes. The upcoming antimicrobial agents showing great potential and can serve as alternative therapeutic options are discussed. We also provided succinct overview of two evolving technologies; specifically network pharmacology and functional genomics profiling. Furthermore, In vivo imaging techniques can provide novel targets and a real time tool for potential lead molecule assessment. The employment of such approaches at prelude of a drug development process, will enables more informed decisions on candidate drug selection and will maximize or predict therapeutic potential before clinical testing.

Antimicrobial Stewardship in Long-Term Care Facilities: A Call to Action

Antimicrobial resistance is a global public health crisis and a national security threat to the United States, as stated in an executive order signed by the president in September 2014. This crisis is a result of indiscriminant antimicrobial use, which promotes selection for resistant organisms, increases the risk of adverse drug events, and renders patients vulnerable to drug-resistant infections. Antimicrobial stewardship is a key measure to combat antimicrobial resistance and specifically seeks to do this by improving antimicrobial use. Antimicrobial stewardship compliments infection control practices and it is important to note that these 2 disciplines are distinct and cannot be discussed interchangeably. Antimicrobial stewardship promotes the appropriate diagnosis, drug, dose, and duration of treatment. The appropriate diagnosis falls into the hands of the prescriber and clinical staff. Optimal antimicrobial drug selection, dosing strategy, and duration of treatment, however, often require expertise in antimicrobial therapy, such as an infectious disease-trained physician or pharmacist. Therefore, successful antimicrobial stewardship programs must be comprehensive and interdisciplinary. Most antimicrobial stewardship programs focus on hospitals; yet, in long-term care, up to 75% of antimicrobial use is inappropriate or unnecessary. Thus, one of the most pressing areas in need for antimicrobial stewardship is in long-term care facilities. Unfortunately, there is little evidence that describes effective antimicrobial stewardship interventions in this setting. This review discusses the need for and barriers to antimicrobial stewardship in long-term care facilities. Additionally, this review describes prior interventions that have been implemented and tested to improve antimicrobial use in long-term care facilities.

Multidisciplinary Treatment Approach for Prosthetic Vascular Graft Infection in the Thoracic Aortic Area

Prosthetic vascular graft infection in the thoracic aortic area is a rare but serious complication. Adequate management of the complication is essential to increase the chance of success of open surgery. While surgical site infection is suggested as the root cause of the complication, it is also related to decreased host tolerance, especially as found in elderly patients. The handling of prosthetic vascular graft infection has been widely discussed to date. This paper mainly provides a summary of literature reports published within the past 5 years to discuss issues related to multidisciplinary treatment approaches, including surgical site infection, timing of onset, diagnostic methods, causative pathogens, auxiliary diagnostic methods, antibiotic treatment, anti-infective structures of vascular prostheses, surgical treatment, treatment strategy against infectious aortic aneurysms, future surgical treatment, postoperative systemic therapy, and antimicrobial stewardship. A thorough understanding of these issues will enable us to prevent prosthetic vascular graft infection in the thoracic aortic area as far as possible. In the event of its occurrence, the early introduction of appropriate treatment is expected to cure the disease without worsening of the underlying pathological condition.

An international cross-sectional survey of antimicrobial stewardship programmes in hospitals

OBJECTIVES

To report the extent and components of global efforts in antimicrobial stewardship (AMS) in hospitals.

METHODS

An Internet-based survey comprising 43 questions was disseminated worldwide in 2012.

RESULTS

Responses were received from 660 hospitals in 67 countries: Africa, 44; Asia, 50; Europe, 361; North America, 72; Oceania, 30; and South and Central America, 103. National AMS standards existed in 52% of countries, 4% were planning them and 58% had an AMS programme. The main barriers to implementing AMS programmes were perceived to be a lack of funding or personnel, a lack of information technology and prescriber opposition. In hospitals with an existing AMS programme, AMS rounds existed in 64%; 81% restricted antimicrobials (carbapenems, 74.3%; quinolones, 64%; and cephalosporins, 58%); and 85% reported antimicrobial usage, with 55% linking data to resistance rates and 49% linking data to infection rates. Only 20% had electronic prescribing for all patients. A total of 89% of programmes educated their medical, nursing and pharmacy staff on AMS. Of the hospitals, 38% had formally reviewed their AMS programme: reductions were reported by 96% of hospitals for inappropriate prescribing, 86% for broad-spectrum antibiotic use, 80% for expenditure, 71% for healthcare-acquired infections, 65% for length of stay or mortality and 58% for bacterial resistance.

CONCLUSIONS

The worldwide development and implementation of AMS programmes varies considerably. Our results should inform and encourage the further evaluation of this with a view to promoting a worldwide stewardship framework. The prospective measurement of well-defined outcomes of the impact of these programmes remains a significant challenge.

Antimicrobial stewardship program prompts increased and earlier infectious diseases consultation

A recent analysis demonstrated that infectious diseases (ID) specialty intervention was associated with decreased mortality and hospital readmission. These benefits were greatest if involvement occurred within two days of hospital admission. Antimicrobial stewardship programs should augment the services of an ID specialist team and promote formal consultation. Implementation of an antimicrobial stewardship program at the Providence Veterans Affairs Medical Center was associated with an increased number of consults (increase of 72.2%) and decreased time to consult (3.5 days sooner), which might also dramatically improve patient outcomes, including mortality and readmission rates.

Strategies for improving antibiotic use in Qatar: a survey of pharmacists' perceptions and experiences

OBJECTIVES

The objectives of this study were to identify antimicrobial stewardship activities in Qatar, identify pharmacist involvement in activities and summarize perceived barriers for implementation of antimicrobial stewardship programs (ASPs).

METHODS

A cross-sectional survey was developed based on study objectives and completed by pharmacists in Qatar.

KEY FINDINGS

Most hospital settings have implemented components of ASP. Lack of infectious disease specialists and training of healthcare providers was the most common barrier to implementation or expansion of ASP identified in the hospital and community settings respectively.

CONCLUSION

Pharmacists report some components of ASP have been implemented; however, barriers must be overcome to further expand ASPs.

Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study)

BACKGROUND

Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality.

OBJECTIVES

The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care-associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used.

METHODS

An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared.

RESULTS

Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care-associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group.

CONCLUSION

An audit and feedback intervention related to hospitalists' prescribing for pneumonia increased adherence to local best practice.

Guidelines for prevention of hospital acquired infections

These guidelines, written for clinicians, contains evidence-based recommendations for the prevention of hospital acquired infections Hospital acquired infections are a major cause of mortality and morbidity and provide challenge to clinicians. Measures of infection control include identifying patients at risk of nosocomial infections, observing hand hygiene, following standard precautions to reduce transmission and strategies to reduce VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be emphasized upon. Infection prevention in special subsets of patients - burns patients, include identifying sources of organism, identification of organisms, isolation if required, antibiotic prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus, early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher risk of opportunistic infections. The post tranplant timetable is divided into three time periods for determining risk of infections. Room ventilation, cleaning and decontamination, protective clothing with care regarding food requires special consideration. Monitoring and Surveillance are prioritized depending upon the needs. Designated infection control teams should supervise the process and help in collection and compilation of data. Antibiotic Stewardship Recommendations include constituting a team, close coordination between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of information technology among other measure. The recommendations in these guidelines are intended to support, and not replace, good clinical judgment. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments.