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Swords KE, Weddle GM, Herigon JC, Stering PD, Lee MS. One size does not fit all: advanced practice provider considerations for the antimicrobial steward. Antimicrob Steward Healthc Epidemiol 2023; 3:e139. [PMID: 37663451 PMCID: PMC10468717 DOI: 10.1017/ash.2023.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 09/05/2023]
Abstract
Advanced practice providers are a diverse and established group of antimicrobial prescribers in both ambulatory and inpatient settings. We outline important considerations for antimicrobial stewardship programs and stewards to consider when engaging this important group of providers.
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Affiliation(s)
- Kyleen E. Swords
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Gina M. Weddle
- Division of Infectious Diseases, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Joshua C. Herigon
- Division of Infectious Diseases, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Paula D. Stering
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Matthew S.L. Lee
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Amin AB, Lash TL, Tate JE, Waller LA, Wikswo ME, Parashar UD, Stewart LS, Chappell JD, Halasa NB, Williams JV, Michaels MG, Hickey RW, Klein EJ, Englund JA, Weinberg GA, Szilagyi PG, Staat MA, McNeal MM, Boom JA, Sahni LC, Selvarangan R, Harrison CJ, Moffatt ME, Schuster JE, Pahud BA, Weddle GM, Azimi PH, Johnston SH, Payne DC, Bowen MD, Lopman BA. Understanding Variation in Rotavirus Vaccine Effectiveness Estimates in the United States: The Role of Rotavirus Activity and Diagnostic Misclassification. Epidemiology 2022; 33:660-668. [PMID: 35583516 PMCID: PMC10100583 DOI: 10.1097/ede.0000000000001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Estimates of rotavirus vaccine effectiveness (VE) in the United States appear higher in years with more rotavirus activity. We hypothesized rotavirus VE is constant over time but appears to vary as a function of temporal variation in local rotavirus cases and/or misclassified diagnoses. METHODS We analyzed 6 years of data from eight US surveillance sites on 8- to 59-month olds with acute gastroenteritis symptoms. Children's stool samples were tested via enzyme immunoassay (EIA); rotavirus-positive results were confirmed with molecular testing at the US Centers for Disease Control and Prevention. We defined rotavirus gastroenteritis cases by either positive on-site EIA results alone or positive EIA with Centers for Disease Control and Prevention confirmation. For each case definition, we estimated VE against any rotavirus gastroenteritis, moderate-to-severe disease, and hospitalization using two mixed-effect regression models: the first including year plus a year-vaccination interaction, and the second including the annual percent of rotavirus-positive tests plus a percent positive-vaccination interaction. We used multiple overimputation to bias-adjust for misclassification of cases defined by positive EIA alone. RESULTS Estimates of annual rotavirus VE against all outcomes fluctuated temporally, particularly when we defined cases by on-site EIA alone and used a year-vaccination interaction. Use of confirmatory testing to define cases reduced, but did not eliminate, fluctuations. Temporal fluctuations in VE estimates further attenuated when we used a percent positive-vaccination interaction. Fluctuations persisted until bias-adjustment for diagnostic misclassification. CONCLUSIONS Both controlling for time-varying rotavirus activity and bias-adjusting for diagnostic misclassification are critical for estimating the most valid annual rotavirus VE.
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Affiliation(s)
- Avnika B. Amin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jacqueline E. Tate
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Mary E. Wikswo
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Umesh D. Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura S. Stewart
- Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - James D. Chappell
- Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - Natasha B. Halasa
- Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - John V. Williams
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Marian G. Michaels
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert W. Hickey
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Eileen J. Klein
- Department of Pediatrics, Seattle Children’s Research Institute, Seattle Children’s Hospital and the University of Washington, Seattle, WA
| | - Janet A. Englund
- Department of Pediatrics, Seattle Children’s Research Institute, Seattle Children’s Hospital and the University of Washington, Seattle, WA
| | | | - Peter G. Szilagyi
- University of Rochester School of Medicine and Dentistry, Rochester, NY
- University of California at Los Angeles, Los Angeles, CA
| | - Mary Allen Staat
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Monica M. McNeal
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Julie A. Boom
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Texas Children’s Hospital, Houston, TX
| | - Leila C. Sahni
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Texas Children’s Hospital, Houston, TX
| | | | | | | | | | | | | | - Parvin H. Azimi
- University of California—San Francisco Benioff Children’s Hospital Oakland, Oakland, CA
| | - Samantha H. Johnston
- University of California—San Francisco Benioff Children’s Hospital Oakland, Oakland, CA
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, CA
| | - Daniel C. Payne
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Michael D. Bowen
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Benjamin A. Lopman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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Wirtz AL, Monsees EA, Gibbs KA, Myers AL, Burns AN, Lee BR, El Feghaly RE, Weddle GM, Day JC, Purandare AV, Goldman JL. Integration of a Lean Daily Management System into an Antimicrobial Stewardship Program. Pediatr Qual Saf 2021; 6:e384. [PMID: 33718745 PMCID: PMC7952113 DOI: 10.1097/pq9.0000000000000384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/17/2020] [Indexed: 11/27/2022] Open
Abstract
Growing demands and limited guidance on efficient use of resources to advance stewardship initiatives challenge antimicrobial stewardship programs (ASP). METHODS The primary aim was to incorporate a Lean Readiness and Metrics Board (RMB) into ASP and assess team member accountability and satisfaction with weekly 15-minute huddle participation within 1 year of implementation. ASP team survey data were analyzed for comments regarding Lean integration, team communication, and productivity. The second aim was to develop 5 shared metrics associated with quality, people, delivery, safety, and stewardship and evaluate ASP team productivity by assessing the impact of projects targeted at each specific metric. Pharmacist-physician ASP scheduling conflicts were addressed through identified rounding times under the "People" metric. The "Quality" metric assessed ASP intervention disagreement rate and collaborations that occurred to reduce disagreement. ASP tracked the number of individuals educated by ASP monthly through the "Delivery" metric. RESULTS Since August 2018, ASP replaced hour-long monthly meetings with weekly huddles at the RMB. On average, 14 members (88%) of the ASP participate weekly. Team members report improvement in communication and satisfaction with Lean integration. Metric utilization enhanced productivity. For the metrics under "People," "Quality," and "Delivery," reduced scheduling conflicts occurred, the ASP intervention disagreement rate decreased (37.0%-25.6%; P < 0.001), and the ASP educated an average of 79 learners per month. CONCLUSIONS Weekly huddles at the RMB enhanced communication and team accountability while visually displaying program needs, progress, and achievements. The RMB helps to ensure ongoing institutional commitment, and Lean methods show promise for evaluating and improving ASP productivity.
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Affiliation(s)
- Ann L Wirtz
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Elizabeth A Monsees
- Patient Care Services Research, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Kate A Gibbs
- Division of Ophthalmology, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Angela L Myers
- Division of Infectious Diseases, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Alaina N Burns
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Brian R Lee
- Division of Infectious Diseases, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Rana E El Feghaly
- Division of Infectious Diseases, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Gina M Weddle
- Department of Advanced Practice Programs, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - James C Day
- Division of Infectious Diseases, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Amol V Purandare
- Division of Infectious Diseases, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
| | - Jennifer L Goldman
- Division of Infectious Diseases, Children's Mercy Kansas City, University of Missouri, Kansas City, Mo
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Campbell AP, Ogokeh C, Lively JY, Staat MA, Selvarangan R, Halasa NB, Englund JA, Boom JA, Weinberg GA, Williams JV, McNeal M, Harrison CJ, Stewart LS, Klein EJ, Sahni LC, Szilagyi PG, Michaels MG, Hickey RW, Moffat ME, Pahud BA, Schuster JE, Weddle GM, Rha B, Fry AM, Patel M. Vaccine Effectiveness Against Pediatric Influenza Hospitalizations and Emergency Visits. Pediatrics 2020; 146:peds.2020-1368. [PMID: 33020249 DOI: 10.1542/peds.2020-1368] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Influenza A(H1N1)pdm09 viruses initially predominated during the US 2018-2019 season, with antigenically drifted influenza A(H3N2) viruses peaking later. We estimated vaccine effectiveness (VE) against laboratory-confirmed influenza-associated hospitalizations and emergency department (ED) visits among children in the New Vaccine Surveillance Network. METHODS We tested children 6 months to 17 years with acute respiratory illness for influenza using molecular assays at 7 pediatric hospitals (ED patients <5 years at 3 sites). Vaccination status sources were parental report, state immunization information systems and/or provider records for inpatients, and parental report alone for ED patients. We estimated VE using a test-negative design, comparing odds of vaccination among children testing positive versus negative for influenza using multivariable logistic regression. RESULTS Of 1792 inpatients, 226 (13%) were influenza-positive: 47% for influenza A(H3N2), 36% for A(H1N1)pdm09, 9% for A (not subtyped), and 7% for B viruses. Among 1944 ED children, 420 (22%) were influenza-positive: 48% for A(H3N2), 35% for A(H1N1)pdm09, 11% for A (not subtyped), and 5% for B viruses. VE was 41% (95% confidence interval [CI], 20% to 56%) against any influenza-related hospitalizations, 41% (95% CI, 11% to 61%) for A(H3N2), and 47% (95% CI, 16% to 67%) for A(H1N1)pdm09. VE was 51% (95% CI, 38% to 62%) against any influenza-related ED visits, 39% (95% CI, 15% to 56%) against A(H3N2), and 61% (95% CI, 44% to 73%) against A(H1N1)pdm09. CONCLUSIONS The 2018-2019 influenza vaccine reduced pediatric influenza A-associated hospitalizations and ED visits by 40% to 60%, despite circulation of a drifted A(H3N2) clade.
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Affiliation(s)
| | - Constance Ogokeh
- Influenza Division and
- Fellowship Program, Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Joana Y Lively
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
- IHRC, Inc, Atlanta, Georgia
| | - Mary A Staat
- Department of Pediatrics, University of Cincinnati College of Medicine and Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rangaraj Selvarangan
- Department of Pathology and Laboratory Medicine, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
- Divisions of Infectious Diseases and
| | - Natasha B Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Janet A Englund
- Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Julie A Boom
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
| | - Geoffrey A Weinberg
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - John V Williams
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Monica McNeal
- Department of Pediatrics, University of Cincinnati College of Medicine and Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher J Harrison
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Laura S Stewart
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eileen J Klein
- Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Leila C Sahni
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
| | - Peter G Szilagyi
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
- Department of Pediatrics, University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California
| | - Marian G Michaels
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Robert W Hickey
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | | | - Barbara A Pahud
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Jennifer E Schuster
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Gina M Weddle
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Brian Rha
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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