Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities

HIGHLIGHTS

The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.

Quality indicators for appropriate in-hospital pharmacotherapeutic stewardship: An international modified Delphi study

AIMS

In-hospital prescribing errors may result in patient harm, such as prolonged hospitalisation and hospital (re)admission, and may be an emotional burden for the prescribers and healthcare professionals involved. Despite efforts, in-hospital prescribing errors and related harm still occur, necessitating an innovative approach. We therefore propose a novel approach, in-hospital pharmacotherapeutic stewardship (IPS). The aim of this study was to reach consensus on a set of quality indicators (QIs) as a basis for IPS.

METHODS

A three-round modified Delphi procedure was performed. Potential QIs were retrieved from two systematic searches of the literature, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. In two written questionnaires and a focus meeting (held between the written questionnaire rounds), potential QIs were appraised by an international, multidisciplinary expert panel composed of members of the European Association for Clinical Pharmacology and Therapeutics (EACPT).

RESULTS

The expert panel rated 59 QIs and four general statements, of which 35 QIs were accepted with consensus rates ranging between 79% and 97%. These QIs describe the activities of an IPS programme, the team delivering IPS, the patients eligible for the programme and the outcome measures that should be used to evaluate the care delivered.

CONCLUSIONS

A framework of 35 QIs for an IPS programme was systematically developed. These QIs can guide hospitals in setting up a pharmacotherapeutic stewardship programme to reduce in-hospital prescribing errors and improve in-hospital medication safety.

Building the future of ID: A call to action for quality improvement research and measurement

Quality is central to value-based care and measurement is essential for assessing performance and understanding improvement over time. Both value-based care and methods for quality measurement are evolving. Infectious Diseases has been less engaged than other specialties in quality measure development, and Infectious Diseases providers must seize the opportunity to engage with quality measure development and research. Antimicrobial stewardship programs are an ideal starting point for Infectious Diseases-related quality measure development; antimicrobial stewardship program interventions and best practices are Infectious Diseases-specific, measurable, and impactful, yet grossly undercompensated. Herein, we provide a scheme for prioritizing research focused on development of Infectious Diseases-specific quality measures. Maturation of quality measurement research in Infectious Diseases, beginning with an initial focus on stewardship-related conditions then expanding to non-stewardship topics, will allow Infectious Diseases to take control of its future in value-based care, and promote the growth of Infectious Diseases through greater recognition of its value.

Animal drug shortages limit veterinary therapeutic options and introduce artifacts in antimicrobial sales reporting

Supply chain issues disrupt veterinary care and cause downstream consequences that alter the practice of veterinary medicine. Antimicrobials are just 1 class of pharmaceuticals that have been impacted by supply chain issues over the last couple of years. Since February 2021, 2 sponsors/manufacturers of penicillin products have reported shortages in the active pharmaceutical ingredient. With the release of the 2021 Summary Report on Antimicrobials Sold or Distributed for Use in Food-Producing Animals by the FDA, a key finding was a 19% decrease in penicillin sales and distribution from 2020 to 2021. Herein, we provide our clinicians' professional perspective regarding how drug shortages, specifically that of penicillin, might contribute to misconstrued patterns in antimicrobial use and what can be done by veterinarians and the FDA to minimize the impact of an antimicrobial drug shortage on animal health and well-being.

Development, implementation and impact of an immunoglobulin stewardship programme in Saskatchewan, Canada

BACKGROUND AND OBJECTIVES

Intravenous immunoglobulin (IVIG) is one of the most costly and limited-supply blood products. Judicious use of this therapy is important to ensure a continued supply is available for patients in need. The Saskatchewan IG Stewardship Program was initiated to monitor and reduce inappropriate IG use.

MATERIALS AND METHODS

The Program was developed and implemented through the collaborative efforts of a multidisciplinary, inter-organizational team. Funding was provided from provincial organizations to create new positions within the Program and to support stakeholder engagement throughout the process of implementation. Data were collected from local and national databases regarding the amount of IVIG used and appropriateness of orders based on published criteria.

RESULTS

Over 20 months, the Program helped to reduce unnecessary IVIG use from pre-intervention levels by more than 20%. Interventions from nurse navigators alone reduced inappropriate IVIG use by 2.6%. During the 20-month period following Program initiation, more than 4 million CAD less was spent on IVIG compared with the previous 20 months.

CONCLUSION

The Saskatchewan IG Stewardship Program has led to more appropriate IVIG use across the province, more effective preservation of this limited healthcare resource, and cost savings that more than cover the cost of administering the Program.

Characterizing Antibiotic Regimen Modification Behavior, Patient Characteristics, and Outcomes for Patients with Gram-Negative Bacterial Infections, A Retrospective Single-Center Study

Few studies describe the frequency of antibiotic regimen modification behaviors in the acute care setting. We sought to ascertain patient and treatment characteristics, details of regimen modification, and clinical outcomes with antibiotic modifications. This retrospective study included patients admitted to Hoag Memorial Hospital from 1 January 2019-31 March 2021 with a complicated infection caused by a Gram-negative organism resistant to extended-spectrum cephalosporins or with the potential for resistance (AmpC producers). A total of 400 patients were included. The predominant sources were bloodstream (33%), urine (26%), and respiratory (24%), including patients with multiple sources. The most isolated organisms were Pseudomonas spp. and ESBL-producing organisms, 38% and 34%, respectively. A total of 72% of patients had antibiotic regimen modifications to their inpatient antibiotic regimens. In patients where modifications occurred, the number ranged from one to six modifications. The most common reasons for modifications included a lack of patient response (14%), additional history reviewed (9%), and decompensation (7%). No difference in clinical outcomes was observed based on antibiotic modifications. The numerous changes in therapy observed may reflect the limitations in identifying patients with resistant organisms early on in admission. This highlights the need for more novel antibiotics and the importance of identifying patients at risk for resistant organisms.

Drivers of Geographic Patterns in Outpatient Antibiotic Prescribing in the United States

In a retrospective, ecological analysis of US medical claims, visit rates explained more of the geographic variation in outpatient antibiotic prescribing rates than per-visit prescribing. Efforts to reduce antibiotic use may benefit from addressing the factors that drive higher rates of outpatient visits, in addition to continued focus on stewardship.

Scientific Rationale and Clinical Basis for Clindamycin Use in the Treatment of Dermatologic Disease

Clindamycin is a highly effective antibiotic of the lincosamide class. It has been widely used for decades to treat a range of skin and soft tissue infections in dermatology and medicine. Clindamycin is commonly prescribed for acne vulgaris, with current practice standards utilizing fixed-combination topicals containing clindamycin that prevent Cutibacterium acnes growth and reduce inflammation associated with acne lesion formation. Certain clinical presentations of folliculitis, rosacea, staphylococcal infections, and hidradenitis suppurativa are also responsive to clindamycin, demonstrating its suitability and versatility as a treatment option. This review describes the use of clindamycin in dermatological practice, the mechanism of protein synthesis inhibition by clindamycin at the level of the bacterial ribosome, and clindamycin's anti-inflammatory properties with a focus on its ability to ameliorate inflammation in acne. A comparison of the dermatologic indications for similarly utilized antibiotics, like the tetracycline class antibiotics, is also presented. Finally, this review addresses both the trends and mechanisms for clindamycin and antibiotic resistance, as well as the current clinical evidence in support of the continued, targeted use of clindamycin in dermatology.

Forcing a square into a circle: why South Africa's draft revised material transfer agreement is not fit for purpose

The South African National Health Research Ethics Council (NHREC) recently released a final draft revision of the standard material transfer agreement (MTA) that was promulgated into law in 2018. This new draft MTA raises pertinent questions about the NHREC's mandate, the way in which the draft MTA deals with data and with human biological material, and its avoidance of the concept of ownership. After South Africa's data protection legislation, the Protection of Personal Information Act (POPIA), became operational in mid 2021, the legal landscape changed and it is doubtful that the NHREC has a residual mandate to govern personal information in health research. Furthermore, data is dealt with in a superficial, throw-away fashion in the draft MTA. The position with human biological material is not substantially better, as the draft MTA fails to recognise that human biological material can contain pathogens, which has important legal and ethical ramifications that are not sufficiently addressed. A central problem with the draft MTA is its use of the term 'steward', and avoidance of the legal concept of 'ownership'. This is not only misaligned with the South African legal framework, but also fails to consider the ethical case for recognising ownership. Finally, a call to embrace decolonial thinking in health research underscores the importance of recognising ownership in order to foster the growth of the local bio-economy. Key recommendations to reshape the draft MTA include: Making use of the eventual revised MTA optional, and allowing it to evolve with input from scientific and legal communities; regulating the transfer of associated data in a separate data transfer agreement that can be incorporated by reference in the MTA; enhancing guidance on liability and risk management in respect of human biological material that contains pathogens; and, finally, adopting a decolonial approach in health research governance, which requires recognising the ownership rights of South African research institutions.

Maximizing opioid stewardship through fentanyl vial size optimization in an independent hospital

In an effort to expedite the publication of articles, AJHP is posting 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.

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid

Antibiotic resistance is a persistent and growing concern. Our objective was to analyze antibiotic prescribing in the United States (US) in the Medical Expenditure Panel System (MEPS) and to Medicaid patients. We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020. We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad-spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. Antibiotic prescriptions in MEPS decreased from 2013 to 2020 by 38.7%, with a larger decline for the broad (-53.7%) than narrow (-23.5%) spectrum antibiotics. Antibiotic prescriptions in Medicaid decreased by 6.7%. Amoxicillin was the predominant antibiotic, followed by azithromycin, cephalexin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, levofloxacin, and moxifloxacin. Substantial geographic variation in prescribing existed, with a 2.8-fold difference between the highest (Kentucky = 855/1000) and lowest (Oregon = 299) states. The South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). This study identified sizable disparities by geography in the prescribing rates of eight antibiotics with over three-fold state-level differences. Areas with high prescribing rates, particularly for outpatients, may benefit from stewardship programs to reduce potentially unnecessary prescribing.

Impact of a pharmacy technician on an interprofessional antithrombotic stewardship program at an academic medical center

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting 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 need for monitoring and standardization of anticoagulation management has garnered the attention of national organizations, driving the implementation of antithrombotic stewardship programs (ASPs). Established ASPs have highlighted interdisciplinary collaboration between physicians, nurses, and pharmacists and demonstrated financial benefits and positive patient care outcomes. While pharmacy technicians are key members of the pharmacy profession, they are rarely utilized to expand clinical programs. The aim of this report is to describe the impact of adding a pharmacy technician to an ASP at an academic medical center.

SUMMARY

The departments of pharmacy and quality at West Virginia University Hospitals (WVUH) developed a business plan and financially justified an ASP. The ASP was implemented in January 2022 and consisted of 2 full-time clinical pharmacist specialists, 1 full-time clinical pharmacy technician, 2 full-time clinical nurse specialists, and 1 part-time physician medical director. The clinical pharmacy technician's primary role was to review patients' sequential compression device (SCD) compliance and newly started oral anticoagulants prior to discharge. The clinical nurse specialists educated patients newly started on oral anticoagulants within 24 hours of discharge and triaged any postdischarge medication access issues. The medical director provided high-level program oversight and acted as a clinical consultant on complex patient cases. In the first 6 months after the program's implementation, the clinical pharmacy technician made 174 recommendations to the clinical pharmacist specialists regarding discharge transitions of care and assessed SCD compliance in 246 patients. Of the 246 patients assessed, 217 patients (88%) were deemed to be noncompliant.

CONCLUSION

The pharmacy department at WVUH successfully justified and implemented an interprofessional ASP at an academic medical center, which is the first ASP to date to incorporate a clinical pharmacy technician.

Lack of Association between Antimicrobial Consumption and Antimicrobial Resistance in a HIV Preexposure Prophylaxis Population: A Cross-Sectional Study

BACKGROUND

In antibiotic naïve populations, there is a strong association between the use of an antimicrobial and resistance to this antimicrobial. Less evidence is available as to whether this relationship is weakened in populations highly exposed to antimicrobials. Individuals taking HIV preexposure prophylaxis (PrEP) have a high intake of antimicrobials. We previously found that there was no difference in the prevalence of pheno- and genotypic antimicrobial resistance between two groups of PrEP clients who had, and had not, taken antimicrobials in the prior 6 months. Both groups did, however, have a higher prevalence of resistance than a sample of the general population.

METHODS

In the current study, we used zero-inflated negative binomial regression models to evaluate if there was an individual level association between the consumption of antimicrobials and 1. the minimum inhibitory susceptibilities of oral Neisseria subflava and 2. the abundance of antimicrobial resistance genes in the oropharynges of these individuals.

RESULTS

We found no evidence of an association between the consumption of antimicrobials and the minimum inhibitory susceptibilities of oral Neisseria subflava or the abundance of antimicrobial resistance genes in these individuals.

CONCLUSIONS

We conclude that in high-antimicrobial-consumption populations, the association between antimicrobial consumption and resistance may be attenuated. This conclusion would not apply to lower-consumption populations.

The Two Routes of Collective Psychological Ownership: Rights and Responsibilities Explain Intentions to Exclude Outsiders and Engage in Stewardship Behavior

People can have a sense of collective ownership of a particular territory, such as "our" country, "our" neighborhood, and "our" park. Collective psychological ownership is argued to go together with rights and responsibilities that have different behavioral implications. We found that collective psychological ownership leads to perceived determination right, and indirectly to the exclusion of outsiders from "our" place. Simultaneously, collective psychological ownership leads to perceived group responsibility, and indirectly to engagement in stewardship behavior. These results were found among Dutch adults, cross-sectionally in relation to their country (Study 1; N = 617) and a neighborhood (Study 2; N = 784), and experimentally in relation to an imaginary local park (Study 3; N = 384, Study 4; N = 502, both pre-registered). Our research shows that the feeling that a place is "ours" can, via perceived rights and responsibilities, result in both exclusionary and prosocial behavioral tendencies.

Evaluating the Impact of Source-specific Order Sets for Sepsis on Empiric Antibiotic Selection in the Emergency Department

This retrospective cohort study found that implementing source-specific antibiotic order sets for sepsis in the emergency department increased appropriate empiric antibiotic selection from 51% to 74% (P = .01).

Variations in antibiotic prescribing among children enrolled in North Carolina Medicaid, 2013-2019

PURPOSE

The majority of pediatric antibiotic prescribing occurs in the outpatient setting and inappropriate use contributes to antimicrobial resistance. There are regional variations in outpatient antibiotic use with the highest rates occurring in the Southern states, including in Appalachia. The purpose of this study was to describe the rates and risk factors for inappropriate antibiotic prescription among pediatric patients enrolled in North Carolina (NC) Medicaid.

METHODS

We used Medicaid prescription claims data from 2013 to 2019 to describe patterns of pediatric antibiotic prescription in NC. We assessed patient and provider factors to identify variations in prescribing.

FINDINGS

Children who were less than 2 years of age, non-Hispanic White, and living in a rural area had the highest overall rates of antibiotic prescription. Compared to pediatricians, the risk of inappropriate antibiotic prescription was highest among other specialists and general practioners and lowest among nurse practitioners. Rural areas of NC had the highest rates of inappropriate antibiotic prescribing, and the risk for non-Hispanic Black children compared to children of other races/ethnicities was compounded by rurality.

CONCLUSIONS

Prescribing practices in NC differ compared to neighboring states with a lower overall risk of inappropriate prescription in Appalachian regions; however, disparities by race and rurality exist. Outpatient stewardship efforts in NC should focus on ensuring health equity by appreciating racial and geographic variations in prescribing patterns and providing education to all health care providers.

An Ocean between the Waves: Trends in Antimicrobial Consumption in Hospitalized Patients with COVID-19

We assessed the antibiotic use in SARS-CoV-2-infected patients during four different waves of the COVID-19 pandemic, as well as its trends over the period and associated risk factors. We performed a cross-sectional retrospective analysis nested in a prospectively collected cohort of hospitalized adult patients with COVID-19 at a university hospital in Spain. A total of 2415 patients were included in this study, among whom 1120 corresponded to the first wave. The highest percentage of patients receiving some sort of antibiotic treatment was higher during the first wave (77.6%) than during the others; nevertheless, our calculation of the average DOT (days of antibiotic treatment) per 100 patient days of stay found that the highest antibiotic prescription rate corresponded to the second pandemic wave (61.61 DOT/100 patient days), which was associated with a higher ICU admission rate and a lower SpO2/FiO2 ratio at admission. After the second wave, the prescription rates presented a steady downward trend. With regard to the use of specific antibiotic families, amoxicillin/clavulanate was the most used antibiotic in our cohort (14.20 DOT/100 patient days) due to a high prescription rate during the first wave. According to the "AWaRe" WHO classification, antibiotics corresponding to the "Watch" group were the most prescribed (27.92 DOT/100 patient days). The antibiotic use rate fell progressively, but it remained high during all four waves analyzed. In conclusion, antibiotic use was high throughout all the waves that were analyzed, despite a relatively low incidence of bacterial coinfection and superinfection. Efforts should be made to keep antimicrobial stewardship programs active, especially in complicated epidemiological situations, such as the SARS-CoV-2 pandemic.

Evaluating the OH-EpiCap tool using the Danish integrated surveillance program for AMU and AMR as a case study

Antimicrobial resistance (AMR) is considered a One Health (OH) challenge, ideally demanding concerted efforts from the animal, human and environmental side. DANMAP, the Danish Integrated Antimicrobial Resistance Monitoring and Research Program, is monitoring AMR and antimicrobial use in animals and humans. OH-EpiCap is an evaluation tool, developed to address essential elements in OH surveillance systems, such as the dimensions of the organization, operational activities and the impact of the surveillance activities. We aimed to evaluate DANMAP using OH-EpiCap and hereby assessed the suitability of OH-EpiCap to evaluate integrated AMR surveillance systems. During the evaluation, the strengths and weaknesses of DANMAP concerning the "OH-ness" of the program were discussed. Furthermore, possible adaptations of the standard operating procedures and governance structure were addressed. Attention was paid to the ability and easiness of DANMAP to cope with current and future challenges connected to integrated AMR surveillance. It was concluded that DANMAP has a strong OH approach covering relevant aspects for humans and animals, whereas environmental aspects are missing. OH-EpiCap proved to be straightforward to use and provided valuable insights. The authors recommend OH-EpiCap to be used by health authorities and stakeholders. It is not suitable for the technical evaluation of a surveillance program.

Stewardship-Guided T2Candida Testing Shortens Time to Antifungal Treatment and Reduces Antifungal Usage Among Medical Intensive Care Unit Patients With Septic Shock

Background

Diagnosis of invasive candidiasis (IC) is limited by insensitivity and slow turnaround of cultures. Our objectives were to define the performance of T2Candida, a nonculture test, under guidance of a diagnostic stewardship program, and evaluate impact on time to antifungal initiation and antifungal utilization.

Methods

This was a retrospective study of adult medical intensive care unit (MICU) patients with septic shock for whom T2Candida testing was performed from March 2017 to March 2020. Patients with positive T2Candida results during this period were compared to MICU patients who did not undergo T2Candida testing but had septic shock and blood cultures positive for Candida from January 2016 through March 2020.

Results

Overall, 155 T2Candida tests from 143 patients were included. Nine percent of T2Candida tests were positive compared to 4.5% of blood cultures. Sensitivity, specificity, positive predictive value, and negative predictive value of T2Candida for proven and probable IC were 78%, 95%, 50%, and 99%, respectively. Patients who tested positive for T2Candida (n = 14) were diagnosed earlier and initiated on antifungal therapy sooner than patients with IC (n = 14) diagnosed by blood culture alone (median, 5.6 vs 60 hours; P < .0001). Median antifungal days of therapy/1000 patient-days were 23.3/month preimplementation and 15/month postimplementation (P  = .007). Following a negative T2Candida result, empiric antifungals were either not administered in 58% or discontinued within 72 hours in 96% of patients.

Conclusions

Diagnostic stewardship guided T2Candida testing resulted in reduced time to IC diagnosis, faster initiation of antifungal therapy, and lower antifungal usage among MICU patients with septic shock.

Antimicrobial Stewardship in the Hospital Setting: A Narrative Review

The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.

Enhancing Medical Students' Confidence and Knowledge in Antibiotic Prescription and Administration through Virtual Education: A Quasi-Experimental Study

BACKGROUND

Antibiotic resistance is a worldwide health concern that necessitates antibiotic stewardship. Medical students significantly impact future healthcare practices; thus, their trust in antibiotic prescription and administration is crucial. This research aims to assess medical students' levels of confidence and knowledge in these areas before and after exposure to virtual antibiotic stewardship education.

METHODS

A one-group pretest-posttest design was conducted with medical students from King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. Participants were enrolled in the WHO-online antibiotic stewardship course.

RESULTS

The group's baseline confidence and background knowledge were reported to be lower than what was offered after introducing the virtual course. The McNemar-Bowker test showed a significant difference in students' confidence in pre-course and post-course scores (Z = 20, p < 0.002); the matched paired t-test revealed a significant difference in students' knowledge scores (M = 7.66 verses M = 5.36, Z = 3.54, p = 0.001). In the sample, 70% of the students were unfamiliar with antibiotic stewardship; thus, the analysis revealed a significant difference in their familiarity before and after enrolling in the online course (30 vs. 100, p < 0.001).

CONCLUSION

Medical students experience low confidence in the safe practice of the antibiotic stewardship program. The WHO-online antibiotic stewardship course is considered a valuable resource that can be used in a formative medical curriculum. Thus, educators and the academic curriculum must promote practical strategies to minimize antibiotic stewardship literacy and increase antibiotic prescribing and administration quality. Introducing antibiotic stewardship across the medical curriculum and establishing educational courses are some strategies that can be undertaken to ensure that future doctors are well-educated in the principles and practices of the appropriate use of antibiotic stewardship.

Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers

Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.

Awareness Regarding Antimicrobial Resistance and Antibiotic Prescribing Behavior among Physicians: Results from a Nationwide Cross-Sectional Survey in India

(1) Background: Understanding the physicians' knowledge, attitudes, and antimicrobial prescribing behavior is a crucial step towards designing strategies for the optimal use of these agents. (2) Methods: A cross-sectional online survey was conducted among clinicians across India between May and July 2022 using a self-administered questionnaire in English comprising 35 questions pertaining to demographic characteristics, knowledge, attitude, and practices domains. (3) Results: A total of 544 responses were received from 710 physicians contacted. Sixty percent of participants were males, with mean age of 34.7 years. Mean ± Standard Deviation scores for knowledge, attitude, and practices domains were 8 ± 1.6, 20.2 ± 3.5, and 15.3 ± 2.1, respectively. Higher scores were associated with basic [odds ratio (95% Confidence Interval), p value: 2.95 (1.21, 7.2), 0.02], medical and allied sciences [2.71 (1.09, 6.67), 0.03], and central zone [3.75 (1.39, 10.12), 0.009]. A substantial proportion of dissatisfactory responses were found regarding hospital antibiograms, antibiotics effective against anaerobes, WHO AWaRe (access, watch, and reserve) classification of antibiotics, and the role of infection prevention and control (IPC) measures in the containment of antimicrobial resistance (AMR). (4) Conclusions: There is a need to sensitize and educate clinicians on various issues related to antimicrobial use, such as antibiograms, double anaerobic cover, IPC practices, and guideline-based recommendations, to curb the AMR pandemic.

Stop antibiotic resistance - A roller coaster ride through "antibiotic stewardship," "prescription auditing" and "AWaRe" assessment tool

The emergence of superbugs and highly resistant organisms like methicillin-resistant staphylococci, vancomycin-resistant enterococci, carbapenem-resistant enterobacteriaceae demands the monitoring of antibiotic prescription and usage in various domains. The impact of antibiotic resistance is huge that it increases mortality, morbidity, and economic costs. The issue has to be addressed at various levels and that is why regulatory bodies implement antibiotic stewardship programs. These programs give a list of guidelines like infection control, tracking antibiotic use, prescription auditing, and involvement of health professionals like pharmacists, nurses, etc., A comparison of the list of guidelines given by the Centre for Disease Control and Prevention and Indian Council of Medical Research gives an idea about the measures to be taken at various levels to reduce the burden of antibiotic resistance. Prescription auditing is one of the major components of antibiotic stewardship. The auditing can be done either prospectively or retrospectively using WHO core prescribing indicators and antibiotic-specific indicators. An AWaRe assessment tool was also used to evaluate antibiotic consumption in countries and hospitals. The antibiotics are classified into access, watch and reserve categories. The aim of implementing the AWaRe tool is to increase the rational use of access antibiotic and reduce the consumption of watch and reserve antibiotics. This review focuses on the importance of prescription auditing, AWaRe tool and antibiotic stewardship in decreasing the threat of antibiotic resistance.

[Experience with the Biofire FilmArray® for infectious meningitis/encephalitis in a high complexity institution in Bogota, Colombia]

INTRODUCTION

Infectious meningoencephalitis (IME) is a neurological emergency with a significant rate of morbidity and mortality. The Biofire FilmArray® meningitis/encephalitis (FAME) panel for testing in cerebrospinal fluid (CSF) has proven to be a valuable tool for the aetiological diagnosis of IME, facilitating targeted antimicrobial therapy. The aim is to determine the impact of the FAME panel on antimicrobial therapeutic decisions in patients with suspected IME in the first 24 hours of clinical assessment.

PATIENTS AND METHODS

This is a descriptive observational study that comments on the clinical manifestations, the neuroimaging and paraclinical findings, and the antibiotic therapy of patients with suspected IME. An analysis was performed to determine the impact of FAME on antimicrobial therapy in the first 24 hours of the clinical assessment of patients.

RESULTS

Altogether 44 patients were included. The average time required to obtain the result of the FAME panel for testing in CSF was nine hours, with 20.4% (9/44) of tests yielding positive results. Within 24 hours of clinical assessment, their outcome had an impact on antimicrobial treatment decisions in 75% (33/44) of cases. In patients with a high clinical suspicion of IME, the result of FAME made it possible to change the initial empirical therapy to a targeted therapy in 15% (3/20) of cases and to discontinue the initial empirical therapy in 35% (7/20) of the subjects. In patients with low clinical suspicion of IME, their result allowed 25% (6/24) to have their suspicion confirmed and they were started on targeted antibiotic therapy; in contrast, 70.8% (17/24) had their diagnosis ruled out and were not started on treatment.

CONCLUSIONS

The result of the FAME panel for testing in CSF has a high impact on antimicrobial therapeutic decisions within 24 hours of clinical assessment. However, it must be interpreted with the clinical context, local epidemiology and other diagnostic studies.

Comparison of Different Antibiotics and the Risk for Community-Associated Clostridioides difficile Infection: A Case-Control Study

Background

Antibiotics are the greatest risk factor for Clostridioides difficile infection (CDI). Risk for CDI varies across antibiotic types and classes. Optimal prescribing and stewardship recommendations require comparisons of risk across antibiotics. However, many prior studies rely on aggregated antibiotic categories or are underpowered to detect significant differences across antibiotic types. Using a large database of real-world data, we evaluate community-associated CDI risk across individual antibiotic types.

Methods

We conducted a matched case-control study using a large database of insurance claims capturing longitudinal health care encounters and medications. Case patients with community-associated CDI were matched to 5 control patients by age, sex, and enrollment period. Antibiotics prescribed within 30 days before the CDI diagnosis along with other risk factors, including comorbidities, health care exposures, and gastric acid suppression were considered. Conditional logistic regression and a Bayesian analysis were used to compare risk across individual antibiotics. A sensitivity analysis of antibiotic exposure windows between 30 and 180 days was conducted.

Results

We identified 159 404 cases and 797 020 controls. Antibiotics with the greatest risk for CDI included clindamycin and later-generation cephalosporins, and those with the lowest risk included minocycline and doxycycline. We were able to differentiate and order individual antibiotics in terms of their relative level of associated risk for CDI. Risk estimates varied considerably with different exposure windows considered.

Conclusions

We found wide variation in CDI risk within and between classes of antibiotics. These findings ordering the level of associated risk across antibiotics can help inform tradeoffs in antibiotic prescribing decisions and stewardship efforts.

Reimagining Preparedness of Health Professional Graduates Through Stewardship

Issue: Preparing health professional students for practice matters and is an important objective of health professional education. But although health professional courses grow in number and continue to graduate entry-level practitioners annually, there are signs that health professional education is not quite hitting the "purpose" mark. Preparedness is a term encountered often in health professional education, but it is besieged with challenges. Those challenges relate to whether graduates are prepared for their future careers and how preparedness for practice is understood; understandings of preparedness influence what curriculum, teaching, and learning prepares graduates about and for. Evidence: There is a wealth of the literature that suggests that graduates are not prepared for practice or believe they are not. This literature tends to grow rather than diminish, with arguments about preparedness materializing time and again. Preparedness means different things to students, academics, and practitioners and this creates misunderstanding as well as lessening the construct's value to research, education, and practice. What it means to be prepared is in fact not a static construct but changes in response to the needs of individuals and communities and broader societal context. When preparedness is defined as competence in skills or knowledge, graduates will be ill equipped to operate in the chaotic, ambiguous times we now face as competencies tend to oversimplify and reduce the demands of practice. Implications: Preparedness is only one purpose that could be attached to the educational formation of university graduates. It is time we expand our thinking about what is valuable and necessary to learn in order to become health professionals equipped to address the health and social care problems now and to come. Furthermore, continuing to address the challenges of preparedness for practice in the same ways as we have done for decades will not result in change; new and different educational approaches are required to meaningfully reimagine health professional education. We need to value education as a scholarly field in its own right, as much as we do evidence-based healthcare. A concept that prompts us to think and act in these reinvigorated ways is stewardship, which I offer as an expansive way to think about the purposes and desired outcomes of health professional education. Stewardship is an idea that sustains and cares for the professions, and therefore is highly relevant to the preparation of healthcare practitioners.

Impact of Rapid Identification and Stewardship Intervention on Coagulase-Negative Staphylococcus Bloodstream Infection

We investigated the impact of rapid diagnostic testing with and without algorithm-based stewardship recommendations on antibiotic use for bloodstream infection with coagulase-negative staphylococci. A significant reduction in antibiotic days of therapy was achieved in the stewardship intervention group that was not seen with rapid diagnostic testing alone.

Collective psychological ownership as a new angle for understanding group dynamics

Even without legal ownership, groups can experience objects, places, and ideas as belonging to them ('ours'). This state of mind-collective psychological ownership-is understudied in social psychology, yet it is central to many intergroup conflicts and stewardship behaviour. We discuss our research on the psychological processes and social-psychological implications of collective psychological ownership. We studied territorial ownership, in different parts of the world and at different geographical levels, offering not only a cross-national but also conceptual replication of the processes. Our findings show that collective psychological ownership is inferred based on primo-occupancy, investment, and formation. Further, we demonstrate that collective psychological ownership can have positive intragroup and negative intergroup outcomes, which are guided by perceived group responsibility and exclusive determination right. We then discuss ownership threat (losing what is 'ours'), and we consider the role of group identification in ownership-related processes. We conclude by providing directions for future research.

Identifying Diagnostic Stewardship Mechanisms in the Electronic Test Result Management Process - Preliminary Findings from a Scoping Review

Digital health can play a key role in diagnostic stewardship, which refers to the coordinated guidance and interventions to ensure the appropriate utilisation of diagnostic tests for therapeutic decision-making. Outcomes of test result management and the impacts of digital health are a result of the interaction between dimensions of a complex environment. This poster will present preliminary findings from a scoping review which identifies the stewardship mechanisms that facilitate safe and effective electronic management of test results.

For the "good of the lab": Insights from three focus groups concerning the ethics of managing a laboratory or research group

To obtain some exploratory, qualitative data on ethical issues and values in managing a research laboratory, we conducted three focus groups with experienced investigators and laboratory managers. After validating the focus group transcripts for accuracy, two coders used deductive and inductive coding to develop themes from the text. Participants regarded ethics as important in managing a laboratory (or research group) for various reasons, ranging from conducting research with integrity to exhibiting leadership and promoting an ethical research climate. Participants identified many different types of ethical issues that arise in managing a research laboratory, including issues involving the management people, financial and material resources, projects, and data. An overarching ethical dilemma identified by participants was balancing the desire for productivity against apparently competing values, such as treating people fairly and promoting the wellbeing of individuals. Participants also indicated that graduate and post-graduate education and training did not prepare them to deal with the ethical, financial, interpersonal, and other issues related to managing a research laboratory, and that communication and leadership are crucial to managing a research laboratory ethically.

Acute Respiratory Infection Hubs: A Service Model with Potential to Optimise Infection Management

Patients with acute respiratory infections (ARI)-including those with upper and lower respiratory infections from both bacterial and viral pathogens-are one of the most common reasons for acute deterioration, with large numbers of potentially avoidable hospital admissions. The acute respiratory infection hubs model was developed to improve healthcare access and quality of care for these patients. This article outlines the implementation of this model and its potential impacts in a number of areas. Firstly, by improving healthcare access for patients with respiratory infections by increasing the capacity for assessment in community and non-emergency department settings and also by providing flexible response to surges in demand and reducing primary and secondary care demand. Secondly, by optimising infection management (including the use of point-of-care diagnostics and standardised best practise guidance to improve appropriate antimicrobial usage) and reducing nosocomial transmission by cohorting those with suspected ARI away from those with non-infective presentations. Thirdly, by addressing healthcare inequalities; in areas of greatest deprivation, acute respiratory infection is strongly linked with increased emergency department attendance. Fourthly, by reducing the National Health Service's (NHS) carbon footprint. Finally, by providing a wonderful opportunity to gather community infection management data to enable large-scale evaluation and research.

Characterisation of antimicrobial usage in Danish pigs in 2020

Introduction

Denmark is one of the world's largest exporters of pigs and pig meat, so the sector plays an important role in the national antimicrobial use (AMU). The Danish government has run antimicrobial stewardship programs in collaboration with the pig industry for more than 25 years. These have resulted in substantial overall reductions in total AMU and limiting the use of fluoroquinolones, the 3rd and 4th generation cephalosporines and the polymyxin colistin. To understand where further reductions in AMU could take place, it is necessary to investigate which antimicrobials are being used, how, and for which reasons.

Materials and methods

We characterized the AMU in the Danish pig sector in 2020, providing new analytical insights based on data retrieved from the VetStat database. The AMU data were segmented into classes, routes of administration, treatment indications and age groups, and interpreted as an outcome of the interventions taken. We evaluated the current AMU regarding choice of antimicrobial class. Moreover, we discussed how to further improve the antimicrobial stewardship in Danish pig production to achieve additional reductions without jeopardizing animal welfare. Where relevant, two pig veterinary specialists were consulted.

Results

In 2020, 43.3 mg antimicrobials per population correction unit (PCU) were ascribed to the Danish pig sector. There was practically no use of fluoroquinolones, 3rd and 4th generation cephalosporins and polymyxins. Weaners related to 45% of the total AMU in pigs when measured in tonnes and 81% when measured in defined animal daily doses, of these 76% were ascribed to gastrointestinal indications and overall, 83% were administered perorally.

Conclusion

To enable further reductions in AMU, it should be investigated how and when to replace group treatments (e.g., all animals in section or a pen) with individual treatments. Moreover, prevention of disease and promotion of animal health should be prioritized, e.g., through focus on feed, vaccination, biosecurity, and disease eradication.

Cross-sectional Analysis of Dermatologists and Sponsored Content on TikTok

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Appropriate Use of Antibiotic and Principles of Antimicrobial Stewardship in Children

Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".

Effects of steroid stewardship on glycemic control in acute exacerbations of chronic obstructive pulmonary disease patients

INTRODUCTION

The adverse effects of corticosteroids are dose-dependent, and guidance is to use the lowest effective dose in most disease states. The study facility recently reported a steroid stewardship program that reduced steroid dosing in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients by 50%. The purpose of this post-hoc analysis was to evaluate the effect of this intervention on glycemic control in hospitalized AECOPD before and after cohorts.

METHODS

This was a retrospective post-hoc review of hospitalized patients in a before and after study design (n = 27 in each group). The primary endpoint was the proportion of glucose readings >180 mg/dL. Baseline characteristics, mean glucose levels, and corrective insulin were also collected. Continuous variables were compared with a Student's t-test (or Mann-Whitney U where appropriate) and nominal variables with a chi-square test in R Studio.

RESULTS

There was a significantly higher proportion of glucose >180 mg/dL readings in the pre-intervention cohort: 38% vs. 25% (p = 0.007). The mean glucose levels were numerically lower post-intervention but did not reach statistical significance (160 mg/dL vs. 145 mg/dL, p = 0.27) both in diabetics (192 mg/dL vs. 181 mg/dl, p = 0.69) and non-diabetics (142 mg/dL vs. 125 mg/dL, p = 0.08). The use of correctional insulin was similar: a median of 25 units vs. 24.5 units (p = 0.92).

CONCLUSION

A stewardship program focused on steroid reduction in AECOPD significantly lowered the proportion of hyperglycemic readings but did not significantly affect mean glucose and corrective insulin usage while hospitalized.

Impact of a Real-Time Diagnostic and Antimicrobial Stewardship Workflow on Time-to-Appropriate Therapy for Infections Caused by Multidrug-Resistant Gram-negative Organisms

INTRODUCTION

Multi-drug resistant (MDR) Gram-negative organisms (GNR) cause life-threatening infections and incidence is rising globally. Timely therapy in these infections has a direct impact on patient survival. We aimed to determine the impact of a multi-disciplinary diagnostic and antimicrobial stewardship (AMS) workflow on time-to-appropriate therapy (TAP) of these infections using novel beta-lactam/beta-lactamase inhibitors (BL/BLIs).

METHODS

This was a retrospective quasi-experimental study of adult patients with carbapenem-resistant Enterobacterales (CRE) and multidrug-resistant Pseudomonas (MDR PsA) infections at a 1,500-bed University hospital. Included patients received ≥72 hours of ceftazidime-avibactam (CZA) or ceftolozane-tazobactam (C/T) from 12/2017-12/2019. During the pre-intervention period (12/2017-12/2018), additional susceptibilities (including CZA and C/T) were performed only upon providers' request. In 2019, we implemented reflex algorithms for faster identification and testing of all CRE/MDR PsA isolates. Results were communicated in real-time to the AMS team to tailor therapy.

RESULTS

A total of 99 patients were included with no differences at baseline between groups; median age 60 years, 56 (56.7%) were in intensive care at time of culture collection. Organisms identified included 71 (71.7%) MDR PsA and 26 CRE, of which 18 were carbapenemase producers (KPC=12, NDM=4, VIM=2). The most common infections were pneumonia (49.5%) and bacteremia (30.3%). We found a decrease in median TAP (103 [IQR 76.0-156.0] vs 75 [IQR 56-100] hours, p < 0.001). Median time from culture collection to final susceptibility results was shorter in the post-intervention group (123 vs 93 hours; p < 0.001).

CONCLUSION

Our study identified improvement in TAP in MDR PsA and CRE infections with implementation of a reflex microbiology workflow and multidisciplinary antimicrobial stewardship initiatives.

A Road to Microbiology Literacy (and More): an Opportunity for a Paradigm Change in Teaching

Microbial activities pervasively impact the wellbeing of all organisms, including humans, and the functioning of the planet itself. In order for society to form informed opinions and take effective actions related to its welfare, it must be able to understand the causes of issues of importance and to appreciate the range of possible responses and their likely effectiveness. Society must become microbiology literate. The International Microbiology Literacy Initiative is creating a comprehensive range of teaching resources that will constitute a child-centric school curriculum of societally relevant microbiology. The core of the teaching resources, the lessons, are somewhat unusual in that each one is designed to be essentially stand-alone, so courses can be individually structured by teachers according to their perception of what is interesting and important for their charges. Moreover, the lessons deal not only with societally pertinent microbial activities, but also discuss and propose discussion of their relevance to sustainable development, of their impact on policies and decisions (personal, community, and national), and of issues of stewardship and stakeholder responsibilities. The class lessons are complemented by other child-centric teaching resources whose functions are to add value, to stimulate pupil imagination and excitement in discovery, to engage pupil interest and enthusiasm for topics like sustainability, climate change, international cooperation, citizen science, etc., and to empower pupils as stakeholders in their microbiology education and as educators and multiplicators.

Effect of semantics in the study of tolerance for wolves

As conservation scholars increasingly recognize the critical role of human thought and behavior in determining the persistence of biodiversity across the globe, a growing line of inquiry regarding the validity and comparability of previous applications of core psychological concepts has emerged. Specifically, inconsistent measurement and use of terms, such as attitudes and acceptance, reveal important questions about previous approaches. Given that these concepts differ by definition, yet have been used interchangeably, we explored what drives differences in people's responses when each concept is operationalized in the context of a contested wildlife species, the gray wolf (Canis lupus). To do so, we used data from a 2014 survey of U.S. residents (n = 1287) to test how measures of six concepts (i.e., acceptance, attitudes, benefits, risks, [prior] behavior, and behavioral intentions) often employed in the conservation social sciences were related with a broad set of possible explanatory variables. Despite moderate to strong correlations between all concepts measured (| Pearson's r | = 0.39-0.65, p < 0.001), results revealed considerable variation in their respective relationships with identical explanatory variables. Specifically, although wildlife value orientation (i.e., domination or mutualism) operated fairly consistently across cognitive and behavioral concepts, the relationship between the six concepts and other factors, such as social trust, identification with various interest groups (i.e., hunter, farmer, or rancher, environmentalist, and animal rights advocate), and political ideology (i.e., liberal vs. conservative), varied considerably. Our findings underscore that differences exist in these measures, which could have serious implications for conservationists integrating social science findings in their decision-making processes if they are unaware of the theoretical underpinnings of and distinctions between core psychological concepts.

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians

OBJECTIVE

To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders.

DATA SOURCES

PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines.

REVIEW METHODS

A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings.

CONCLUSIONS

Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss.

IMPLICATIONS FOR PRACTICE

Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Technology, Training, and Task Shifting at the World's Largest Mass Gathering in 2025: An Opportunity for Antibiotic Stewardship in India

The role of antibiotic overuse in intensifying selection pressures and contributing to the emergence of antimicrobial resistance is well established. The Kumbh Mela, a religious festival that occurs in 4 Indian cities of spiritual significance, is the world's largest mass gathering, attracting over 80 million pilgrims in 2013. Digital syndromic surveillance from the 2013 and 2015 Melas demonstrated a consistent pattern of antibiotic overuse, with an antibiotic prescribing rate of up to 31% for all patient encounters. As preparations for the 2025 Kumbh Mela begin, task shifting, point-of-care diagnostic and digital tools, robust clinician training, and community awareness can promote the restrained and evidence-based use of antibiotics, minimizing the potential for the emergence of antimicrobial resistance at the world's largest mass gathering.

Antimicrobial susceptibility testing: An updated primer for clinicians in the era of antimicrobial resistance: Insights from the Society of Infectious Diseases Pharmacists

Antimicrobial susceptibility testing (AST) is a critical function of the clinical microbiology laboratory and is essential for optimizing care of patients with infectious diseases, monitoring antimicrobial resistance (AMR) trends, and informing public health initiatives. Several methods are available for performing AST including broth microdilution, agar dilution, and disk diffusion. Technological advances such as the development of commercial automated susceptibility testing platforms and the advent of rapid diagnostic tests have improved the rapidity, robustness, and clinical application of AST. Numerous accrediting and regulatory agencies are involved in the process of AST and setting and revising breakpoints, including the U.S. Food and Drug Administration and the Clinical and Laboratory Standards Institute. Challenges to optimizing AST include the emergence of new resistance mechanisms, the development of new antimicrobial agents, and generation of new data requiring updates and revisions to established methods and breakpoints. Together, the challenges in AST methods and their interpretation create important opportunities for well-informed clinicians to improve patient outcomes and provide value to antimicrobial stewardship programs, especially in the setting of rapidly changing and increasing AMR. Addressing AST challenges will involve continued development of new technologies along with collaboration between clinicians and the laboratory to facilitate optimal antimicrobial use, combat the increasing burden of AMR, and inform the development of novel antimicrobials. This updated primer serves to reinforce important principles of AST, and to provide guidance on their implementation and optimization.

Optimizing Treatment of Staphylococcus aureus Bloodstream Infections Following Rapid Molecular Diagnostic Testing and an Antimicrobial Stewardship Program Intervention

Pending antibiotic susceptibility results, vancomycin is often used for bloodstream infections (BSIs) to ensure treatment of methicillin-resistant Staphylococcus aureus (MRSA). As rapid discrimination of methicillin-susceptible S. aureus (MSSA) from MRSA in BSIs could decrease vancomycin use and allow early optimization of beta-lactam therapy, this study evaluated the impact of the use of rapid molecular testing for MSSA and MRSA coupled with an antimicrobial stewardship program (ASP) intervention. Between January and July 2020, the Cepheid Xpert MRSA/SA blood culture assay was performed on blood cultures with Gram-positive cocci in clusters that were identified as S. aureus using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). The ASP team member then consulted with the treating physician. The time to optimal therapy (TTOT) and clinical outcomes, including length of hospital stay (LOS), were compared between the intervention (n = 29) and historical (n = 27) cohorts. TTOT was defined as the time from the first blood culture draw to the use of appropriately dosed antistaphylococcal beta-lactam monotherapy without vancomycin. Molecular testing significantly reduced the median time to MSSA and MRSA discrimination to 7.8 h, compared to 24.3 h with culture-based methods (P < 0.001). Compared to the control group, the median TTOT in the ASP intervention group was significantly shorter (P = 0.041) at 38.0 h (versus 50.1 h). Rapid discrimination between MRSA and MSSA using molecular testing, paired with an ASP intervention, significantly reduced the TTOT in patients with MSSA BSIs. IMPORTANCE Our research shows that time to optimal antibiotic treatment for serious bloodstream infections can be improved with rapid molecular sensitivity testing and feedback to prescribers. This can be implemented in laboratories without full microbiology services or training to improve patient outcomes by improving antimicrobial use.

Estimated Impact of Low Isolate Numbers on the Reliability of Cumulative Antibiogram Data

Antibiograms are cumulative reports of antimicrobial susceptibility results that are used to guide the selection of empirical antibiotic therapy. Although Clinical and Laboratory Standards Institute (CLSI) guidelines recommend including only organisms that have at least 30 isolates in an antibiogram, previous studies demonstrated that adherence to this recommendation is highly variable. This paper aims to model the impact of small sample sizes on expected levels of error in cumulative antibiograms by comparing percent susceptibility results for random samples to those of the larger, entire data set. The results demonstrate relatively high error rates when utilizing low numbers of isolates in cumulative antibiograms, and provide a discussion point for considering the appropriate number of isolates that could be utilized, and the impact of increasing isolate numbers by including multiple years of data. IMPORTANCE Antibiograms are reports of local antimicrobial susceptibility patterns for common bacteria and yeast that are used to make empirical decisions for patient therapy and also to inform institution therapy guidelines. This study evaluates the impact of low isolate counts on the reliability of antibiograms, and suggests that more institutions should utilize multiple years of data to overcome this issue.

What is "Opioid Stewardship"? An Overview of Current Definitions and Proposal for a Universally Acceptable Definition

Introduction

Opioid stewardship has been widely used to promote rational use, monitoring and discontinuation of opioid therapy; however, its definition and scope of practice remain unclear.

Objective

To synthesize definitions of opioid stewardship proposed by clinical practice guidelines and professional societies, and to offer a proposal for a universally acceptable definition.

Methods

Systematic literature searches were performed (earliest records to May 2022) in six databases (MEDLINE, EMBASE, APA PsycINFO, Scopus, and CENTRAL) and grey sources guidelines development bodies and professional societies through Google. The conventional but widely applied content analysis and word frequencies were used to analyze the definitions and scope of practice.

Results

After removing duplicates, 449 articles were retrieved (439 databases and registers and 11 from other sources), 19 of which included a definition of "opioids stewardship". A total of 12 themes was identified in the definitions, including 1) improvement or appropriateness of prescribing opioids use, 2) mitigation of risk from opioids, 3) monitoring opioid use, 4) evaluation of opioid use, 5) judicious opioid use, 6) appropriateness of opioid disposal, 7) identification and treatment of opioid use disorder, 8) reduction in mortality associated with opioid overdoses, 9) appropriate procurement practices, 10) appropriate storage, 11) promoting better communications between patients and prescribers including education provision and 12) patient-centered decision-making.

Conclusion

Opioid stewardship is inconsistently defined across professional and research literature. While there is a greater focus on appropriateness and need for improvement of prescribing and monitoring of opioid use, the importance of communications between patients and prescribers, and patient involvement in both prescribing and deprescribing decision-making remains sparse. A comprehensive definition has been proposed as part of the work. There is a need to develop and validate the proposed definition and scope of practice to promote rationale for opioid prescribing, use and attainment of favourable outcomes through international consensus involving practitioners, researchers, and patients.

The Effect of Decreased Antipseudomonal Drug Consumption on Pseudomonas aeruginosa Incidence and Antimicrobial Susceptibility Profiles over 9 Years in a Lebanese Tertiary Care Center

Pseudomonas aeruginosa (PAE) is intrinsically resistant to numerous classes of antimicrobials such as tetracycline and β-lactam antibiotics. More epidemiological surveillance studies on the antimicrobial susceptibility profiles of PAE are needed to generate clinically significant data and better guided therapeutic options. We describe and analyze in a retrospective study the epidemiologic trends of 1827 Pseudomonas spp. isolates (83.5% PAE, 16.4% Pseudomonas sp., and 0.2% Pseudomonas putida) from various clinical specimens with their resistance patterns to antimicrobial consumption at a tertiary medical center in Lebanon between January 2010 and December 2018. We report a significant drop in the incidence of PAE from sputum (p-value = 0.05), whereas bloodstream infection isolation density showed no trend over the study period. We also registered a minimal but statistically significant drop in resistance of Pseudomonas to certain antibiotics and a decrease in the consumption of antipseudomonal antibiotics (p-value < 0.001). Only 61 PAE isolates from a total of 1827 Pseudomonas cultures (3.33%) were difficult to treat, of which only one was a bacteremia. Interestingly, we found that the carbapenem susceptibility of Pseudomonas was unaffected by the decrease in their consumption. These results augur that antimicrobial pressure may not be the sole contributor to resistance emergence. Finally, antimicrobial stewardship seems to have a positive impact on nosocomial epidemiology.

Evaluation of an Antifungal Stewardship Initiative Targeting Micafungin at an Academic Medical Center

Delays in the treatment of proven invasive fungal disease have been shown to be harmful. However, empiric treatment for all patients at risk of infection has not demonstrated benefit. This study evaluates the effects of a micafungin stewardship initiative on the duration of therapy and clinical outcomes at the University of Mississippi Medical Center in Jackson, Mississippi. This single-center quasi-experiment evaluated patients who received micafungin. Adult inpatients who received at least one treatment dose of micafungin in the pre-intervention (1 October 2020 to 30 September 2021) or post-intervention (1 October 2021 to 30 April 2022) groups were included. Patients were placed on micafungin for prophylaxis and those who required definitive micafungin therapy were excluded. An algorithm was used to provide real-time recommendations in order to assess change in the treatment days of micafungin therapy. A total of 282 patients were included (141 pre-group versus 141 post-group). Over 80% of the patients included in the study were in an intensive care unit, and other baseline characteristics were similar. The median number of treatment days with micafungin was 4 [IQR 3-6] in the pre-group and 3 [IQR 2-6] in the post-group (p = 0.005). Other endpoints, such as time to discontinuation or de-escalation, hospital mortality, and hospital length of stay, were not significantly different between the groups. An antifungal stewardship initiative can be an effective way to decrease unnecessary empiric antifungal therapy for patients who are at risk of invasive fugal disease.