Impact of antimicrobial stewardship in intensive care units by multi-drug-resistant organism surveillance – An approach for a better future

Objectives The primary objective of the study was to compare the effectiveness of different methods (broth microdilution [BMD], colistin agar test [CAT], colistin disc elution [CDE], and Vitek) in detecting colistin resistance among clinical isolates. The secondary objective was to analyze risk factors associated with colistin-resistant organisms in intensive care unit (ICU) and high-dependency unit (HDU) settings. Material and Methods A total of 65 colistin-resistant isolates from various clinical samples were utilized. The resistant organisms were predominantly found in ICUs and HDUs. Colistin minimum inhibitory concentration (MIC) was determined using BMD, CAT, CDE, and the Vitek system. The sensitivity of each method was compared. Additionally, risk factor analysis was conducted to identify factors contributing to MDRO infections. Results The analysis revealed that BMD and Vitek methods demonstrated 100% sensitivity in detecting colistin resistance. The CAT method showed 96.92% sensitivity, ranking it as the second-best method, while the CDE method exhibited 70.76% sensitivity. Among the resistant organisms, Klebsiella pneumoniae (n=51) was most frequently encountered. Risk factor analysis indicated that long-term hospital stays and immunocompromised conditions in ICU patients increased the susceptibility to multidrug-resistant organisms (MDROs) infections. Conclusion The emergence of colistin resistance poses a serious threat to public health, particularly in ICUs and HDUs. Accurate detection of colistin resistance is vital for appropriate antibiotic therapy and infection control. This study demonstrates that while BMD and Vitek methods offer the highest sensitivity, CAT also provides reliable results and can be used in clinical practice. The findings highlight the need for ongoing surveillance, stringent infection control measures, and robust antimicrobial stewardship programs (AMSP) to combat the spread of MDROs and improve patient outcomes. Implementing rigorous infection prevention and control practices, as recommended by the US Centers for Disease Control and Prevention (CDC), can significantly mitigate the risks associated with MDROs.

COVID-19 has significantly affected hospital infection prevention and control (IPC) practices, especially in intensive care units (ICUs). This frequently caused dissemination of multidrug-resistant organisms (MDROs), including carbapenem-resistant Acinetobacter baumannii (CRAB). Here, we report the management of a CRAB outbreak in a large ICU COVID-19 hub Hospital in Italy, together with retrospective genotypic analysis by whole-genome sequencing (WGS). Bacterial strains obtained from severe COVID-19 mechanically ventilated patients diagnosed with CRAB infection or colonization between October 2020 and May 2021 were analyzed by WGS to assess antimicrobial resistance and virulence genes, along with mobile genetic elements. Phylogenetic analysis in combination with epidemiological data was used to identify putative transmission chains. CRAB infections and colonization were diagnosed in 14/40 (35%) and 26/40 (65%) cases, respectively, with isolation within 48 h from admission in 7 cases (17.5%). All CRAB strains belonged to Pasteur sequence type 2 (ST2) and 5 different Oxford STs and presented bla OXA-23 gene-carrying Tn2006 transposons. Phylogenetic analysis revealed the existence of four transmission chains inside and among ICUs, circulating mainly between November and January 2021. A tailored IPC strategy was composed of a 5-point bundle, including ICU modules' temporary conversion to CRAB-ICUs and dynamic reopening, with limited impact on ICU admission rate. After its implementation, no CRAB transmission chains were detected. Our study underlies the potentiality of integrating classical epidemiological studies with genomic investigation to identify transmission routes during outbreaks, which could represent a valuable tool to ensure IPC strategies and prevent the spread of MDROs. IMPORTANCE Infection prevention and control (IPC) practices are of paramount importance for preventing the spread of multidrug-resistant organisms (MDROs) in hospitals, especially in the intensive care unit (ICU). Whole-genome sequencing (WGS) is seen as a promising tool for IPC, but its employment is currently still limited. COVID-19 pandemics have posed dramatic challenges in IPC practices, causing worldwide several outbreaks of MDROs, including carbapenem-resistant Acinetobacter baumannii (CRAB). We present the management of a CRAB outbreak in a large ICU COVID-19 hub hospital in Italy using a tailored IPC strategy that allowed us to contain CRAB transmission while preventing ICU closure during a critical pandemic period. The analysis of clinical and epidemiological data coupled with retrospective genotypic analysis by WGS identified different putative transmission chains and confirmed the effectiveness of the IPC strategy implemented. This could be a promising approach for future IPC strategies.

Cultural determinants of infection control behaviour: understanding drivers and implementing effective change

Chapter 16 - Antimicrobial Stewardship in ICU

Background : On World Health Day 2011, WHO’s statement read “Combat drug resistance: no action today means no cure tomorrow”.  Eleven years on, antimicrobial resistance remains a global crisis. Drug resistance claims up to 700,000 lives globally each year, and is poised to reach ten million per year by 2050. Experts have classified antimicrobial resistant pathogens into 3 categories: Multi drug resistant organism (MDRO) - non-susceptible to at least 1 agent in 3 antimicrobial categories Extensively drug-resistant organism (XDRO)—non-susceptible to at least 1 agent in all but 2 or fewer antimicrobial categories. Pan-drug-resistant—non-susceptible to all agents in all antimicrobial categories Infections with such resistant pathogens have limited therapeutic options and are life threatening.  MDROs significantly contribute to mortality and morbidity in ICU patients, with increased duration of hospital stay as well as cost of care. MDROs are identified through in vitro culture and drug susceptibility tests. Common MDROs in healthcare settings include (MRSA, VRE, ESBL producers, CRE etc.).  MDR and XDR organisms are common in Indian health care settings, with a large multi-centric study in the country having identified MDR Staphylococcus aureus, Enterococcus sp., Pseudomonas aeruginosa, Acinetobacter baumanii, and Enterobacteriaceae (E.coli, Klebsiella sp.) as causes of concern.It is important to know the MDRO pattern of a healthcare institute to devise new antibiotic guidelines and adopt better infection control practices so that nosocomial outbreaks may be reduced. Materials & Methods including: Samples received from the ICU in the Bacteriology laboratory of urban tertiary health care centre in South India for culture and sensitivity testing were screened for MDRO. Urine samples were screened using CHROM agar, while other samples were cultured using Blood agar and Mac Conkey agar. Isolates were identified by conventional biochemical testing. Antibiotic sensitivity patterns were studied using Kirby Bauer disk diffusion method and interpreted as per CLSI guidelines. Data were analysed using Microsoft Excel software. Result: Our study found a significantly higher prevalence of MDROs and P-XDROs compared to NMDROs (P = 0.004). The predominant isolates were E. coli and K. pneumoniae, showing high levels of resistance while showing susceptibility with carbapenems. Common resistance mechanisms included PMQR genes, ESBLs and mcr genes, carbapenemases.  Cephalosporin and carbapenem resistance were widespread, limiting treatment options to higher level antibiotics that usually are not economical for patients. Acinetobacter species, many times linked to ventilator-associated pneumonia, showed high resistance and persistence. ICU patients with comorbidities were particularly vulnerable. The results show the growing threat of AMR, limited antibiotic efficacy, and the need for improved infection control, stewardship, and awareness. Conclusion: The rise of MDROs and P-XDROs, especially in E. coli and K. pneumoniae, demands the urgent need for stronger antibiotic stewardship, infection control, and public awareness to address the growing threat of antimicrobial resistance.

The coronavirus disease (COVID-19) pandemic has resulted in necessary modifications of infection control policies and practices in acute healthcare facilities globally. This is often accompanied by infrastructure modifications, ward redesignations, as well as healthcare staff redeployments and changes to infection prevention and control (IPC) practices. We review the potential for both negative and positive impacts these major changes can have on nosocomial transmission of multidrug-resistant organisms (MDROs). Healthcare facilities around the world have reported outbreaks of MDROs during the COVID-19 pandemic. In contrast some centres have reported a decrease in baseline rates due to a number of possible factors. While implementing crucial preventive measures for COVID-19, is it important to consider any collateral effects of changes in IPC and antimicrobial stewardship program (ASP) practices. The disruption caused to IPC and ASP practices during the pandemic are likely to see a counter intuitive increase in transmission of MDROs.

Hospital infection in Intensive Care Units is a significant problem that affects patient safety and clinical outcomes, resulting in complications that can lead to high mortality. This study aims to investigate hospital infection control practices in Intensive Care Units, focusing on the role of nurses and the impact of these practices on reducing the incidence of infections. The methodology used was an integrative literature review, which followed six steps: identification of the topic, systematic bibliographic search, screening of titles and abstracts, critical reading of articles, data extraction and analysis and interpretation of information. The search was carried out in relevant databases, using specific keywords, with a time frame that covered publications from 2013 to 2023. The inclusion criteria included studies available in Portuguese, English or Spanish, which addressed infection control practices in Intensive Care Units and the role of nurses. The results of the review revealed that implementing strict infection control protocols, including hand hygiene, appropriate use of Personal Protective Equipment and adherence to international guidelines, has a positive impact on reducing hospital-acquired infections. The data indicated that Intensive Care Units that follow standardized practices observe significantly lower rates of infections, which contributes to better clinical outcomes, such as reduced mortality and length of stay. Furthermore, ongoing education and training of nurses were identified as critical factors for adherence to these practices, with regular training programs associated with greater effectiveness in interventions. However, the review also highlighted significant challenges faced in implementing these practices, such as nurses' high workload and resistance to change in organizational culture, which can compromise the effectiveness of infection control interventions. These challenges indicate the urgent need for health policies that prioritize institutional support, the provision of adequate resources and the development of an organizational culture that values patient safety. The conclusion of this study emphasizes the importance of infection control practices in Intensive Care Units and the fundamental role of nurses in their implementation. The promotion of effective infection control strategies, combined with continuing education and institutional support, can not only reduce the incidence of nosocomial infections, but also improve the clinical outcomes of critically ill patients. Therefore, healthcare institutions must invest in continuous training, ensure adequate resources and foster a culture that prioritizes the safety and health of patients, thus contributing to improving the quality of care in Intensive Care Units.

Background: Antimicrobial resistance poses a significant challenge in neurosurgical intensive care units (ICU). The excessive use of broad-spectrum antibiotics is closely linked to the emergence and dissemination of drug-resistant bacteria within neurosurgical ICUs. This study assessed the effects of implementing a comprehensive Antimicrobial Stewardship (AMS) program in a neurosurgical ICU setting.Methods: From April 2022 to September 2022, an AMS program was implemented in the neurosurgical ICU. The program involved the regular presence of a pharmacist and an infectious disease physician who conducted prospective audits and provided feedback. To assess the impact of the AMS program, the outcome measures were compared between the AMS period and the 6 months before AMS implementation (pre-AMS period). The primary outcome was the use of antibacterial agents, including anti-pseudomonal beta-lactams (APBLs), polymyxin, and tigecycline. Additionally, the study evaluated the appropriateness of antimicrobial de-escalation and the susceptibility of Gram-negative bacilli to antimicrobial agents.Results: A total of 526 were included during the AMS period, while 487 patients were included in the pre-AMS period. The two groups had no significant differences in disease severity and mortality rates. During the AMS period, there was a notable decrease in the use of APBLs as empiric treatment (43.92% vs. 60.99%, p < 0.001). Multi-drug resistant organism (MDRO) infections decrease significantly during AMS period (11.03% vs. 18.48%, p < 0.001). The number of prescription adjustment increased significantly in all patients (0 item vs. 0 item, p < 0.001) and MDRO-positive patients (3 items vs. 2 items, p < 0.001) during the AMS period. Additionally, appropriate antimicrobial de-escalation for patients with MDRO showed improvement during the AMS period (39.66% vs. 20%, p = 0.001). Polymyxin utilization also decreased during the AMS period (15.52% vs. 31.11%, p = 0.034). Furthermore, the susceptibility of Gram-negative Bacilli isolates to APBLs was significantly higher during the AMS period.Conclusion: Implementing a comprehensive pharmacist-led AMS program led to a decrease in the use of antibacterial agents. This reduction in usage is significant because it can potentially delay the emergence of bacterial resistance.

Supplement: STRIVE1 October 2019The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care–Associated Infections at the Local LevelFREEKyle J. Popovich, MD, MS, David P. Calfee, MD, Payal K. Patel, MD, MPH, Shelby Lassiter, BSN, RN, CPHQ, Andrew J. Rolle, MPH, Louella Hung, MPH, Sanjay Saint, MD, MPH, and Vineet Chopra, MD, MScKyle J. Popovich, MD, MSRush University Medical Center, Chicago, Illinois (K.J.P.), David P. Calfee, MDWeill Cornell Medicine, New York, New York (D.P.C.), Payal K. Patel, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), Shelby Lassiter, BSN, RN, CPHQHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Andrew J. Rolle, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Louella Hung, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.L., A.J.R., L.H.), Sanjay Saint, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.), and Vineet Chopra, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (P.K.P., S.S., V.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3529 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Health care–associated infection (HAI) remains an important problem in the United States (1, 2). Central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are among the most common device-associated infections, whereas Clostridioides difficile and methicillin-resistant Staphylococcus aureus (MRSA) are among the most prevalent pathogens causing HAI. In 2011, there were an estimated 721 800 HAIs in U.S. acute care hospitals, with C difficile, S aureus, Enterococcus species, and gram-negative bacilli being the most common pathogens (3). To address the burden of these infections, evidence-based infection prevention strategies, including "bundles" or combinations of interventions, have been developed and successfully implemented in many hospitals to prevent HAIs (4–8). For example, bundles have been created to decrease CLABSI (4), CAUTI (5, 9), and MRSA bloodstream infection (6, 7). In U.S. intensive care units, there has been a substantial reduction in CLABSIs, thought to be in large part due to implementation of bundles (4, 10).Many U.S. hospitals, unfortunately, continue to experience high rates of HAI (11) because of low compliance with infection prevention practices, poor organizational culture, financial limitations, limited engagement from front-line personnel, and limited leadership support (12). Of note, assistance from external sources, such as local, state, and national groups (including public health departments, quality improvement organizations, hospital associations, and academic medical centers), can help reduce HAI (13, 14). However, the ways and extent to which these entities engage with hospitals to improve HAI rates vary, resulting in heterogeneity of outcomes (12). Comprehensive solutions to this complex dynamic within and across hospitals, states, and the country have not been developed. In particular, strategies to help hospitals that continue to have high rates of HAI are needed.To reduce infections in hospitals with high rates of HAI, the Centers for Disease Control and Prevention (CDC) funded a prospective, interventional, nonrandomized, quality improvement program that spanned multiple hospitals and states. Development, implementation, and execution of the program was performed by the Health Research & Educational Trust (HRET), a not-for-profit research and education affiliate of the American Hospital Association, along with several partners, such as state hospital associations (SHAs), professional societies, and scientific experts from academic medical centers. Collectively, the program was titled CDC STRIVE (States Targeting Reduction in Infections via Engagement). This article provides a summary of how STRIVE constructed the building blocks for a national effort intended to reduce HAIs in participating hospitals.Program Goals and StructureThe STRIVE initiative focused on bringing national health care professional societies, subject-matter experts, and state-level health care organizations together with short-stay and long-term acute care hospitals to improve infection prevention and control practices. The overall objective of the program was to identify, partner with, and collaborate with hospitals struggling to reduce HAI by pairing national subject-matter experts with state, regional, and local organizations to effect sustainable change (Figure 1).Figure 1. Overall flow of the CDC STRIVE program.CDC = Centers for Disease Control and Prevention; STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint To deliver on this ambitious goal, the STRIVE initiative had 3 specific aims: 1) strengthen infection control practices through dissemination and implementation of CDC's Targeted Assessment for Prevention (TAP) strategy; 2) strengthen relationships among SHAs, state health departments, and other state HAI partners, such as the Centers for Medicare & Medicaid Services Quality Innovation Network–Quality Improvement Organizations, to create a structure to facilitate durable implementation of best infection control practices; and 3) provide technical assistance to facilities to improve implementation of infection control practices in existing and newly constructed health care facilities. Reductions in C difficile infection (CDI), CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection in participating hospitals were chosen as measures to determine initiative success.Program planning for STRIVE began in September 2015. Subject-matter experts from multiple organizations were identified by CDC and HRET and brought together to form a national program team to provide oversight for the program and build educational content. Members of the national program team included representatives from CDC, HRET, Association for Professionals in Infection Control and Epidemiology, American Society for Health Care Engineering, Society of Hospital Medicine, and University of Michigan Health System.Stakeholder Considerations in Designing STRIVE InterventionsThe CDC outlined several objectives to increase alignment and coordination of HAI prevention efforts across stakeholders: First, identify strategies to improve infection control implementation activities on a state- and facility-level; second, identify indicators of capacity (infrastructure, staffing, partnerships, and training), ongoing regional collaboratives, and other contextual factors (such as state-level mandates) that may affect implementation of infection prevention efforts; and third, identify roles of state partners (state health departments, SHAs, Quality Innovation Network–Quality Improvement Organizations) in the coordination, integration, and alignment of infection prevention and control activities.Eligibility and Selection of Participating HospitalsThe CDC STRIVE initiative focused specifically on hospitals with a disproportionately high burden of HAI. To target these facilities, the CDC used National Healthcare Safety Network (NHSN) data from the first 2 quarters of 2015 to identify states with hospitals that had a high burden of CDI and a high burden of at least 1 of the following HAIs: CLABSI, CAUTI, or hospital-onset MRSA bloodstream infection. "High burden" was defined by examining the cumulative attributable difference (15) (using the U.S. Department of Health and Human Services' 2020 HAI goals as the standardized infection ratio target). Hospitals with a cumulative attributable difference above the first tertile (that is, the top one third) were designated as having a high burden of HAIs. Data for all 4 infection types were combined to identify hospitals with CDIs plus at least 1 other HAI with cumulative attributable differences above the first tertile.Three methods were used to identify eligible states. First, CDC identified states with the largest number of hospitals that met inclusion criteria. These states thus became the main focus of STRIVE efforts. Second, to include sites that may also benefit from STRIVE, HRET applied the CDC approach with publicly available Hospital Compare state-specific data to identify additional hospitals with a high burden of HAIs not included in the cumulative attributable difference first tertile. Finally, a few interested states not included in the above were allowed to volunteer to participate in STRIVE. Using these methods, 34 states and the District of Columbia were identified for possible inclusion in STRIVE.Rather than approach hospitals directly (and in keeping with the STRIVE goal to strengthen state and local partnerships to combat HAI), HRET shared the list of potentially eligible hospitals with SHAs and asked them to recruit sites. In this way, the CDC and HRET engaged SHAs to reach out to hospitals to inform them about the program, solicit their interest, and recruit them to participate. As word of the intervention and program spread, a few states that were not identified by the CDC also requested to participate in the STRIVE program, because they viewed this program as important to help improve hospital infection control practices.To better consolidate efforts and understand the impact of interventions, recruitment within STRIVE occurred within waves, leading to 4 cohorts of hospitals (Table): cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Cohort 1 was identified as a pilot cohort in which interventions to reduce HAI were developed and pilot-tested in conjunction with key stakeholders. In total, 443 short-stay and long-term acute care hospitals from 28 states and the District of Columbia participated in 4 overlapping, 10- to 12-month cohorts (Appendix Figure). In 2015 (before the intervention), the median cumulative attributable difference values for cohorts 2, 3, and 4 were as follows: CAUTI, 0.67 (interquartile range [IQR], –0.62 to 4.22); CLABSI, 1.46 (IQR, –0.02 to 5.44); CDI, 5.04 (IQR, 0.16 to 17.48); and MRSA, 0.45 (IQR, –0.15 to 2.67).Table. Characteristics of Hospitals Participating in the STRIVE ProgramAppendix Figure. States that enrolled with the STRIVE program.In total, 443 hospitals from 28 states and the District of Columbia participated. Recruitment occurred as follows: cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). Hashing indicates states that participated in more than 1 cohort. STRIVE = States Targeting Reduction in Infections via Engagement. Download figure Download PowerPoint Informing Change—Designing InterventionsPractice Change AssessmentDuring STRIVE, participating hospitals were asked to complete a survey instrument to identify and address gaps in HAI prevention at the beginning of cohort enrollment (baseline) and at the end of the study wave (comparison) (Figure 2). This gap assessment could be done using either the CDC's Infection Control Assessment and Response (ICAR) survey (16) or the STRIVE Practice Change Assessment (PCA). The ICAR had been previously developed for state health departments to assess infection prevention practices in hospitals. The PCA, based on the ICAR, was modified to focus on 8 domains germane to the STRIVE program. Four of the domains focused on specific HAIs—CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection—whereas the remaining 4 domains focused on hand hygiene, personal protective equipment, environmental cleaning, and antimicrobial stewardship.Figure 2. Education and engagement interventions implemented for participating hospitals.CDC = Centers for Disease Control and Prevention. Download figure Download PowerPoint Baseline surveys were administered by each participating hospital with support and (at times) a site visit by the state partners. If a hospital had completed an ICAR in the year before STRIVE, they were able to reuse that survey for their baseline assessment. A summary report from these assessments was provided to each site, highlighting opportunities for improvement and a list of STRIVE content and resources to assist in addressing these gaps.Education: Foundational and HAI-Specific Web-Based ModulesSubject-matter experts created educational materials for 12 different topics. Development of educational materials by experts occurred via in-person meetings and work group conference calls. Two primary topic domains were identified around which program education would be focused: foundational and HAI-specific elements.The foundational domain emphasized core infection control practices that are known to have variable compliance but are critical for success of any HAI prevention initiative (for example, hand hygiene, personal protective equipment use, and environmental cleaning). Many are considered "horizontal" infection control strategies in that they affect not one but many pathogens and HAIs. Eight elements for the foundational domain were identified: 1) competency-based training, auditing, and feedback; 2) hand hygiene; 3) personal protective equipment; 4) environmental cleaning; 5) antimicrobial stewardship; 6) making an effective infection prevention business case; 7) patient and family engagement; and 8) socioadaptive strategies for preventing infection.The HAI-specific domains were concentrated on best practices for preventing CDI, CLABSI, CAUTI, and hospital-onset MRSA bloodstream infection. In total, subject-matter experts created 51 short (10 to 20 minutes), Web-based, on-demand educational modules covering key topics in the 2 domains (Appendix Table).Appendix Table. Overview of the 51 Web-Based Learning Modules Developed for the STRIVE ProgramA 2-tiered intervention approach was developed for the HAIs targeted in STRIVE. Tier 1 interventions were defined as basic, evidence-based interventions that every hospital should have in place (for example, ensuring that central lines are placed aseptically). Foundational elements remained a critical aspect across tier 1 for the HAI-specific modules as these elements generally have demonstrated success, are economically efficient, and have multiplicative effects across HAIs. Foundational elements are also crucial to have in place before more complex technical and social interventions are introduced. Tier 2 interventions were generally considered more complex, "advanced" steps for hospitals to take once tier 1 interventions were reliably in place but not leading to a decline in a particular HAI. In general, tier 2 interventions were considered to require increased human and economic capital compared with tier 1.Engaging Sites: Learning Action ForumsIn conjunction with the Web-based modules, monthly learning action forums were hosted by HRET for all cohorts. These monthly, 1-hour webinars were discussion-based and interactive and were built on supporting the didactic content from the curriculum's on-demand courses. They provided hospitals with an opportunity to share their infection prevention strategies, challenges, and successes, thereby strengthening engagement and learning across member sites. The learning action forums also allowed national subject-matter experts to interact with hospitals and answer questions related to webinar content or materials. The lead for most learning action forums was often an infection preventionist or someone with a role in quality at the local hospital. The lead would distribute the webinar information to staff, which typically included nurse managers, environmental services, frontline clinicians, and other clinical and nonclinical staff, depending on the topic of the learning action forum.Education: TAP StrategyThe TAP strategy (15) developed by the CDC can be used not only to identify facilities and units with a high burden of HAIs, but also to highlight gaps in infection prevention. In this way, finite infection prevention resources can be directed to areas of greatest opportunity. The TAP strategy incorporates the TAP reports generated in the CDC's NHSN, along with standardized assessment tools and implementation strategies for CLABSI, CAUTI, and CDI.Feedback from the cohort 1 pilot revealed that additional, more intense education and training on how best to use TAP reports was needed. Although most hospital infection preventionists had heard of the TAP strategy, most lacked in-depth knowledge, and few organizations were actively using TAP resources. Therefore, many state-level in-person meetings incorporated TAP training, provided by their state health departments, to drive increased understanding of this strategy. In addition, from June 2017 to January 2018, the CDC collaborated with HRET to develop and deliver four 90-minute webinars on how to run and interpret TAP reports and use TAP strategies and resources to maximize HAI prevention. To further support state partner knowledge of this valuable resource, the CDC provided a webinar in December 2017 for state partners, providing additional education around how to use TAP reports and strategies at the state level to promote HAI prevention work.Strengthening Partnerships Through Coaching and CollaborationState health departments and SHAs collaborated to support hospitals in administering the PCA or ICAR, interpreting results, and finding resources to address identified gaps. In addition, state health departments were instrumental in educating hospitals on running and using TAP reports, utilizing STRIVE venues, such as in-person meetings and site visits in each state, along with the SHA. In addition, the SHA program lead (and often their health department partners) supported hospitals via monthly one-on-one calls, webinars, or office hours open to all STRIVE hospitals. These touch points were used for shared learning and coaching from the state mentors and experts around barriers and action planning to reach goals. Upon request, subject-matter experts from the national program team would also join such calls to add expertise. The state partners often acted in the role of encourager and cheerleader for teams to support momentum as well.State In-Person MeetingsOn the basis of feedback from cohort 1 pilot sites, state-level in-person meetings were implemented for all participating states in cohorts 2 to 4. Although the online and virtual materials were felt to be helpful, sites in cohort 1 felt that bringing hospitals and state partners together in person was necessary to support building relationships. Such meetings also provided protected time and space for hospital participants' learning and networking with peers as well as state and national experts.ImplementationIn contrast to single-unit interventions often found in infection control projects, the focus of this program was large-system transformation (17) to influence multiple hospitals, organizations, and health care providers. The national program team developed a full STRIVE implementation plan focused on leveraging content for both foundational and HAI-specific practices. The curriculum was divided into 3 phases: onboarding to the STRIVE program, foundational infection prevention strategies, and education targeted to the program's 4 HAIs.In May 2016, onboarding started for cohort 1, which included a general program overview, team formation, and education regarding ICAR/PCA assessments and TAP strategy. The rollout for Web-based modules then occurred for cohort 1 as follows: July to October 2016 (foundational elements modules), November 2016 to January 2017 (HAI-specific tier 1 modules), and February 2017 to March 2017 (HAI-specific tier 2 modules). These modules were available to all subsequent cohorts throughout their 12-month collaborative after their onboarding. Web modules for STRIVE can be found at www.cdc.gov/infectioncontrol/training/strive.html.ConclusionThe STRIVE initiative, coordinated by the HRET and funded by the CDC, brought together state-level organizations with short-stay and long-term acute care hospitals across the country to improve infection prevention and control practices for hospitals with a disproportionately high burden of HAIs. Federal funds for this initiative were in part in response to the lessons learned with Ebola and how stakeholders were interested in strengthening state partnerships and infection control measures in preparation for any future emerging infectious disease. Through the STRIVE initiative, the architecture of preventing HAI shifted from hospital-based to instead utilizing national efforts to effect local improvement efforts in hospitals across the United States.

Looking back to move forward

IntroductionThe Kawaguchi City Public Health Center (PHC) conducted training sessions (TSs) focusing on infection control (IC) practices for multidrug-resistant organisms (MDROs) at healthcare facilities (HCFs) in its jurisdiction in June 2023. We planned to examine whether the TS programs by the PHC have had any effect on the development of IC practices for hospital sinks, to support the hospitals in their development of IC practices to prevent MDRO infections. In this study, we aim to identify effective PHC strategies for developing hospital sink IC practices using post-TS survey results.MethodsIn June 2023, we completed a TS for 30 HCFs, offered information on IC practices, and then sent out a questionnaire. We examined both current IC practices and practices that the hospitals intended to conduct for sinks and identified the first learned information from the TSs organized by the PHC.ResultsTwenty-four HCFs responded to the survey, a response rate of 80.0%. Current IC practices for hospital sinks included refraining from disposing substances like medications and liquid food (refrain from disposing) by 16 hospitals (66.7%), dedicating sinks for handwashing (dedicate sinks) by 14 hospitals (58.3%), installing splash guards by two hospitals (8.3%), and keeping supplies off surfaces within 1 m of the sinks (keep supplies off) by two hospitals (8.3%). IC practices that hospitals planned to conduct for sinks included refraining from disposing by two hospitals (8.3%), dedicating sinks by two hospitals (8.3%), installing splash guards by six hospitals (25.0%), and keeping supplies off by seven hospitals (29.2%). Components of the first learned information included the effects of cleaning bundles by 10 hospitals (41.7%), knowledge sharing organized by the PHC for four hospitals (16.7%) and the effect of TSs on IC, such as a decrease in MDROs associated with TSs (the effect of TSs) by three hospitals (12.5%).The first piece of learned information “the effect of TSs (evidence that TSs reduce MDRO infections)” was significantly associated with the intention of dedicating sinks (p = 0.008). Other planned IC practices for sinks such as refraining from disposing substances, installing splash guards, and keeping supplies off were not associated with the TS programs.ConclusionsPlanned IC practices such as dedicating sinks for handwashing were linked to providing information on the effects of the TSs. We suggest that the PHC should develop TSs, including information about the effects of TSs, for IC practices that cannot be strengthened without staff support.

Background The irrational use of broad-spectrum antibiotics in intensive care units (ICUs) has led to increasing bacterial resistance in recent years. However, research on the effectiveness of antimicrobial stewardship programs (ASPs) in Chinese ICUs is limited. This study aimed to assess the impact of ASP implementation on antibiotic use and bacterial resistance in a Chinese ICU.Methods This retrospective, interventional study employed an interrupted time series design and was conducted in an ICU beginning on June 1, 2019. The ASP included the formation of a multidisciplinary team, the development of facility-specific criteria, prescriber education, the implementation of preauthorization processes, and retrospective prescription audit and feedback (RPAF). Patient data were collected from June 1, 2018, to May 31, 2020. An interrupted time series analysis was used to evaluate the impact of the ASP.ResultsA total of 862 patients were admitted during the pre-intervention period, and 946 patients were admitted during the post-intervention period. The interrupted time series analysis demonstrated a reduction in the monthly consumption of carbapenems (β3: −2.25 DDD/100 PD, p < 0.001) and linezolid (β3: −0.49 DDD/100 PD, p = 0.003) after the intervention. Additionally, a decrease in the incidence of bacteremia caused by multidrug-resistant (MDR) organisms overall (β3:−0.03 events/100 PD, p = 0.036) and MDR Gram-positive organisms (β3:−0.01 events/100 PD, p = 0.002) was observed post-intervention.ConclusionReduced antimicrobial consumption and decreased incidence of infections associated with MDR organisms were observed following the implementation of an ASP strategy that incorporated clinical pharmacists as core team members.Clinical trial numberNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12879-025-11718-4.

Antimicrobial stewardship in the intensive care unit

Objectives. This rapid review summarizes literature for patient safety practices intended to prevent and control the transmission of multidrug-resistant organisms (MDROs). Methods. We followed rapid review processes of the Agency for Healthcare Research and Quality Evidence-based Practice Center Program. We searched PubMed to identify eligible systematic reviews from 2011 to May 2023 and primary studies published from 2011 to May 2023, supplemented by targeted gray literature searches. We included literature that addressed patient safety practices intending to prevent or control transmission of MDROs which were implemented in hospitals and nursing homes and that included clinical outcomes of infection or colonization with MDROs as well as unintended consequences such as mental health effects and noninfectious adverse healthcare-associated outcomes. The protocol for the review has been registered in PROSPERO (CRD42023444973). Findings. Our search retrieved 714 citations, of which 42 articles were eligible for review. Systematic reviews, which were primarily of observational studies, included a wide variety of infection prevention and control (IPC) practices, including universal gloving, contact isolation precautions, adverse effects of patient isolation, patient and/or staff cohorting, room decontamination, patient decolonization, IPC practices specifically in nursing homes, features of organizational culture to facilitate implementation of IPC practices and the role of dedicated IPC staff. While systematic reviews were of good or fair quality, strength of evidence for the conclusions was always low or very low, due to reliance on observational studies. Decolonization strategies showed some benefit in certain populations, such as nursing home patients and patients discharging from acute care hospitalization. Universal gloving showed a small benefit in the intensive care unit. Contact isolation targeting patients colonized or infected with MDROs showed mixed effects in the literature and may be associated with mental health and noninfectious (e.g., falls and pressure ulcers) adverse effects when compared with standard precautions, though based on before/after studies in which such precautions were ceased. There was no significant evidence of benefit for patient cohorting (except possibly in outbreak settings), automated room decontamination or cleaning feedback protocols, and IPC practices in long-term settings. Infection rates may be improved when IPC practices are implemented in the context of certain logistical and staffing characteristics including a supportive organizational culture, though again strength of evidence was low. Dedicated infection prevention staff likely improve compliance with other patient safety practices, though there is little evidence of their downstream impact on rates of infection. Conclusions. Selected infection prevention and control interventions had mixed evidence for reducing healthcare-associated infection and colonization by multidrug resistant organisms. Where these practices did show benefit, they often had evidence that applied only to certain subpopulations (such as intensive care unit patients), though overall strength of evidence was low.

Infection control practices at facilities providing monetary incentives for facility births: An assessment at selected labour and delivery rooms in two states of India