The sex hormone-gut microbiome axis: mechanistic drivers of sex-disparate bacterial infection outcomes and precision clinical interventions.

Human resources estimates and funding for antibiotic stewardship teams are urgently needed

Antibiotic stewardship programmes (ASP) are essential to tackle antibiotic resistance. Clinical microbiologists (CMs) play a key role in these programmes; however, few studies describe their actual involvement. Our objective was to explore CMs' involvement in French hospital ASP. In 2018, we conducted a survey among CMs working in large public French hospitals (600 acute care beds or more). The questionnaire focused on the following topics: microbiology department's characteristics, hospital ASP, and CMs' involvement in this programme, including their use of rapid diagnostic tests (RDT). Fifty/74 CMs answered (response rate 68%), with 68% working in a teaching hospital. CMs were leading the ASP in 6% of cases, and 57% of hospitals had a multidisciplinary antibiotic stewardship team. Most microbiology departments (92%) were using specific PCR, processed 24/7 in 74% of hospitals. More than half (58%) were using syndromic panel-based testing, 94% mass spectrometry, and 96% immunochromatographic/colorimetric RDT. Blood cultures were processed 24/7 in 44% of hospitals. CMs were involved in this. Finally, 42% of CMs wished to be more involved in their hospital's ASP, the most frequently reported barrier being lack of time (36%). CMs should be more involved in ASP. RDT are widely used, but not implemented in an optimal way.

Clinical microbiology laboratories in low-resource settings, it is not only about equipment and reagents, but also good governance for sustainability

In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. WHAT IS KNOWN ABOUT THE TOPIC?: The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. WHAT DOES THE PAPER ADD?: This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.

ABSTRACTThe overuse of antibiotics has led to various healthcare problems such as the emergence of resistance in infectious microbes and mortality due to antibiotic resistant healthcare associated infections (HAIs). An antimicrobial stewardship (AMS) program is the set of interventions used worldwide to enhance the rational use of antibiotics especially for the hospitalized patients. This review aimed to describe the characteristics of the implemented AMS programs in various hospitals of the world mainly focusing on the interventions and patients outcomes. The literature about AMS program was searched through various databases such as PubMed, Google Scholar, Science Direct, Cochran Library, Ovid (Medline), Web of Science and Scopus. In this review the literature pertaining to the AMS programs for hospitalized patients is sorted on the basis of various interventions that are categorized as formulary restriction (pre-authorization), guideline development, clinical pathway development, educative interventions and prospective audit. Moreover a clear emphasis is laid on the patient outcomes obtained as a result of these interventions namely the infection control, drop in readmission rate, mortality control, resistance control and the control of an overall cost of antibiotic treatment obtained mainly by curbing the overuse of antibiotics within the hospital wards. AMS program is an efficient strategy of pharmacovigilance to rationalize the antimicrobial practice for hospitalized patients as it prevents the misuse of antibiotics, which ultimately retards the health threatening effects of various antibiotics.

Antimicrobial resistance (AMR) poses a critical global health threat in India due to the high burden of infectious diseases and widespread misuse of antibiotics. Secondary care hospitals, being pivotal in the Indian healthcare system, require effective Antimicrobial Stewardship (AMS) programs to optimize antimicrobial use and combat AMR. However, significant barriers, such as limited resources, lack of trained personnel, and inadequate infrastructure, hinder AMS implementation. This narrative review evaluated the current state of AMS programs in secondary care hospitals in India. It examined their implementation, impact, challenges, and enablers. Successful case studies of AMS programs were analysed to highlight multidisciplinary approaches involving clinicians, pharmacists, microbiologists, and infection control teams. Key strategies, such as formulary restriction, prospective audit with feedback, antibiotic time-outs, and development of evidence-based guidelines, were identified and discussed. AMS programs have shown potential in improving antimicrobial usage, reducing AMR, and enhancing patient outcomes. Critical components for successful AMS implementation include leadership commitment, drug expertise, accountability, and continuous education. Identified challenges include inadequate funding, insufficient training, and resource limitations. Despite these barriers, examples of effective AMS programs demonstrate the feasibility of scaling these interventions with strong policy support and infrastructure development. Strengthening AMS programs in Indian secondary care hospitals is crucial for controlling AMR, improving patient outcomes, and preserving antimicrobial effectiveness. Overcoming existing barriers requires policy frameworks, funding, infrastructure development, and continuous training. Scaling up AMS efforts can significantly contribute to combating AMR at national and global levels. This review offers recommendations to rationalize AMS practices and enhance implementation in India.

A practice guide to help nursing homes set up an antimicrobial stewardship (AMS) program was developed based on experiences gained during a project at one of the largest providers of elderly care in the South-east of the Netherlands. The guideline for the implementation of AMS in Dutch hospitals served as a starting point and were tailored to the unique characteristics of a nursing home setting. This practice guide offers recommendations and practical tools while emphasizing the importance of establishing a multidisciplinary approach to oversee AMS efforts. The recommendations and practical tools address various elements of AMS, including the basic conditions to initiate an AMS program and a comprehensive approach to embed an AMS program. This approach involves educating nurses and caregivers, informing volunteers and residents/their representatives, and the activities of an antibiotic team (A-team). The practice guide also highlights a feasible work process for the A-team. This process aims to achieve a culture of continuous learning and improvement that can enhance the overall quality of antibiotic prescribing rather than making individual adjustments to client prescriptions. Overall, this practice guide aims to help nursing homes establish an AMS program through collaborative efforts between involved physicians, pharmacists, clinical microbiologists, and infection control practitioners. The involved physician plays a crucial role in instilling a sense of urgency and developing a stepwise strategy.

1The Review on AMR was an expert panel commissioned by the UK Government in 2014 tasked with analysing the economic and social impacts of AMR and proposing solutions to these. 2NICE is a UK non-departmental public body that sponsored by but separate from the Department of Health that produces evidence-based guidance for health practitioners. 3NHS England is a non-departmental public body sponsored by the Department of Health that oversees planning and delivery of health services in England. 4Note that circulation of the News of the World ceased in July 2011; the Sun on Sunday was launched by the same newsgroup in 2012, but is unavailable on the Nexis database.

Antimicrobial stewardship (AMS) remains a cornerstone of efforts aimed at improving antimicrobial-related patient safety. It slows the development and spread of antimicrobial resistance (AMR), while helping clinicians to improve clinical outcomes and minimise harm by improving antimicrobial prescribing. AMS programmes (ASPs) are driven through various processes and people. An AMS structure comprises the core elements that should be in place to support the ASP including the AMS team, treatment guidelines, and surveillance of AMR and antimicrobial use (AMU). This manual aims to provide a practical guide to health care facilities in Nigeria and other low-and- middle-income countries, for establishing, implementing and sustaining ASPs, and is structured into 14 sections. Section 1 introduces the subject matter and gives background information on the current situation of AMS in Nigeria. It describes the efforts of the National Antimicrobial Stewardship Working Group (NASWOG), an arm of the Clinical Microbiology and Infectious Diseases Society of Nigeria (CLIMIDSON), in identifying the AMR issues in health care facilities in the country and providing evidence-based recommendations for ASPs. Section 2 describes the goals of AMS and core elements which must be in place for successful and sustainable ASPs. Section 3 presents how a health care facility could start an ASP depending on the size, highlighting the important role of point prevalence survey (PPS) in obtaining baseline data on AMU and prescribing practice in health care facilities, which is useful in developing an action plan. Although management support is key for a successful ASP, the governance of the programme rests with the AMS committee, which composition and size will depend on the level of health care facility. Section 4 describes AMS strategies, which include the core and supplemental strategies. Every hospital should aspire to do at least a core strategy, although it may be convenient to start with other stewardship activities and supplemental strategies. Section 5 describes the antibiotic policy and guidelines, which provide the framework for all AMS activities, and is an effective means of changing behaviour in antimicrobial prescribing. The guidelines should be written by a multidisciplinary team and due consideration must be given to the local antibiotic susceptibility data and the common infectious disease syndromes in the facility or region. Dissemination of the policy and guidelines should be given wide publicity. At the primary health care facilities, where there may be no doctors to prescribe, “standing orders” are used to guide antibiotic prescribing. Section 6 describes the critical importance of stakeholder engagement to a successful ASP. If stakeholders are more informed about AMR issues and ASP, they are better able to positively support the programme. AMS stakeholders will differ from facility to facility but generally include health care facility management, clinicians, pharmacists, nurses, infection prevention and control (IPC) practitioners, clinical microbiologists, other relevant laboratory staff, and patients. The importance of education and training to the successful implementation of AMS is presented in section 7. Health care facilities should provide induction and in-service training to all staff on AMS and IPC. Training objectives should be clear and targets of education and training should include AMS committee and team(s), clinicians, pharmacists, nurses and other health care staff, patients and caregivers, and advocacy and community campaigns. Sections 8 and 9 explain how monitoring and evaluation (M&E) of ASP, and feedback to stakeholders are conducted. Monitoring and evaluation are critical to identifying the impact of intervention measures and opportunities for improvement. This involves the evaluation of the structures, processes and outcomes of ASPs. Sections 10 and 11 delved into the roles of clinical microbiology laboratory support for AMS, and diagnostic stewardship as well as information and communication technology (ICT) in ASPs. The clinical microbiology laboratory should provide quality antibiotic susceptibility testing data, and standard antibiograms periodically to the AMS committee. Sections 12, 13 and 14 enumerated the core elements of outpatient ASP, institutional mentoring in AMS, and system building approach to sustainability of ASP. The recommendations for outpatient AMS in this document apply to either stand-alone clinics and casualties or those located in secondary or tertiary hospitals.

Compared with younger populations, adults 65 years and older are more likely to suffer infection-related morbidity and mortality, experience antibiotic-related adverse events, and acquire multidrug-resistant organisms. We developed a series of case-based discussions that stressed antibiotic stewardship while addressing management of common infections in older adults. Five 1-hour case-based discussions address recognition, diagnosis, and management of infections common in older adults, including those living in long-term care settings: urinary tract infections, upper respiratory tract infections, lower respiratory tract infections, skin and soft tissue infections, and Clostridium difficile infection. The education was implemented at the skilled nursing centers at 15 Veterans Affairs medical centers. Participants from an array of disciplines completed an educational evaluation for each session as well as a pre- and postcourse knowledge assessment. The number of respondents to the educational evaluation administered following each session ranged from 68 to 108. Learners agreed that each session met its learning objectives (4.80-4.89 on a 5-point Likert scale, 5 = strongly agree) and that they were likely to make changes (2.50-2.89 on a 3-point scale, 3 = highly likely to make changes). The average score on the five-question knowledge assessment increased from 3.6 (72%) to 3.9 (78%, p = .06). By stressing recognition of atypical signs and symptoms of infection in older adults, diagnostic tests, and antibiotic stewardship, this series of five case-based discussions enhanced clinical training of learners from several disciplines.

ESCMID generic competencies in antimicrobial prescribing and stewardship: towards a European consensus

The increasing antimicrobial resistance worldwide, combined with dwindling antimicrobial armamentarium, has resulted in a critical threat to the public health and safety of patients. To combat this hazard, antimicrobial stewardship programs (ASPs) have emerged. Antimicrobial stewardship programs prevent or slow the emergence of antimicrobial resistance by coordinated interventions designed to optimize antimicrobial use to achieve the best clinical outcomes and limiting selective pressures that drive the emergence of resistance. This also reduces excessive costs attributable to suboptimal antimicrobial use. Even though an ideal effective ASP should incorporate more than one element simultaneously, it also requires a multidisciplinary team, which should include an infectious diseases physician, a clinical pharmacist with infectious diseases training, infection control professionals, hospital epidemiologist, a clinical microbiologist and an information specialist. However, for antimicrobial stewardship (AMS) programs to be successful, they must address the specific needs of individual institutions, must be built on available resources, the limitations and advantages of each institution, and the available staffing and technological infrastructure.

The growing problem of antimicrobial resistance (AMR) has led to calls for antimicrobial stewardship programs (ASP) to control antibiotic use in healthcare settings. Key strategies include prospective audit with feedback and intervention, and formulary restriction and preauthorization. Education, guidelines, clinical pathways, de-escalation, and intravenous to oral conversion are also part of some programs. Impact and quality of ASP can be assessed using process or outcome measures. Outcome measures are categorized as microbiological, patient or financial outcomes. The objective of this review was to provide an overview of quality measures for assessing ASP and the reported impact of ASP in peer-reviewed studies, focusing particularly on patient outcomes. A literature search of papers published in English between 1990 and June 2015 was conducted in five databases using a combination of search terms. Primary studies of any design were included. A total of 63 studies were included in this review. Four studies defined quality metrics for evaluating ASP. Twenty-one studies assessed the impact of ASP on antimicrobial utilization and cost, 25 studies evaluated impact on resistance patterns and/or rate of Clostridium difficile infection (CDI). Thirteen studies assessed impact on patient outcomes including mortality, length of stay (LOS) and readmission rates. Six of these 13 studies reported non-significant difference in mortality between pre- and post-ASP intervention, and five reported reductions in mortality rate. On LOS, six studies reported shorter LOS post intervention; a significant reduction was reported in one of these studies. Of note, this latter study reported significantly (p < 0.001) higher unplanned readmissions related to infections post-ASP. Patient outcomes need to be a key component of ASP evaluation. The choice of metrics is influenced by data and resource availability. Controlling for confounders must be considered in the design of evaluation studies to adequately capture the impact of ASP and it is important for unintended consequences to be considered. This review provides a starting point toward compiling standard outcome metrics for assessing ASP.

Background Antimicrobial resistance (AMR) threatens global health and progress towards the United Nations Sustainable Development Goals (SDGs), particularly SDG 3.1 Strengthening antimicrobial stewardship (AMS), using frameworks like ‘Start Smart, Then Focus’, is essential.2 The COVID-19 pandemic has intensified the AMR crisis, highlighting the urgent need for innovative tools like an antibiotic dashboard.3,4 Objectives To explore antimicrobial stewardship and propose an innovative antibiotic dashboard. Methods This research consisted of three sequential studies. Study one conducted a systematic literature review on AMS implementation in acute care settings prior to and during the COVID-19 pandemic. Study two was a retrospective cross-sectional review of 640 medical records, evaluating antibiotic prescribing in hospitalized adults with respiratory infections. Study three involved a prospective survey of 240 healthcare professionals, exploring their knowledge, attitudes, and perceptions towards antibiotic prescribing and AMS. Ethical approval was secured, and public and patient involvement through the Citizens Senate was integral, with registration in ISRCTN. Results Study One identified key antimicrobial stewardship (AMS) strategies in acute care settings, with prospective audits (85%) and quality metrics (77%) being the most prevalent. Study Two demonstrated effective AMS interventions, achieving antibiotic discontinuation in 47% of cases and de-escalation to narrow-spectrum antibiotics in 37%. Study Three highlighted the COVID-19 pandemic’s disruptive impact, with interruptions in antibiotic reviews (81%), AMS audits (70%), and IV-to-oral switches (67%). Based on these findings, an Antimicrobial Stewardship Dashboard was developed to visualize trends in antibiotic prescribing, bacterial infections, AMS interventions, and hospital outcomes, supporting data-driven improvements in AMS practices (Figure 1). Conclusions This research highlights the urgent need to strengthen AMS to combat the escalating threat of antimicrobial resistance, supporting the objectives of the United Nations SDGs. The innovative Antibiotic Dashboard introduced in this study provides essential AMS metrics that enhance antibiotic management and improve patient outcomes. By featuring dynamic sections for both initial empirical therapy and pathogen-directed therapy, the dashboard facilitates real-time clinical decision-making, which is especially critical during health emergencies such as the COVID-19 pandemic. Implementing such a digital innovation is vital to sustaining effective AMS practices, expanding research opportunities, and advancing global health standards to address future AMR challenges.Figure 1.Antimicrobial stewardship (AMS) Dashboard: trends in antibiotic use, infections, and stewardship outcomes.

Antibiotic misuse and overuse are important contributors to the development of antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) programs are coordinated sets of actions aiming to promote appropriate antibiotic use, improving patient outcomes whilst reducing AMR. Two main organizational models for AMS programs have been described: restrictive strategies (RS) vs. enabling strategies (ES). Evaluating and understanding social and cultural influences on antibiotic decision-making are critical for the development of successful and sustainable context-specific AMS programs. Characteristics and surrogate outcomes of AMS programs operating in acute-care hospitals of Piedmont in north-western Italy were investigated. The aim of this study was assessing whether RS vs. ES operating in our context were associated with different outcomes in terms of total antimicrobial usage and percentage of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) over invasive isolates. In total, 24 AMS programs were assessed. ES were more frequently chosen compared to RS, with the latter being implemented only in broader AMS programs involving enabling components (combined strategy, CS). This study found no difference in evaluated outcomes among hospitals implementing ES vs. CS, suggesting both approaches could be equally valid in our context.