Antibiotic Decisions Research Articles

P-1795. Antimicrobial Stewardship Knowledge, Attitudes, and Practices (KAP) Among Health Care Providers in a Community Hospital Network

Abstract Background Drivers of inappropriate antimicrobial use (AU) and antimicrobial resistance (AMR) can be linked to deficiencies in prescribers’ knowledge, attitude, and practice (KAP) regarding antibiotics. Currently, KAP information in community hospitals throughout the United States (US) is not well known, and survey information is not standardized. Understanding clinicians’ KAP regarding AU and AMR may provide valuable information for improving antimicrobial stewardship (AS) efforts.Figure 1 Methods Prescribers, pharmacists, nurses, and administrators at 40 community hospitals within the Duke Antimicrobial Stewardship Outreach Network (DASON) were invited to take an anonymous, voluntary, 41-question web-based IRB-approved AS KAP survey. This survey is an internationally validated tool translated for use in the US (www.oucru.org/wp-content/uploads/2023/10/KAP_tool.pdf). Responses were collected via REDCap from Feb – Apr 2024.Figure 2 Results A total of 167 survey responses were received from 24 hospitals; 77 (46%) were pharmacists, 62 (37%) were nurses, and 16 (10%) were physicians. Respondents had a median of 15 years (15.3) of experience in their current healthcare profession and 8.5 years (14.3) in their current institution. Most respondents were familiar with AS (74.3%), strongly agree that antimicrobial overuse can cause harm (79.6%), and that appropriate antibiotic use can reduce AMR (74.3%) (Fig 1). More than half of the respondents who prescribe antibiotics agreed that education and feedback via peer comparison or direct feedback would improve their prescribing (Fig 2). Prescribing respondents also agreed that AS teams impact their antibiotic decisions (87.5%). 63% of prescribers and 46% of non-prescribers agreed antibiotics are overused at their institution. Providers were the most likely to agree AMR is a problem at their institutions (Fig 3).Figure 3 Conclusion Healthcare workers within DASON were aware of the importance of AS and its effect on AMR and patient outcomes. Prescriber feedback was seen as a valuable educational tool, as most prescribers valued AS feedback and agreed feedback would improve antibiotic selection. Disclosures Melissa D. Johnson, PharmD MHS AAHIVP, Biomeme: Licensed Technology|Scynexis, Inc: Grant/Research Support|UpToDate: Author Royalties Elizabeth Dodds Ashley, PharmD, MHS, HealthtrackRx: Advisor/Consultant|UpToDate: Royalties

175. Concordance of UTI Antibiotic Treatments with Facility-Specific Antibiograms in Nursing Homes

Abstract Background Empiric antibiotic treatment of urinary tract infections (UTI) in nursing homes (NHs) is complicated by increasing antibiotic resistance. Antibiograms may enhance empiric antibiotic treatment decisions in this setting. We conducted a pilot study of a urine-specific antibiogram in 9 NHs in Oregon and Pennsylvania. The objectives of this study were to (1) characterize patterns of antibiotic resistance among uropathogens recovered from study NHs and (2) determine the concordance between antibiotic prescriptions and facility-specific antibiograms.Table 1.WISCA-Concordant Antibiotics across 9 NHs Methods We developed a facility-specific weighted incidence syndromic cumulative antibiogram (WISCA) using two years of urine culture results for each study NH. The WISCA conveyed the cumulative susceptibility of facility-collected uropathogens to 7 antibiotics in three susceptibility strata ( >90%, 80-89%, and < 80%). Data on antibiotic prescriptions for the empiric treatment of UTI during the 6-month pilot were abstracted from facility health records and entered into a REDCap database. Antibiotic prescriptions with a probability of activity exceeding the 80% susceptibility threshold were classified as WISCA-concordant.Figure 1.Concordance of Empiric Antibiotic Selection with Facility-Specific WISCAs Results WISCA susceptibility patterns varied considerably across NHs and regions (Table 1). On average, two oral antibiotic options with projected activity exceeding 80% were available in most Oregon NHs. In contrast, oral antibiotic options with activity exceeding 80% were uncommon in Pennsylvania NHs. Ceftriaxone and Ciprofloxacin were the only antibiotics with activity in these facilities. There were 173 empiric antibiotic treatments for UTI in study NHs during the pilot. A minority of the antibiotics chosen were concordant with the facility-specific WISCA (n = 69, 39.9%), although this varied by facility (Figure 1). Conclusion Our study demonstrates wide variability in antibiotic susceptibility of uropathogens at both the facility and regional levels. Antibiotics selected for the empiric treatment of UTI in study NHs were projected to have limited activity based on facility-specific WISCAs. Further studies to examine the factors influencing antibiotic choice and level of concordance with patient-specific culture results are ongoing. Disclosures Robin Jump, MD, PhD, Abacus: Grant/Research Support|Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support Jon P. Furuno, PhD, Merck & Co., Inc: Grant/Research Support

P-1533. Assessing the Impact of Antimicrobial Stewardship on Antibiotic De-escalation, Escalation, Discontinuation, and Continuation: A Prospective Observational Study

Abstract Background This study focuses on the involvement of infectious disease (ID) specialists in patient care regarding the de-escalation, escalation, discontinuation, and continuation of antibiotics, aimed at reducing unnecessary antibiotic usage, in alignment with the World Health Organization (WHO) AWaRe classification Methods This prospective observational study was conducted over the month of March 2024 at a 240-bed tertiary hospital in South India. Infectious disease (ID) consultants were actively involved in patient assessment to evaluate the appropriateness of antibiotic prescriptions. Following their assessment, ID consultants made decisions regarding antibiotic management, including de-escalation, escalation, discontinuation, and continuation, based on the patient's clinical condition. Data on antibiotic usage and outcomes, including appropriateness and clinical response, were collected using a simple audit tool. These data were subsequently entered into an Excel spreadsheet and analysed using descriptive statistics. Results Out of [1141] patients admitted to the tertiary care hospital, [597] patients received antibiotics, in that [80] were seen by infectious disease (ID) consultants. Among these, [30] patients underwent de-escalation, [10] experienced escalation, [28] had discontinuation, and [12] underwent continuation of antibiotic therapy CategoryFrequencypercentageTotal patients admitted1141100%Patients received antibiotics59752%Infectious disease consultant seen807%De- escalation303%Escalation100.87%Discontinuation283%Continuation121% Conclusion The study highlights the critical role of infectious disease specialists in guiding antibiotic therapy decisions, which can lead to more personalized and effective patient care. By reducing unnecessary antibiotic usage and promoting antimicrobial stewardship, this research contributes to improving patient outcomes and combating antimicrobial resistance. Disclosures All Authors: No reported disclosures

P-84. Microbiologic and histologic concordance of pedal osteomyelitis and association with infection progression

Abstract Background Diabetes-related infections and peripheral artery disease are the leading causes of foot amputation worldwide, resulting in significant morbidity and mortality. Clinical management practices vary widely. We sought to describe the concordance of microbiology and pathology results among persons undergoing forefoot or midfoot bone resection. Methods We conducted a retrospective cohort study of adults in Veteran’s Administration (VA) care who underwent forefoot or midfoot bone debridement at VA Portland from January 1, 2017 through December 31, 2019. We used VA’s Corporate Data Warehouse, a centralized database with comprehensive demographic and clinical data, and obtained additional clinical information through chart review. We excluded patients who underwent hindfoot debridement, or intervention on the ipsilateral foot within the preceding year. We defined positive pathology as acute or chronic osteomyelitis and positive microbiology as any bacterial growth from the resection clean margin. Descriptive analyses included calculation of the proportion of individuals with both microbiology and pathology results available versus microbiology or pathology results alone. Results From January 1, 2017 – December 31, 2019, there were 379 eligible resections performed among 343 patients, who were 97% male, 82% white, and with median age 69 years. Of the 379 resections, 44% (N=167) had both microbiology and pathology results, 11% (N=44) had microbiology alone, and 45% (N=172) had pathology alone. Of resections with both microbiology and pathology results, 87% (146/167) had bacterial growth and 58% (97/167) had osteomyelitis on pathology; bacterial growth was present in 90.7% and 82.6% of specimens with and without osteomyelitis on pathology, respectively. Of those with microbiology alone, 93% (41/44) had bacterial growth. Of those with pathology alone, 50% (87/172) had osteomyelitis on pathology. Conclusion Similar proportions of bacterial growth were observed whether pathology evidence of osteomyelitis was present. The utility of microbiology results alone to inform antibiotic treatment decisions requires further study. Disclosures All Authors: No reported disclosures

P-1649. Nursing Home Clinician Rationales Underlying Antibiotic Decision-Making for Suspected Urinary Tract Infection

Abstract Background The factors underlying antibiotic decision-making in nursing homes (NHs) remains poorly understood. We conducted an analysis of discrete and free text responses from a mixed-methods survey presenting NH clinicians with two patient clinical vignettes on asymptomatic bacteriuria (ASB) and cystitis (CYS) designed to assess clinicians’ treatment (TX) threshold.Table 1:Clinical Vignettes Methods NH clinicians were recruited nationally via professional organizations from December 2021 to April 2022. A web-based survey tool was used to administer the vignettes (Table 1) to participants who were asked to document their TX decision and justification. Treater (TRT) and non-treater (NTRT) responses were stratified by vignette and textual responses were uploaded to NVivo. A hybrid directed and conventional content approach was utilized to develop a codebook using the constant comparison technique.Table 2:Factors Contributing to Clinicians’ Treatment Decisions by Vignette and Treatment Choice Results Among 298 survey respondents; 10.4% treated ASB while 61.1% treated CYS. Seven factors contributing to clinicians’ TX decisions were identified (Table 2). For the ASB vignette (Table 3), TRTs framed the patient’s positive test results as infection (84%) while NTRTs framed it as contamination (79%). TRTs were less likely than NTRTs (26% vs 91%) to note the absence of signs and symptoms (S/S). Both groups cited the patient’s comorbidities and/or medical history (42% vs. 54%) in their TX decision. In the CYS vignette (Table 4), TRTs focused on positive patient S/S (91%) while NTRT did not feel there were sufficient frequency or severity of symptoms to justify immediate therapy (77%). TRTs were more likely to rely on positive test results (59%) and have more concern for patients’ comorbidities and/or medical history (18%).Table 3:Asymptomatic Bacteriuria Vignette Illustrative Quotes Conclusion Both TRTs and NTRTs use urine diagnostics in their decision-making, with TRTs having more confidence in the positive predictive value of urine diagnostics. NTRTs highlighted the lack of S/S as a justification for withholding therapy in both vignettes. TRTs accurately identified S/S for CYS, however, TRTs for ASB expressed concern that S/S might be underreported. This study shows how TRTs and NTRTs justify their rationales, however the next steps involve understanding how these decision-making patterns are amenable to education, information framing and/or risk management interventions.Table 4:Cystitis Vignette Illustrative Quotes Disclosures Robin Jump, MD, PhD, Abacus: Grant/Research Support|Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support

582. Feeling the Vibes: An Investigation Into Resident Physician Antibiotic Prescribing Practices

Abstract Background Efforts to improve inpatient antibiotic prescribing are limited by a lack of insight into the heuristics and thought processes that influence the complicated decisions around antimicrobial use. We aimed to explore antimicrobial therapeutic decision making among resident physicians at a large academic health system. Figure 1. Thematic map of resident trainee antibiotic decision making process Methods We performed a qualitative study with a constructivist paradigm employing semi-structured, in-person focus groups of Internal Medicine interns and residents at the UCLA Ronald Reagan and Santa Monica Medical Centers from December 2023 through January 2024. Sessions were recorded, auto-transcribed, and edited for accuracy. Two researchers independently performed a thematic analysis of three distinct focus group transcripts. Results 25 residents participated in a total of three focus groups. Residents consistently identified a clear general approach to prescribing antibiotics, including triaging critical illness and identifying the following: the presence of infection; the source of infection; the antibiotic that covers the likely pathogens; and co-morbid conditions and risk factors. Two broad themes regarding initial acquisition of an approach to antibiotics emerged: institutional culture or “oral tradition,” and internal and external clinical resources. A major challenge in therapeutic decision-making centered around navigating uncertainty (Figure 1). Comments on the inconsistency of clinical reasoning and “vibes-based” prescribing were common. Residents identified certain safety net strategies to mitigate the anxieties associated with this uncertainty (Figure 1). Resident confidence improved over time via habit formation and trial and error, particularly when working independently as the Night Admitting Resident. ID physicians and pharmacists provided a model approach for therapeutic reasoning and supported residents to take risks they were otherwise reluctant to take (such as de-escalation). Conclusion Despite articulating a systematic approach to antimicrobial prescribing, resident therapeutic decision-making remains subject to many vulnerabilities, including emotional prescribing. A reliance on the ID consult as a safety net may account for increases in consult volume and requires further investigation. Disclosures All Authors: No reported disclosures

P-1641. Comparing Traditional and Weighted Incidence Combined Syndromic Antibiograms in Nursing Homes

Abstract Background Aggregate susceptibility reports, commonly referred to as antibiograms, may assist empiric antibiotic decisions. Creating traditional antibiograms (TAs) is hampered by the limited number of cultures collected in NHs. A weighted incidence syndromic combined antibiogram (WISCA) is an alternative method of representing susceptibility data. We compared TAs and WISCAs in a sample of NHs from three U.S. regions. Table: Success Rate of Creating a TA and WISCA Using One Year of Culture Data in 75 Nursing Homes Methods Data on urine cultures collected in 75 NHs in Ohio, Oregon, and Pennsylvania (2018-2021) were obtained from their reference laboratories. Clinical & Laboratory Standards Institute (CLSI) breakpoints were used to normalize susceptibility interpretations across laboratories. We attempted to create a TA and WISCA for each study NH using the 3 most prevalent uropathogens (Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae) and susceptibilities to 5 commonly prescribed antibiotics. Sensitivity analyses using different isolate number thresholds (10 & 30) and years of culture data (1 & 2) were conducted.Figure:Success Rate of Creating a TA and WISCA Using Two Years of Culture Data in 75 Nursing Homes Results 15,238 unique urine cultures obtained from 7,703 residents were obtained from reference laboratories. The final sample was 12,789 cultures after excluding duplicate isolates obtained from the same resident within 3 monthsof an index urine culture. A TA could be constructed for ∼5% (1.5% - 5.1%) of NHs using a single year of culture data and an isolate number threshold of 10 (Table). This increased to ∼11% when combining two years of culture data (Figure). A 1- or 2-year TA could not be constructed for any of the NHs using the CLSI recommended isolate threshold of 30. We were able to construct a WISCA for most of the study NHs (63% - 80%) using a 10-isolate threshold and this improved slightlyby combining two years of culture data. We were only able to construct a 1-year WISCA for a third of NHs (29% - 34%) using a 30-isolate threshold but this improved to 57% of NHs when combining 2 years of culture data. Conclusion A facility-specific urinary antibiogram can be produced for the majority of NHs by using a WISCA approach and combining more than one year of culture data. Additional study to examine the effects of pooling facility culture results on WISCA success rates and effects on susceptibility estimates are needed. Disclosures Jon P. Furuno, PhD, Merck & Co., Inc: Grant/Research Support Robin Jump, MD, PhD, Abacus: Grant/Research Support|Merck: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support

P-2238. A Novel Transcriptomic-based Host Response Point-of-care Test to Distinguish Bacterial from Viral Infection: Results of a Diagnostic Accuracy Study in Adults Hospitalised with Acute Respiratory Illness

Abstract Background Acute respiratory infections (ARI) are the commonest reason for antibiotic use, but much of this is unnecessary as a high proportion is caused by viruses. Distinguishing bacterial from viral ARIs is challenging, and detecting viral pathogens does not rule out concurrent bacterial infection, leading to inappropriate antibiotic use and driving antimicrobial resistance. Novel tests assessing the host immune response have the potential to differentiate bacterial and viral ARIs and direct antibiotic use. In this study, we evaluated the accuracy of the TriVerity Acute Infection and Sepsis Test (Inflammatix, Sunnyvale, CA, US), a transcriptomic-based host response point-of-care test which measures 29 mRNAs to determine the likelihood of bacterial and viral infection, in adults with acute respiratory illness. Methods Adults hospitalised with ARI were enrolled as part of the FluPOC study. The aetiology for each patient (bacterial and viral), was clinically adjudicated by 3 clinicians independently using a pre-specified guidance document. RNA paxgene blood samples were tested using the TriVerity test on the Myrna platform (Inflammatix, Sunnyvale CA, US). The test assigns one of five probability bands (very low, low, moderate, high, very high) for both bacterial and viral infection. Measures of diagnostic accuracy were calculated between the TriVerity results and adjudicated infection status. Results 169 patients were tested, and TriVerity testing gave an initial valid result in 168 (99%). The median (IQR) time to result was 32.49 (32.41, 32.53) minutes. Median age was 60 (45, 74) years and baseline characteristics are shown in table 1. 61 (36%) were adjudicated as bacterial, 54 (32%) as viral, 26 (15%) as viral/bacterial co-infection and 29 (17%) as non-infected. Measures of diagnostic accuracy for bacterial and viral infection compared to adjudication are shown in table 2 and 3 respectively. Conclusion The TriVerity test demonstrated good levels of accuracy in distinguishing bacterial from viral ARIs compared with clinical adjudication and was reliable with a short turnaround time. TriVerity could support early informed antibiotic decisions and reduce unnecessary antibiotics use. Prospective impact trials with clinical outcome measures are needed. Disclosures Tristan William Clark, BM MRCP DTM&H MD, Biomerieux/Biofire diagnositcs: Advisor/Consultant|Biomerieux/Biofire diagnositcs: Grant/Research Support|Biomerieux/Biofire diagnositcs: Honoraria|Cepheid: Advisor/Consultant|GSK: Advisor/Consultant|Inflammatix: Grant/Research Support|Roche: Advisor/Consultant|Sanofi: Advisor/Consultant|Sanofi: Grant/Research Support|Sequirus: Advisor/Consultant|Sherlock Biosciences: Grant/Research Support|Shionogi: Advisor/Consultant|Synairgen: Advisor/Consultant|Synairgen: Grant/Research Support|Synairgen: Honoraria|Synairgen: Stocks/Bonds (Public Company)

P-2235. Implementation of a Host-Protein Test (MMBV) Into Routine Care for Children Hospitalized with Symptoms of Lower Respiratory Tract Infection

Abstract Background Infectious etiology is often unclear in children hospitalized with symptoms of lower respiratory tract infection (LRTI), driving antibiotic misuse. A host-protein test (MMBV) exhibits high diagnostic accuracy for differentiating bacterial from viral etiology. Best practices for test implementation should be established. We evaluate the effectiveness of implementing MMBV into routine care without specific antimicrobial stewardship (AMS) education by assessing impact on antibiotic administration to children hospitalized with LRTI symptoms. Patient flow Eligibility required age 3 months to 5 years old and hospitalized with 1 or more of the following signs or symptoms that concern for lower respiratory tract infection (LRTI): accessory muscle use, chest pain, cough, crepitation or rales, decreased breath sound, dyspnea, prolonged expiration, wheezing. MMBV, MeMed BV. Methods Retrospective pragmatic study of MMBV implementation at a single medical center without specific AMS education. Children 3 months to 5 years old hospitalized with LRTI symptoms were included. In the non-interventional arm (2014-2017) MMBV results were not available in time to impact antibiotic decisions. In the interventional arm (2021-2022) MMBV results were rapidly available. Patients were assigned into discharge diagnosis classes: bronchiolitis, community acquired pneumonia (CAP), viral diagnosis and other diagnosis. Antibiotic administration was compared between arms per diagnosis class. The relative reduction in antibiotic administration in the interventional arm versus the non-interventional arm according to discharge diagnosis class There was a relative reduction in antibiotic administration in the interventional arm relative to the non-interventional arm from 60.0% (12/20) to 22.5% (9/40) for bronchiolitis; from 98.7% (74/75) to 97.3% (71/73) for CAP; from 15.0% (12/80) to 13.3% (6/45) for viral diagnosis; and from 60.7% (51/84) to 51.8% (43/83) for other diagnosis. P-values were calculated using Richardson’s method. CAP, community-acquired pneumonia. Results Age, sex and MMBV results were similar across arms. Viral MMBV rates were high (39%-90%) across all diagnosis classes in the non-interventional (n=259) and interventional (n=241) arms. A significant relative reduction in antibiotic administration of 62.5% (p=0.004) was attained in patients discharged with bronchiolitis without impacting length of stay (p=0.530). Non-significant reductions in antibiotic administration were observed for CAP, viral diagnosis and other diagnosis. Conclusion MMBV availability is associated with judicious antibiotic administration to children hospitalized with bronchiolitis without AMS education. Combining MMBV introduction with AMS education is required to reduce potentially unwarranted antibiotics in children hospitalized with CAP. Disclosures All Authors: No reported disclosures

Facilitators of antibiotic decision-making in home-based primary care: a qualitative investigation.

Interviews with 22 home-based primary care (HBPC) clinicians revealed that infectious disease physicians and clinical pharmacists facilitate infection management and antibiotic selection, respectively, and that local initiatives within programs support antibiotic prescribing decisions. Interventions that facilitate specialist engagement and tailored approaches that address the unique challenges of HBPC are needed.

Duration of antibiotic therapy in the intensive care unit: factors influencing decision-making during multidisciplinary meetings

ObjectivesIn the intensive care unit (ICU), antibiotics are often given longer than recommended in guidelines. A better understanding of the factors influencing antibiotic therapy duration is needed to develop improvement...

Broiler farming and antibiotic use through an agency theory lens. A case study from West Bengal, India.

Chicken meat (broiler) production is a rapidly growing livestock sector in India, and one dominated by contract farming. Studies have reported high levels of antibiotic use in Indian broiler farms which is concerning given this is one of the driving forces for the development of antibiotic resistance. This study used the economic lens of agency theory to examine strategic decisions which occur during contract broiler production and their potential impact on antibiotic use, using West Bengal as a case study. Agency theory focuses on the informational asymmetry and opportunism between service providers and seekers and the subsequent agency cost needed to avoid aberrant outcomes. Interviews were conducted with key informants (n = 6) and stakeholders (n = 20) associated with broiler production, and broiler farmers (17 contract and four non-contract), using online and face-to-face interviews. Data were analysed descriptively using manifest content analysis and interpretatively using reflexive thematic analysis. Contract farming in West Bengal exists within a series of inter-dependent relationships, many of which contain information asymmetry and can be subject to opportunism. Positioning contract companies as principals seeking labour from agents, we see how out-sourcing of production to distal farms led to antibiotics being used as a risk mitigation strategy. This was further compounded by concerns about the Mycoplasma status of breeding stock, and a perception that broiler day old chicks were infected, resulting in use of antibiotics belonging to classes deemed critically important for human health. While antibiotic use decisions were predominately made by contract companies, they were dependent on the decisions farmers and breeding companies made concerning biosecurity and production practices. In turn, farmers' decisions were shaped by factors such as access to financial and social capital. Thus, efforts to reduce antibiotic use in West Bengal's broilers must not just focus on changing the prescribing behavior of individuals but more broadly consider the environment within which contracting exists.

Point-of-care tests, diagnostic uncertainty and antimicrobial stewardship in the ICU: procalcitonin or PCR to aid antibiotic-stop decisions – an observational cohort study

ObjectivesIntensive care unit (ICU) clinicians stop antibiotics more often, with a negative infection: point-of-care test (PCR-POCT). Simulated cases of diagnostic uncertainty regarding infection resolution led clinicians to choose options such...

The social experience of uncertainty: a qualitative analysis of emergency department care for suspected pneumonia for the design of decision support

BackgroundThis study sought to understand the process of clinical decision-making for suspected pneumonia by emergency departments (ED) providers in Veterans Affairs (VA) Medical Centers. The long-term goal of this work is to create clinical decision support tools to reduce unwarranted variation in diagnosis and treatment of suspected pneumonia.MethodsSemi-structured qualitative interviews were conducted with 16 ED clinicians from 9 VA facilities demonstrating variation in antibiotic and hospitalization decisions. Interviews of ED providers focused on understanding decision making for provider-selected pneumonia cases and providers’ organizational contexts.ResultsThematic analysis identified four salient themes: i) ED decision-making for suspected pneumonia is a social process; ii) the “diagnosis drives treatment” paradigm is poorly suited to pneumonia decision-making in the ED; iii) The unpredictability of the ED requires deliberate and effortful information management by providers in CAP decision-making; and iv) the emotional stakes and high uncertainty of pneumonia care drive conservative decision making.ConclusionsEnsuring CDS reflects the realities of clinical work as a socially organized process with high uncertainty may ultimately improve communication between ED and admitting providers, continuity of care and patient outcomes.

Clinical and Analytical Performance Evaluation of an Automated Procalcitonin Assay.

Procalcitonin (PCT) measurement is useful for guiding antibiotic therapy and risk assessment in lower respiratory infections and/or sepsis. This study evaluated clinical and analytical performance of the Vitros® Immunodiagnostic Products B·R·A·H·M·S PCT assay (Vitros PCT). Precision, limits of blank (LoB), detection (LoD), and quantitation (LoQ) were determined for Vitros PCT, along with method comparison and clinical concordance with the B·R·A·H·M·S PCT™-sensitive KRYPTOR™ assay (KRYPTOR PCT). All-cause 28-day mortality was evaluated according to the change in PCT values (ΔPCT) from day 0 through day 4 in samples from 598 intensive care unit patients with sepsis. Comparison of Vitros PCT and KRYPTOR PCT results yielded a Deming regression slope of 1.057, intercept of -0.010, and correlation coefficient (r) of 0.994. Precision analysis demonstrated within-laboratory coefficients of variation for Vitros PCT ranging from 3.1% to 6.4%. The LoD and observed LoQ were determined as 0.007 and 0.013 ng/mL, respectively. Overall agreement between assay methods was 98.5%, 98.0%, 97.4%, and 97.8%, at PCT clinical decision cutoffs of 0.100, 0.250, 0.500, and 2.00 ng/mL, respectively, with Cohen's Kappa coefficients (κ) > 0.91. ΔPCT values ≤80% vs >80% were associated with increased 28-day-all-cause mortality (P = 0.006). Vitros PCT compares well with KRYPTOR PCT, showing excellent agreement at relevant clinical decision cutoffs that have been used for antibiotic decision-making and assessment of risk for sepsis progression. ΔPCT values determined with Vitros PCT were useful for evaluation of 28-day mortality risk in patients with severe sepsis.

Procalcitonin-guided antibiotic treatment in patients with cancer: a patient-level meta-analysis from randomized controlled trials

BackgroundUse of serum procalcitonin (PCT), an inflammatory biomarker for bacterial infections, has shown promising results for early stopping antibiotic treatment among patients with respiratory infections and sepsis. There is need for additional data regarding effectiveness and safety of this concept among patients with cancer.MethodsIndividual data of patients with a documented diagnosis of cancer and proven or suspected respiratory infection and/or sepsis were extracted from previous trials where adult patients were randomized to receive antibiotic treatment based on a PCT protocol or usual care (control group). The primary efficacy and safety endpoints were antibiotic exposure and 28-day all-cause mortality.ResultsThis individual-patient data meta-analysis included 777 patients with a diagnosis of cancer from 15 randomized-controlled trials. Regarding efficacy, there was a 18% reduction in antibiotic exposure in patients randomized to PCT-guided care compared to usual care ([days] 8.2 ± 6.6 vs. 9.8 ± 7.3; adjusted difference, − 1.77 [95% CI, − 2.74 to − 0.80]; p < 0.001). Regarding safety, there were 72 deaths in 379 patients in the PCT-guided group (19.0%) compared to 91 deaths in 398 participants in the usual care group (22.9%) resulting in an adjusted OR of 0.78 (95% CI, 0.60 to 1.02). A subgroup analysis showed a significant reduction in mortality in patients younger than 70 years (adjusted OR, 0.58 [95% CI, 0.40 to 0.86]).ConclusionResult of this individual patient meta-analysis from 15 previous trials suggests that among patients with cancer and suspected or proven respiratory infection or sepsis, use of PCT to guide antibiotic treatment decisions results in reduced antibiotic exposure with a possible reduction in mortality, particularly among younger patients.

Antibiotic Prescribing Decisions for Upper Respiratory Tract Infections Among Primary Healthcare Physicians in China: A Mixed-Methods Approach Based on the Theory of Planned Behavior.

Objectives: In China, primary healthcare (PHC) facilities have high antibiotic prescribing rates for upper respiratory tract infections (URTIs), which are primarily viral and self-limited. This study aimed to identify the main factors influencing PHC physicians' antibiotic decisions for URITs based on the theory of planned behavior. Methods: A convergent mixed-methods study was conducted at 30 PHC facilities across Shaanxi Province, China. A total of 108 PHC physicians completed a five-point Likert Scale questionnaire focused on behavioral components of antibiotic prescribing, including attitudes, subjective norms, perceived behavioral control, belief in past experiences, and prescribing intentions. Twenty-two physicians participated in semi-structured interviews. Results: Respondents had a good awareness of AMR (Mean = 4.49) and a weak belief regarding the benefit of antibiotics (Mean = 2.34). The mean score for subjective norms was 3.36, and respondents had good control over their prescribing behavior (Mean = 4.00). A reliance on past prescribing experiences was observed (Mean = 3.34), and physicians' antibiotic prescribing intention was 3.40 on average. Multiple linear regression revealed that physicians showing a more favorable attitude towards antibiotics (p = 0.042) and relying more on their past experiences (p = 0.039) had a higher antibiotic prescribing intention. Qualitative interviews indicated that most physicians would consider prescribing antibiotics when facing diagnostic uncertainty. Low utilization of diagnostic tests, limited effectiveness of training programs, inadequate knowledge of guidelines, and lack of feedback on antibiotic prescriptions all contributed to antibiotic overprescribing. Conclusions: PHC physicians in China demonstrated strong intentions to prescribe antibiotics for URTIs when facing diagnostic uncertainty. Beliefs about antibiotics and previous prescribing behavior were significantly linked to prescribing intentions. Multifaceted interventions that focus on facilitating diagnostic tests, improving the quality of training, effectively implementing clinical guidelines, and providing practical feedback on antibiotic prescriptions may help reduce antibiotic overprescribing in China's PHC facilities.

Rapid laboratory diagnosis of urinary tract infection, with or without antibiotic decision support-a small pilot study investigating accuracy and clinical impact.

The study evaluated the accuracy and clinical impact of rapid diagnostics (RD) with or without antibiotic decision support (ADS) for hospitalized patients with urinary tract infections. A two-centre prospective intervention was conducted with 230 patients divided into three groups: RD-only (n = 59), RD plus ADS (n = 56) and a control group (n = 115). Mean laboratory turnaround time for RD was 10 h and 50 min. Of 115 microorganisms, 108 were correctly identified. The error rate for rapid susceptibility determination was 0.85%. Total antibiotic consumption, measured in defined daily doses (DDD), was lower in the intervention groups compared to the control group (ADS: 10.3 DDD, p = 0.01; RD: 10.9 DDD, p = 0.06; control: 13.0 DDD). No significant differences were observed in the use of broad-spectrum antibiotics (p = 0.816). Adherence to antibiotic guidelines was significantly better in the ADS group compared to the control group (p = 0.015) (RD vs control; p = 0.261). The ADS group also received fewer doses of ineffective antibiotics (ADS: 1.8 doses, p = 0.012; RD: 2.4 doses, p = 0.195; control: 3.4 doses). Length of hospital and ICU stays or 30-day readmission rates did not differ across groups. No in-hospital mortality was observed in any group.

'Some patients demand for a prescription of an antibiotic': an assessment of barriers and facilitators to rational antimicrobial use in a private health facility in Uganda.

Antimicrobial misuse and overuse propagate antimicrobial resistance, yet data on factors influencing antibiotic prescription decisions in low-resource settings are limited. We describe factors influencing antimicrobial prescription at a large tertiary care private not-for-profit hospital in Uganda. We conducted a descriptive phenomenology qualitative study involving face-to-face in-depth interviews of 12 purposively selected prescribers (four intern doctors, six medical officers and two Internal Medicine physicians) in a private not-for-profit hospital in Kampala, Uganda. Audio recordings and filed notes were transcribed verbatim and analysed manually by content analysis. Emerging themes and sub-themes were recorded and reported. Three broad themes emerged: experience with antimicrobial use in Uganda, barriers and facilitators to rational antimicrobial prescription and measures to address irrational antimicrobial use. Participants recognized that antibiotics are often used irrationally, prescribed even when there is uncertainty regarding clinical evidence for infection, and influenced by drug promoters, and noted high levels of antibiotic resistance. Patients' symptoms and clinical signs, previous experience using antibiotics, fear of bad outcomes, patient demand and expectations, influence from senior colleagues, the turnaround time of clinical investigations and drug marketers were the barriers and facilitators to antimicrobial prescription. Prescribers also acknowledged the need to update clinical guidelines, set up hospital antibiograms, and provide continuous medical education on rational antimicrobial use. A complex interplay of intrinsic and extrinsic factors influences antibiotic prescribing decisions in this hospital. Targeted interventions through continuous education and training for prescribers, providing local prescription guidelines and antibiograms and implementing regulations on over-the-counter antibiotic sales are needed to implement robust antimicrobial stewardship programmes to curb antimicrobial resistance successfully.

Antimicrobial Prescription Practices and Stewardship in Washington State Small and Mixed Animal Veterinary Medicine.

Judicious antimicrobial use is essential for the continued treatment of infections in small and mixed animal veterinary medicine. To better support Washington (WA) State veterinarians in antimicrobial stewardship, we surveyed licensed small and mixed animal veterinarians and led group conversations regarding antimicrobial prescription practices. Survey questions included demographic information, factors influencing prescription practices and clinical cases. Responses were summarised and logistic regressions were performed to identify factors associated with antibiotic treatment choices. Group conversations, led by a licensed veterinarian, focused on resource gaps for veterinarians, management of clinical scenarios and interpretation of minimum inhibitory concentrations (MICs) and breakpoints. A systematic qualitative analysis of conversation transcripts identified key themes such as common barriers to stewardship. Among 53 responses to clinical scenarios, veterinarians selected the most appropriate treatment choice, according to a veterinary microbiologist, 62% of the time. Variability was observed in culture and susceptibility practices and antibiotic choices. Survey respondents reported an influence of the client ability to medicate (92%), considerations of resistance (91%), client finances (75%) and availability of antimicrobials (75%) on their prescription decisions. There were no significant associations between opinions about contributing factors to antimicrobial resistance (AMR) or guidelines used and treatment choices in clinical scenarios. Among 15 veterinarians interviewed in group conversations, a systematic qualitative analysis of conversation transcripts revealed key themes, including reliance on human medicine as a resource and a lack of support for veterinarians in interpreting MICs and breakpoints. The variability in veterinary antibiotic treatment decisions in this study suggests a need for further dissemination of standardised antimicrobial stewardship resources for veterinarians. Client-related challenges and the cost of culture and susceptibility are major barriers to stewardship. To address these barriers, it is necessary to provide standardised, easy-to-access guidance for veterinarians in interpreting MICs and breakpoints, as well as develop antimicrobial use resources for clients.