Antibiotic Stewardship Interventions Research Articles

222. Comparison of Outpatient Antibiotic Prescriptions in a High Prescribing State, 2016–2018

BackgroundAbout 80% of antibiotic prescriptions are written in outpatient settings. Outpatient antibiotic use (AU) is highest in the Southern United States. Tennessee consistently has one of the highest AU rates in the country. Previous analyses found that 1,195 prescriptions were filled in Tennessee per 1,000 total population in 2016. Moreover, 50% of all outpatient antibiotic prescriptions were written by 9.3% of prescribers. We sought to assess Tennessee outpatient antibiotic prescribing trends, comparing 2016 with 2018 data.MethodsThe Tennessee IQVIA outpatient antibiotic prescription dataset from January 1 to December 31, 2018 was analyzed and compared to 2016 results. Orally administered antibacterial agents were included. Patients < 20 years old were classified as pediatric. County level population data were obtained from the Tennessee Department of Health. Antibiotic prescription rates were calculated as antibiotics prescribed per 1,000 population in the specified age group. Analysis was performed using SAS 9.4.ResultsThe statewide AU rate decreased from 1,195 in 2016 to 1,074 in 2018 per 1,000 population. Consistent with the previous analysis, female patients (1,288), those over 65 years (1,459), and those < 2 years (1,372) had the highest rates of AU in 2018. Lower rates were observed in all age groups in 2018 except for the 3–9 years group. While narrow penicillins and macrolides remain the most frequently prescribed antibiotics, amoxicillin-clavulanate and ciprofloxacin fell out of the top five antibiotics used in adults, and amoxicillin-clavulanate fell out of the top five antibiotics used in pediatrics. Similar to 2016, 9.2% (3,098) of the providers contributed to 50% of the total prescriptions in 2016, and 2,090 of the 2,994 (69.8%) 2016 highest prescribing providers were also among the highest prescribers in 2018.ConclusionDespite a decline in outpatient antibiotic prescription volume, Tennessee remains one of the nation’s highest prescribing states. While a decline in broad spectrum antibiotic prescriptions may indicate a shift to more appropriate usage, these data do not include indication, excluding appropriate use assessment. Identifying and focusing antibiotic stewardship interventions for consistently high prescribers remains a priority for Tennessee.Disclosures All Authors: No reported disclosures

Surgeon-led 7-VINCut Antibiotic Stewardship Intervention Decreases Duration of Treatment and Carbapenem Use in a General Surgery Service.

Antibiotic stewardship programs optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. In this prospective interventional study, a multidisciplinary team led by surgeons implemented a program aimed at shortening the duration of antibiotic treatment <7 days. The impact of the intervention on antibiotic consumption adjusted to bed-days and discharges, and the isolation of multiresistant bacteria (MRB) was also studied. Furthermore, the surgeons were surveyed regarding their beliefs and feelings about the program. Out of 1409 patients, 40.7% received antibiotic therapy. Treatment continued for over 7 days in 21.5% of cases, and, as can be expected, source control was achieved in only 48.8% of these cases. The recommendations were followed in 90.2% of cases, the most frequent being to withdraw the treatment (55.6%). During the first 16 months of the intervention, a sharp decrease in the percentage of extended treatments, with R2 = 0.111 was observed. The program was very well accepted by surgeons, and achieved a decrease in both the consumption of carbapenems and in the number of MRB isolations. Multidisciplinary stewardship teams led by surgeons seem to be well received and able to better manage antibiotic prescription in surgery.

Does Antimicrobial Therapy Affect Mortality of Patients with Carbapenem-Resistant Klebsiella pneumoniae Bacteriuria? A Nationwide Multicenter Study in Taiwan.

Few clinical studies have previously discussed patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteriuria. This study aimed to assess the effect of antimicrobial therapy on the mortality of patients with CRKP bacteriuria. Hospitalized adults with CRKP bacteriuria were enrolled retrospectively from 16 hospitals in Taiwan during 2013 and 2014. Critically ill patients were defined as those with an Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥ 20. Multivariate Cox regression analysis was used to determine independent risk factors for 14- and 28-day mortality. Of 107 patients with CRKP bacteriuria, the 14-day and 28-day mortality was 14.0% and 25.2%, respectively. Thirty-three patients received appropriate antimicrobial therapy. In the multivariate Cox regression analysis, the APACHE II score ≥ 20 was the only independent risk factor for 14-day mortality (hazard ratio [HR]: 6.15, p = 0.024). APACHE II score ≥ 20 (HR: 3.05, p = 0.018) and male sex (HR: 2.57, p = 0.037) were associated with 28-day mortality. Among critically ill patients with CRKP bacteriuria, appropriate antimicrobial therapy was not associated with 14-day or 28-day survival. In conclusion, in patients with CRKP bacteriuria, the use of appropriate antimicrobial therapy was not an independent factor associated with reduced mortality. Our findings may inform future antibiotic stewardship interventions for bacteriuria caused by multidrug resistant pathogens.

Time Trends and Factors Associated with Antibiotic Prescribing in Swiss Primary Care (2008 to 2020).

Antibiotic resistance (ABR) is a major threat to public health, and the majority of antibiotics are prescribed in the outpatient setting, especially in primary care. Monitoring antibiotic consumption is one key measure in containing ABR, but Swiss national surveillance data are limited. We conducted a retrospective cross-sectional study to characterise the patterns of antibiotic prescriptions, assess the time trends, and identify the factors associated with antibiotic prescribing in Swiss primary care. Using electronic medical records data, we analysed 206,599 antibiotic prescriptions from 112,378 patients. Based on 27,829 patient records, respiratory (52.1%), urinary (27.9%), and skin (4.8%) infections were the commonest clinical indications for antibiotic prescribing. The most frequently prescribed antibiotics were broad-spectrum penicillins (BSP) (36.5%), fluoroquinolones (16.4%), and macrolides/lincosamides (13.8%). Based on the WHO AWaRe classification, antibiotics were 57.9% Core-Access and 41.7% Watch, 69% of which were fluoroquinolones and macrolides. Between 2008 and 2020, fluoroquinolones and macrolides/lincosamides prescriptions significantly declined by 53% and 51%; BSP prescriptions significantly increased by 54%. Increasing patients’ age, volume, and employment level were significantly associated with antibiotic prescribing. Our results may inform future antibiotic stewardship interventions to improve antibiotic prescribing.

Antibiotic prescription for febrile outpatients: a health facility-based secondary data analysis for the Greater Accra region of Ghana

BackgroundMisguided prescription of antibiotics is an important contributor towards the emergence and spread of antibiotic resistance. The absence of effective interventions to control antibiotic use leads to increased consumption beyond the needed requirements. Antibiotic stewardship interventions must be appropriately targeted and assessed to enhance the controlled use of antibiotics. The objective of this study was to determine the factors associated with antibiotic prescription to febrile outpatients who seek care in health facilities within the Greater Accra region of Ghana.MethodsSecondary data obtained from the medical records of 2519 febrile outpatients, consecutively sampled at the outpatient department of 6 health facilities in 3 municipalities during the baseline survey of a quasi-experiment in 2015 was used. The primary outcome was prescription of any antibiotic. Independent variables included patients’ demographics, symptoms, laboratory investigations (blood film microscopy, malaria rapid diagnostic test, full blood count, urine and stool routine examinations), diagnoses, and prescribers’ demographics. Crude and adjusted logistic regression analyses were used to determine the factors associated with antibiotic prescription.ResultsThe prevalence of antibiotic prescription was 70.1% (95% CI: 67.7–72.4). Prescribers with more years of practice (> 5 years) were more likely to prescribe antibiotics compared to those with less than 3 years of practice (p < 0.001). Integrated Management of Neonatal and Childhood Illnesses (IMNCI) training was associated with a 2.3 (95% CI: 1.54, 3.53, p < 0.001) fold odds of antibiotic prescribing. Patients aged 5 years or more were 60% less likely to receive antibiotics compared with those under 5 years (AOR = 0.40, 95% CI: 0.32, 0.51; p < 0.001). Patients referred for laboratory investigations were 29% less likely to be prescribed antibiotics than those not referred. The presence of cough as a presenting symptom was associated with a 3.5 (95% CI: 2.54, 4.92) fold odds of antibiotic prescription.ConclusionPrescription of antibiotics to febrile outpatients was high. Promoting laboratory testing can potentially reduce irrational antibiotic prescription. Prescribing antibiotics for children under five and the prescribing practices of prescribers with longer years of practice should be targeted with interventions to reduce high use of antibiotics.

A pharmacist-led prospective antibiotic stewardship intervention improves compliance to community-acquired pneumonia guidelines in 39 public and private hospitals across South Africa

Introduction: Pharmacists in low-middle-income countries (LMIC) are few and lack antibiotic stewardship (AS) training. The ability was assessed of non-specialised pharmacists to implement stewardship interventions and improve adherence to the South African community-acquired pneumonia (CAP) guideline in public and private hospitals.Methods: This was a multicentre, prospective cohort study of adult CAP patients hospitalised between July 2017 and July 2018. A CAP bundle was developed of seven process measures (diagnostic and AS) that pharmacists used to audit compliance and provide feedback. CAP bundle compliance rates and change in outcome measures [mortality, length of stay (LOS) and infection-related (IR)-LOS] during pre- and post-implementation periods were compared.Results: In total, 2464 patients in 39 hospitals were included in the final analysis. Post-implementation, overall CAP bundle compliance improved from 47·8% to 53·6% (confidence interval [CI] 4·1-7·5, p<0·0001), diagnostic stewardship compliance improved from 49·1% to 54·6% (CI 3·3-7·7, p<0·0001) and compliance with AS process measures from 45·3% to 51·6% (CI 4·0-8·6, p<0·0001). Improved compliance with process measures was significant for five (2 diagnostic, 3 AS) of seven components: radiology, laboratory, antibiotic choice, duration and intravenous to oral switch. There was no difference in mortality between the two phases, [4·4%(55/1247) vs. 3·9%(47/1217); p=0·54], median LOS or IR LOS 6·0 vs. 6·0 days (p=0·20) and 5·0 vs. 5·0 days (p=0·40).Conclusion: Non-specialised pharmacists in public and private hospitals implemented stewardship interventions and improved compliance to SA CAP guidelines. The methodology of upskilling and a shared learning stewardship model may benefit LMIC countries.

VA Antibiotic Stewardship Intervention to Improve Outpatient Antibiotic Use for ARIs: A Cost-Effectiveness Analysis

Background: The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use, but cost-effectiveness data on interventions to improve antibiotic use are limited. Beginning in September 2017, an antibiotic stewardship intervention was launched in within 10 outpatient Veterans Healthcare Administration clinics. The intervention was based on the Core Elements and used an academic detailing (AD) and an audit and feedback (AF) approach to encourage appropriate use of antibiotics. The objective of this analysis was to evaluate the cost-effectiveness of the intervention among patients with uncomplicated acute respiratory tract infections (ARI). Methods: We developed an economic simulation model from the VA’s perspective for patients presenting for an index outpatient clinic visit with an ARI (Fig. 1). Effectiveness was measured as quality-adjusted life-years (QALYs). Cost and utility parameters for antibiotic treatment, adverse drug reactions (ADRs), and healthcare utilization were obtained from the published literature. Probability parameters for antibiotic treatment, appropriateness of treatment, antibiotic ADRs, hospitalization, and return ARI visits were estimated using VA Corporate Data Warehouse data from a total of 22,137 patients in the 10 clinics during 2014–2019 before and after the intervention. Detailed cost data on the development of the AD and AF materials and electronically captured time and effort for the National AD Service activities by specific providers from a national ARI campaign were used as a proxy for the cost estimate of similar activities conducted in this intervention. We performed 1-way and probabilistic sensitivity analyses (PSAs) using 10,000 second-order Monte Carlo simulations on costs and utility values using their means and standard deviations. Results: The proportion of uncomplicated ARI visits with antibiotics prescribed (59% vs 40%) was lower and appropriate treatment was higher (24% vs 32%) after the intervention. The intervention was estimated to cost $110,846 (2018 USD) over a 2-year period. Compared to no intervention, the intervention had lower mean costs ($880 vs $517) and higher mean QALYs (0.837 vs 0.863) per patient because of reduced inappropriate treatment, ADRs, and subsequent healthcare utilization, including hospitalization. In threshold analyses, the antibiotic stewardship strategy was no longer dominant if intervention cost was &gt;$64,415,000 or the number of patients cared for was &lt;3,672. In the PSA, the antibiotic stewardship intervention was dominant in 100% of the 10,000 Monte Carlo iterations (Fig. 2). Conclusions: In every scenario, the VA outpatient AD and AF antibiotic stewardship intervention was a dominant strategy compared to no intervention.Funding: NoneDisclosures: None

Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving &gt;250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

Clinical Team Distribution and Antibiotic Use Patterns at a Tertiary-Care Academic Medical Center

Background: As more US hospitals report antibiotic utilization to the CDC, standardized antimicrobial administration ratios (SAARs) derived from patient care unit-based antibiotic utilization data will increasingly be used to guide local antibiotic stewardship interventions. Location-based antibiotic utilization surveillance data are often utilized given the relative ease of ascertainment. However, aggregating antibiotic use data on a unit basis may have variable effects depending on the number of clinical teams providing care. In this study, we examined antibiotic utilization from units at a tertiary-care hospital to illustrate the potential challenges of using unit-based antibiotic utilization to change individual prescribing. Methods: We used inpatient pharmacy antibiotic use administration records at an adult tertiary-care academic medical center over a 6-month period from January 2019 through June 2019 to describe the geographic footprints and AU of medical, surgical, and critical care teams. All teams accounting for at least 1 patient day present on each unit during the study period were included in the analysis, as were all teams prescribing at least 1 antibiotic day of therapy (DOT). Results: The study population consisted of 24 units: 6 ICUs (25%) and 18 non-ICUs (75%). Over the study period, the average numbers of teams caring for patients in ICU and non-ICU wards were 10.2 (range, 3.2–16.9) and 13.7 (range, 10.4–18.9), respectively. Units were divided into 3 categories by the number of teams, accounting for ≥70% of total patient days present (Fig. 1): “homogenous” (≤3), “pauciteam” (4–7 teams), and “heterogeneous” (&gt;7 teams). In total, 12 (50%) units were “pauciteam”; 7 (29%) were “homogeneous”; and 5 (21%) were “heterogeneous.” Units could also be classified as “homogenous,” “pauciteam,” or “heterogeneous” based on team-level antibiotic utilization or DOT for specific antibiotics. Different patterns emerged based on antibiotic restriction status. Classifying units based on vancomycin DOT (unrestricted) exhibited fewer “heterogeneous” units, whereas using meropenem DOT (restricted) revealed no “heterogeneous” units. Furthermore, the average number of units where individual clinical teams prescribed an antibiotic varied widely (range, 1.4–12.3 units per team). Conclusions: Unit-based antibiotic utilization data may encounter limitations in affecting prescriber behavior, particularly on units where a large number of clinical teams contribute to antibiotic utilization. Additionally, some services prescribing antibiotics across many hospital units may be minimally influenced by unit-level data. Team-based antibiotic utilization may allow for a more targeted metric to drive individual team prescribing.Funding: NoneDisclosures: None

Novel Method to Evaluate Diagnostic Shifting After a Pediatric Antibiotic Stewardship Intervention

Background: Audit-and-feedback interventions track clinician practice patterns for a targeted practice behavior. Audit and feedback of antibiotic prescribing data for acute respiratory infections (ARI) is an effective stewardship strategy that relies on administrative coding to identify eligible visits for audit. Diagnostic shifting is the misclassification of a patient’s diagnosis in response to audit and feedback and is a potential unintended consequence of audit and feedback. Objective: To develop a method to identify patterns consistent with diagnostic shifting including both positive shifting (improved diagnosis and documentation) and negative shifting (intentionally altering documentation of diagnosis to justify antibiotic prescribing), after implementation of an audit-and-feedback intervention to improve ARI management. Methods: We evaluated the intervention effect on diagnostic shifting within 12 University of Utah pediatric clinics (293 providers). Data included 66,827 ARI diagnoses: pneumonia, sinusitis, bronchitis, pharyngitis, upper respiratory infection (URI), acute otitis media (AOM), or serous otitis with effusion (OME). To determine whether rates of ARI diagnoses changed after the intervention, we developed logistic generalized estimating equation (GEE) models with robust sandwich standard error estimates to account for clinic-wise clustering. Outcomes included the change in each ARI diagnosis relative to the competing 6 diagnoses included in audit-and-feedback reports before and after intervention implementation. Models tested for a change in outcomes after the intervention (ie, diagnostic shift) after adjustment for month of diagnosis. For each diagnosis, we estimated the population attributable fraction (PAF) for antibiotic prescriptions due to combined shifts in diagnostic frequencies and prescription rates for each diagnosis. The PAF is the estimated fraction of antibiotic prescriptions that would have changed under a population-level intervention. Results: In month-adjusted analyses, diagnoses of pneumonia and OME decreased after the intervention: odds ratio (OR), 0.46 (95% CI, 0.31–0.68) and OR, 0.81 (95% CI, 0.67–0.99), respectively. In addition, URI diagnoses increased: OR, 1.05 (95% CI 1.00, 1.11). We did not detect changes in the diagnosis rates of sinusitis, AOM, bronchitis, and pharyngitis post intervention. The intervention effect on the PAF for antibiotics prescriptions was consistently positive but relatively small in magnitude. PAF was highest for URIs (PAF, 8.87%), followed by AOM (PAF, 3.56%) and sinusitis (PAF, 2.76%), and was lowest for pneumonia and bronchitis (PAF, 0.41% for both). Conclusions: Our analysis found minimal evidence overall of diagnostic shifting after a stewardship intervention using audit and feedback in these pediatric clinics. Small changes in diagnostic coding may reflect more appropriate diagnosis and coding, a positive effect of audit and feedback, rather than intentional negative diagnostic shift.Funding: NoneDisclosures: None

Implementation of a Resource-Efficient Indirect Handshake Stewardship Model at an Academic Medical Center

Background: Handshake antibiotic stewardship is an effective but resource-intensive strategy for reducing antimicrobial utilization. At larger hospitals, widespread implementation of direct handshake rounds may be constrained by available resources. To optimize resource utilization and mirror handshake antimicrobial stewardship, we designed an indirect feedback model utilizing existing team pharmacy infrastructure. Methods: The antibiotic stewardship program (ASP) utilized the plan-do-study-act (PDSA) improvement methodology to implement an antibiotic stewardship intervention centered on antimicrobial utilization feedback and patient-level recommendations to optimize antimicrobial utilization. The intervention included team-based antimicrobial utilization dashboard development, biweekly antimicrobial utilization data feedback of total antimicrobial utilization and select drug-specific antimicrobial utilization, and twice weekly individualized review by ASP staff of all patients admitted to the 5 hospitalist teams on antimicrobials with recommendations (discontinuation, optimization, etc) relayed electronically to team-based pharmacists. Pharmacists were to communicate recommendations as an indirect surrogate for handshake antibiotic stewardship. As reviewer duties expanded to include a rotation of multiple reviewers, a standard operating procedure was created. A closed-loop communication model was developed to ensure pharmacist feedback receipt and to allow intervention acceptance tracking. During implementation optimization, a team pharmacist-champion was identified and addressed communication lapses. An outcome measure of days of therapy per 1,000 patient days present (DOT/1,000 PD) and balance measure of in-hospital mortality were chosen. Implementation began April 5, 2019, and data were collected through October 31, 2019. Preintervention comparison data spanned December 2017 to April 2019. Results: Overall, 1,119 cases were reviewed by the ASP, of whom 255 (22.8%) received feedback. In total, 236 of 362 recommendations (65.2%) were implemented (Fig. 1). Antimicrobial discontinuation was the most frequent (147 of 362, 40.6%), and most consistently implemented (111 of 147, 75.3%), recommendation. The DOT/1,000 PD before the intervention compared to the same metric after intervention remained unchanged (741.1 vs 725.4; P = .60) as did crude in-hospital mortality (1.8% vs 1.7%; P = .76). Several contributing factors were identified: communication lapses (eg, emails not received by 2 pharmacists), intervention timing (mismatch of recommendation and rounding window), and individual culture (some pharmacists with reduced buy-in selectively relayed recommendations). Conclusion: Although resource efficient, this model of indirect handshake did not significantly impact total antimicrobial utilization. Through serial PDSA cycles, implementation barriers were identified that can be addressed to improve the feedback process. Communication, expectation management, and interpersonal relationship development emerged as critical issues contributing to poor recommendation adherence. Future PDSA cycles will focus on streamlining processes to improve communication among stakeholders.Funding: NoneDisclosures: None

Organizational Readiness to Change Assessment Highlights Differential Readiness for Antibiotic Stewardship

Background: Targeted antibiotic stewardship interventions are needed to reduce unnecessary treatment of asymptomatic bacteriuria (ASB). Organizational readiness for change is a precursor to successful change implementation. The Organizational Readiness to Change Assessment (ORCA) is a validated survey instrument that has been used to detect potential obstacles and tailor interventions. In an outpatient stewardship study, primary care practices with high readiness to change trended toward greater improvements in antibiotic prescribing. We used the ORCA to assess barriers to change before implementing a multicenter inpatient stewardship intervention for ASB. Methods: Surveys were self-administered by healthcare professionals in inpatient medicine and long-term care units at 4 geographically diverse Veterans’ Affairs facilities during January–December 2018. Participants included providers (physicians, physician assistants, and nurse practitioners), nurses, pharmacists, infection preventionists, and quality managers. The survey included 7 subscales: evidence (perceived evidence strength) and 6 context subscales (favorability of the organizational context to support change). Responses were scored on a 5-point Likert scale, with 1 meaning very weak or strongly disagree. Scores were compared between professional types and sites. We also measured allocated employee effort for stewardship at each site. Results: Overall, 104 surveys were completed, with an overall response rate of 69.3%. For all sites combined, the evidence subscale had the highest score of the 7 subscales (mean, 4; SD, 0.9); the resources subscale was significantly lower than other subscales (mean, 2.8; SD, 0.9; P &lt; .001). Scores for budget and staffing resources were lower than scores for training and facility resources (P &lt; .001 for both comparisons). Pharmacists had lower scores than providers for the staff culture subscale (P = .04). Comparing subscales between sites, ORCA scores were significantly different for leadership behavior (communication and management), measurement (goal setting and accountability), and general resources (Fig. 1). The site with the lowest scores for resources (mean, 2.4) also had lower scores for leadership behavior and measurement, and lower pharmacist effort devoted to antibiotic stewardship. Conclusions: Although healthcare professionals endorsed the evidence about nontreatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and lack of leadership support. These findings provide targets for tailoring the intervention to maximize the success of our stewardship program. Our support to sites with lower leadership scores includes training of local champions who are dedicated to supporting the intervention. For sites with low scores for resources, our targeted implementation strategies include analyzing local needs and avoiding increased workload for existing personnel.Funding: NoneDisclosures: None

Measuring Antibiotic Stewardship Programmes and Initiatives: An Umbrella Review in Primary Care Medicine and a Systematic Review of Dentistry.

Antibiotic stewardship aims to tackle the global problem of drug-resistant infections by promoting the responsible use of antibiotics. Most antibiotics are prescribed in primary care and widespread overprescribing has been reported, including 80% in dentistry. This review aimed to identify outcomes measured in studies evaluating antibiotic stewardship across primary healthcare. An umbrella review was undertaken across medicine and a systematic review in dentistry. Systematic searches of Ovid Medline, Ovid Embase and Web of Science were undertaken. Two authors independently selected and quality assessed the included studies (using Critical Appraisal Skills Programme for the umbrella review and Quality Assessment Tool for Studies with Diverse Designs for the systematic review). Metrics used to evaluate antibiotic stewardship programmes and interventions were extracted and categorized. Comparisons between medical and dental settings were made. Searches identified 2355 medical and 2704 dental studies. After screening and quality assessment, ten and five studies, respectively, were included. Three outcomes were identified across both medical and dental studies: All focused on antibiotic usage. Four more outcomes were found only in medical studies: these measured patient outcomes, such as adverse effects. To evaluate antibiotic stewardship programmes and interventions across primary healthcare settings, measures of antibiotic use and patient outcomes are recommended.

Clinician and Patient Factors Influencing Treatment Decisions: Ethnographic Study of Antibiotic Prescribing and Operative Procedures in Out-of-Hours and General Dental Practices.

Operative treatment is indicated for most toothache/dental abscesses, yet antibiotics instead of procedures are often prescribed. This ethnographic study aimed to identify clinician and patient factors influencing urgent dental care for adults during actual appointments; and to identify elements sensitive to context. Appointments were observed in out-of-hours and general dental practices. Follow-up interviews took place with dentists, dental nurses, and patients. Dentist and patient factors were identified through thematic analysis of observation records and appointment/interview transcripts. Dentist factors were based on a published list of factors influencing antibiotic prescribing for adults with acute conditions across primary health care and presented within the Capability-Opportunity-Motivation-Behaviour model. Contextually sensitive elements were revealed by comparing the factors between settings. In total, thirty-one dentist factors and nineteen patient factors were identified. Beliefs about antibiotics, goals for the appointment and access to dental services were important for both dentists and patients. Dentist factors included beliefs about the lifetime impact of urgent dental procedures on patients. Patient factors included their communication and negotiation skills. Contextual elements included dentists’ concerns about inflicting pain on regular patients in general dental practice; and patients’ difficulties accessing care to complete temporary treatment provided out of hours. This improved understanding of factors influencing shared decisions about treatments presents significant opportunity for new, evidence-based, contextually sensitive antibiotic stewardship interventions.

A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections.

BackgroundUncomplicated urinary tract infections (UTIs) can often be diagnosed based solely on symptoms and should be treated with a short course of narrow spectrum antibiotics. However, clinicians often order urine analyses and prescribe long courses of broad spectrum antibiotics.ObjectiveThe objectives of our study are: 1) Understand how primary care providers and residents clinically approach UTIs and 2) to understand specific opportunities, based on provider type, to target future antibiotic stewardship interventions.Design and participantsWe conducted semi-structured qualitative interviews of community primary care providers (n = 15) and internal medicine residents (n = 15) in St. Louis, Missouri from 2018–2019. A 5-point Likert scale was used to evaluate participant preferences for possible interventions. Interviews were transcribed, de-identified, and coded by two independent researchers using a combination inductive and deductive approach.Key resultsSeveral common themes emerged. Both providers and residents ordered urine tests to “confirm” presence of urinary tract infections. Antibiotic prescription decisions were often based on historical practice and anecdotal experience rather than local susceptibility data or clinical practice guidelines. Community providers were more comfortable treating patients over the phone than residents and tended to prescribe longer courses of antibiotics. Both community providers and residents voiced frustrations with guidelines being difficult to easily incorporate due to length and extraneous information. Preferences for receiving and incorporating guidelines into practice varied. Both groups felt benchmarking would improve prescribing practices but had reservations about implementation. Community providers preferred pragmatic clinical decision support systems and nurse triage algorithms. Residents preferred order sets.ConclusionsSignificant opportunities exist to optimize urinary tract infection management among residents and community providers. Multifaceted interventions that include provider education, synthesis of guidelines, and pragmatic clinical decision support systems are needed to improve antibiotic prescribing and diagnostic testing; optimal interventions to improve UTI management may vary based on provider training level.

Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data.

Antibiotic resistance is an increasing threat to public health globally. Indicators on antibiotic prescribing are required to guide antibiotic stewardship interventions in nursing homes. However, such indicators are not available in the literature. Our main objective was to provide a set of quantity metrics and proxy indicators to estimate the volume and appropriateness of antibiotic use in nursing homes. Recently published articles were first used to select quantity metrics and proxy indicators, which were adapted to the French nursing home context. A cross-sectional observational study was then conducted based on reimbursement databases. We included all community-based nursing homes of the Lorraine region in northeastern France. We present descriptive statistics for quantity metrics and proxy indicators. For proxy indicators, we also assessed performance scores, clinimetric properties (measurability, applicability, and room for improvement), and conducted case-mix and cluster analyses. A total of 209 nursing homes were included. We selected 15 quantity metrics and 11 proxy indicators of antibiotic use. The volume of antibiotic use varied greatly between nursing homes. Proxy indicator performance scores were low, and variability between nursing homes was high for all indicators, highlighting important room for improvement. Six of the 11 proxy indicators had good clinimetric properties. Three distinct clusters were identified according to the number of proxy indicators for which the acceptable target was reached. This set of 15 quantity metrics and 11 proxy indicators may be adapted to other contexts and could be used to guide antibiotic stewardship programs in nursing homes.

The effect of an antibiotic stewardship program on tigecycline use in a Tertiary Care Hospital, an intervention study

BackgroundA drug-oriented antibiotic stewardship intervention targeting tigecycline utilization was launched at Makassed General Hospital, Beirut, Lebanon, in 2016 as a part of a comprehensive Antibiotic Stewardship Program (ASP). In this study, we evaluated the effect of this intervention on changing tigecycline prescription behavior in different types of infections, patient outcome and mortality, along with tigecycline drug use density, when compared to an earlier period before the initiation of ASP.MethodsThis is a retrospective chart review of all adult inpatients who received tigecycline for more than 72 h between Jan-2012 and Dec-2013 [period (P) 1 before ASP] and between Oct-2016 and Dec-2018 [period (P) 2 during ASP].ResultsTigecycline was administered to 153 patients during P1 and 116 patients during P2. The proportion of patients suffering from cancer, those requiring mechanical ventilation, and those with hemodynamic failure was significantly reduced between P1 and P2. The proportion of patients who received tigecycline for FDA-approved indications increased from 19% during P1 to 78% during P2 (P < 0.001). On the other hand, its use in off-label indications was restricted, including ventilator-associated pneumonia (26.1% in P1, 3.4% in P2, P < 0.001), hospital-acquired pneumonia (19.6% in P1, 5.2% in P2, P = 0.001), sepsis (9.2% in P1, 3% in P2, P = 0.028), and febrile neutropenia (15.7% in P1, 0.9% in P2, P < 0.001). The clinical success rate of tigecycline therapy showed an overall significant increase from 48.4% during P1 to 65.5% during P2 (P = 0.005) in the entire patient population. All-cause mortality in the tigecycline-treated patients decreased from 45.1% during P1 to 20.7% during P2 (P < 0.0001). In general, mean tigecycline consumption decreased by 55% between P1 and P2 (P < 0.0001).ConclusionThe drug-oriented ASP intervention targeting tigecycline prescriptions improved its use and patient outcomes, where it helped curb the over-optimistic use of this drug in off-label indications where it is not a suitable treatment option.

Identifying targets for antibiotic stewardship interventions through analysis of the antibiotic prescribing process in hospitals - a multicentre observational cohort study

BackgroundIn order to change antibiotic prescribing behaviour, we need to understand the prescribing process. The aim of this study was to identify targets for antibiotic stewardship interventions in hospitals through analysis of the antibiotic prescribing process from admission to discharge across five groups of infectious diseases.MethodsWe conducted a multi-centre, observational cohort study, including patients with lower respiratory tract infections, exacerbation of chronic obstructive pulmonary disease, skin- and soft tissue infections, urinary tract infections or sepsis, admitted to wards of infectious diseases, pulmonary medicine and gastroenterology at three teaching hospitals in Western Norway. Data was collected over a 5-month period and included antibiotics prescribed and administered during admission, antibiotics prescribed at discharge, length of antibiotic therapy, indication for treatment and discharge diagnoses, estimated glomerular filtration rate (eGFR) on admission, antibiotic allergies, place of initiation of therapy, admittance from an institution, patient demographics and outcome data. Primary outcome measure was antibiotic use throughout the hospital stay, analysed by WHO AWaRe-categories and adherence to guideline. Secondary outcome measures were a) antibiotic prescribing patterns by groups of diagnoses, which were analysed using descriptive statistics and b) non-adherence to the national antibiotic guidelines, analysed using multivariate logistic regression.ResultsThrough analysis of 1235 patient admissions, we identified five key targets for antibiotic stewardship interventions in our population of hospital inpatients; 1) adherence to guideline on initiation of treatment, as this increases the use of WHO Access-group antibiotics, 2) antibiotic prescribing in the emergency room (ER), as 83.6% of antibiotic therapy was initiated there, 3) understanding prescribing for patients admitted from other institutions, as this was significantly associated with non-adherence to guideline (OR = 1.44 95% CI 1.04, 2.00), 4) understanding cultural and contextual drives of antibiotic prescribing, as non-adherent prescribing differed significantly between the sites of initiation of therapy (between hospitals and ER versus ward) and 5) length of therapy, as days of antibiotic therapy was similar across a wide range of diagnoses and with prolonged therapy after discharge.ConclusionsAnalysing the process of antibiotic prescribing in hospitals with patient-level data identified important targets for antibiotic stewardship interventions in hospitals.

Thinking Beyond the "Core" Antibiotic Stewardship Interventions: Shifting the Onus for Appropriate Antibiotic Use from Stewardship Teams to Prescribing Clinicians.

United States guidance for hospital antibiotic stewardship has emphasized prospective audit and feedback and prior authorization of select antibiotics as core interventions. These remain the most common interventions implemented by stewardship programs. Although these approaches have been shown to reduce unnecessary antibiotic use, they incorrectly put the onus for appropriate antibiotic use on the stewardship team rather than the prescribing clinician. We propose that a primary focus of stewardship programs should be implementation of broader interventions that engage frontline clinicians and equip them with tools to integrate antibiotic stewardship into their own daily practice, thus reducing the need for day-to-day stewardship team oversite. We discuss a framework of broader interventions and policies that will facilitate this paradigm shift.

Frequency and Predictors of Suboptimal Prescribing Among a Cohort of Older Male Residents with Urinary Tract Infections.

Unnecessary antibiotic treatment of suspected urinary tract infections (UTI) is common in long-term care facilities (LTCFs). However, less is known about the extent of suboptimal treatment, in terms of antibiotic choice, dose, and duration, after the decision to use antibiotics has been made. We described the frequency of potentially suboptimal treatment among residents with an incident UTI (the first during the study with none in the year prior) in Department of Veterans Affairs (VA) community living centers (CLCs; 2013-2018). Time trends were analyzed using Joinpoint regression. Residents with UTIs receiving potentially suboptimal treatment were compared with those receiving optimal treatment, to identify resident characteristics predictive of suboptimal antibiotic treatment, using multivariable unconditional logistic regression models. We identified 21 938 residents with an incident UTI treated in 120 VA CLCs, of whom 96.0% were male. Potentially suboptimal antibiotic treatment was identified in 65.0% of residents and decreased 1.8% annually (P < .05). Potentially suboptimal initial drug choice was identified in 45.6% of residents, suboptimal dose frequency in 28.6%, and longer than recommended duration in 12.7%. Predictors of suboptimal antibiotic treatment included prior fluoroquinolone exposure (adjusted odds ratio, 1.38), chronic renal disease (1.19), age ≥85 years (1.17), prior skin infection (1.14), recent high white blood cell count (1.08), and genitourinary disorder (1.08). Similar to findings in non-VA facilities, potentially suboptimal treatment was common but improving in CLC residents with an incident UTI. Predictors of suboptimal antibiotic treatment should be targeted with antibiotic stewardship interventions to improve UTI treatment.