Antimicrobial Stewardship Research Articles

Environmental Antimicrobial Resistance: Implications for Food Safety and Public Health

Antimicrobial resistance (AMR) is a serious global health issue, aggravated by antibiotic overuse and misuse in human medicine, animal care, and agriculture. This study looks at the different mechanisms that drive AMR, such as environmental contamination, horizontal gene transfer, and selective pressure, as well as the severe implications of AMR for human and animal health. This study demonstrates the need for concerted efforts across the scientific, healthcare, agricultural, and policy sectors to control the emergence of AMR. Some crucial strategies discussed include developing antimicrobial stewardship (AMS) programs, encouraging targeted narrow-spectrum antibiotic use, and emphasizing the significance of strict regulatory frameworks and surveillance systems, like the Global Antimicrobial Resistance and Use Surveillance System (GLASS) and the Access, Watch, and Reserve (AWaRe) classification. This study also emphasizes the need for national and international action plans in combating AMR and promotes the One Health strategy, which unifies environmental, animal, and human health. This study concludes that preventing the spread of AMR and maintaining the effectiveness of antibiotics for future generations requires a comprehensive, multidisciplinary, and internationally coordinated strategy.

Assessing veterinarians’ opinions of antimicrobial stewardship initiative acceptability for farm practice in Wales

AbstractBackgroundAntimicrobial stewardship (AMS) initiatives are imperative to safeguard antimicrobials and reduce resistance. Across the UK, AMS relies in part on the self‐regulation of the veterinary profession, particularly in farm animal practice, alongside voluntary schemes and quality assurance systems. In Europe, AMS initiatives are often statutory and require responsibility from several sectors. Consideration of broader AMS initiatives, potentially unfamiliar to the Welsh veterinary profession, could optimise future policy and align it with the requirements of Welsh veterinarians.MethodsAMS initiatives were collated from nations with long‐standing low antimicrobial use. A survey was constructed permitting veterinarians' evaluation of initiative feasibility and effectiveness (collectively, ‘acceptability’) within Welsh farm animal practice.ResultsVeterinarian‐directed AMS initiatives, particularly those implemented within individual practices, were considered most acceptable. Initiatives that demanded cooperation from entities outside practices, or those regarded as punitive, were less acceptable.LimitationsThe findings of this voluntary survey may be biased towards particularly motivated respondents in the veterinary sector. Additionally, the cause or effect of the recorded professional behaviour is not known in this study.ConclusionFuture antimicrobial policy should consider AMS acceptability by veterinarians, alongside farmers and other stakeholders, to promote compliance and attainment. The study data suggest that veterinarians may perceive continuous professional development/knowledge exchange as being most acceptable, alongside activities allied to a strong veterinarian‒client prescribing relationship. Continued support should focus on expanding these areas. Decoupling (ie, abolishing the professional licence for veterinarians to both prescribe and dispense medicines) was viewed as least acceptable by veterinarians in this study.

Efficiency of a Long-term Infectious Disease Consultation and Antimicrobial Stewardship Program at a Japanese Cancer Center: An Interrupted Time-Series Analysis

Abstract Background Patients with cancer are particularly susceptible to developing drug-resistant organisms due to the high frequency of infections during cancer treatment and the use of broad-spectrum antimicrobial agents. Therefore, patients with cancer are ideal candidates for an antimicrobial stewardship program (ASP); however, no established ASPs specifically target these patients. In this study, we evaluated the effect of a 46-month ASP intervention and infectious diseases (ID) consultation using a unique antimicrobial quality measure. Methods Our single-center, retrospective, observational study was conducted from April 1, 2018, to January 31, 2024, and evaluated two phases: pre-intervention (antimicrobial notification by the infection control team) and post-intervention (implementation of ASP and establishment of the ID consultation service). Results The days of therapy (DOT) for three intravenous carbapenems significantly decreased, and the DOT of narrow-spectrum antimicrobials significantly increased after the intervention. A significant reduction was observed in the length of hospital stay, with no change in the incidence of hospital-acquired resistant microorganisms. All-cause in-hospital mortality rates and the 30-day mortality rate among patients with bacteremia episodes were numerically reduced, although not significantly, compared to the pre-intervention period. The rate of appropriate use of antimicrobial agents increased significantly during the late post-intervention period (April 1, 2021, to January 31, 2024). Conclusions Our intervention was associated with the promotion of appropriate use of antimicrobial agents and a reduction in the length of hospital stay. These findings can help establish safer cancer treatments and improve patient prognosis.

Antibiotic Stewardship in Hospital-Acquired Pneumonia

Antibiotic Stewardship in Hospital-Acquired Pneumonia

A mixed method approach to analysing patterns and drivers of antibiotic use and resistance in beef farms in Argentina

IntroductionAntimicrobial resistance is a challenge to be faced by all livestock sectors; within beef farming, antibiotic use patterns vary by country and management practices. Argentina is a country with high beef production & consumption but limited information surrounding antibiotic use. The aims of this project was to understand how antibiotics are being used across the beef industry in Argentina and exploring drivers of usage.MethodsQuantitative and qualitative data was collected by: A survey of breeding and feedlot farms including antibiotic use (from purchase data); a detailed analysis of two feedlot farms’ therapeutic antibiotic use records; a survey of vets’ views on certain antibiotic practices; and a focus group of farmers and vets focusing on wider influences affecting decision making. Antibiotic use data was calculated using mg/population corrected unit (PCU) (ESVAC) and thematic analysis was used to identify drivers of antibiotic use among participants.ResultsThe median use across 17 farms that supplied purchase data was 76.52 mg/kg PCU (ESVAC; IQR = 36.81 mg/kg PCU [ESVAC]). The detailed farm records showed that the largest reason for treatment was group treatments (72.92% of treatments) followed by treatment for respiratory disease (12.75% of treatments). Macrolides accounted for 76.37% of treatments. Nearly half of farms used routine prophylactic treatment for arriving animals (n = 7/18). The use of quarantine and ‘sick pens’ were seen as important by surveyed vets with antibiotic prophylaxis and in-feed antibiotics seen as contributors to antibiotic resistance. The focus group highlighted the influence of the economic and political landscape on husbandry practices and the responsibility the farming sector had towards antibiotic stewardship.DiscussionOverall, Argentine beef feedlots resemble North American beef feedlots in terms of antibiotic practices but with considerably lower usage, with in-feed monensin representing a large proportion of total ABU. The adaptation period presents a challenge to animal health; antibiotics are administered a prophylaxis, metaphylactic and individual treatments depending on farm management practices. Further research into internationally comparable measures of ABU and detailed cost-benefit analysis of practical, on-farm interventions are needed to aid improved antimicrobial stewardship in livestock systems globally.

BN SO48 - Antibiotic prescribing for elective inguinal hernia repairs

Abstract Background Inguinal hernia repairs are a common procedure with over one million operations performed annually in Europe and the US. The European Hernia Society do not recommend the routine use of antibiotics in low-risk patients due to no significant benefit. They advise the consideration of prophylaxis for patients with risk factors including recurrence, age > 70 years or immunosuppression. Many surgeons are using antibiotic prophylaxis in all patients. However, inappropriate antibiotic use contributes to increased antibiotic resistance and increased healthcare cost. Our trust guidelines recommend a single dose of Cefuroxime in all patients undergoing an inguinal hernia repair with mesh. Method The aim of the project was to determine the compliance with current trust guidelines regarding antibiotic use in elective inguinal hernia repair with mesh. We also aimed to report on antibiotic prescribing patterns. Patients undergoing an elective inguinal hernia repair with mesh over a six-month period were identified. Data was collected retrospectively from electronic patient records and included patient’s age, if they were classed as high risk (age over 70, recurrence of hernia, diabetic, steroid therapy), if antibiotics were prescribed, and if so, which antibiotics were utilised. Results Eighty-five patients were included in the final data analysis. The median age of patients included was 67 years of age, and 93% were male. 41 patients were identified as high risk, and most patients were ASA II. Our results reported that 48% of patients were prescribed prophylactic antibiotics at induction. However, only two patients were prescribed the correct antibiotic, as per trust guidelines. Most patients were prescribed Co-Amoxiclav (78%), with a range of other antibiotics being used, including Flucloxacillin, Clarithromycin and Metronidazole. We identified 37% of high-risk patients were not prescribed antibiotics. Conclusion Our trust guidelines were not reflective of best practice and did not consider individual patient or procedure risk factors. We identified varied antibiotic prescribing patterns with low compliance to trust guidelines. Utilising our findings, we have created new guidelines, which recommend that in low-risk patients, routine antibiotic prophylaxis is not required. However, in the presence of patient-related risk factors as mentioned above, then a single dose of Cefuroxime is recommended. The updated guidelines will ensure good antimicrobial stewardship and reduce unnecessary antibiotic prescriptions. In addition, they accurately reflect the current evidence base surrounding antibiotic prophylaxis.

Macrolide resistance is pervasive in oral streptococci in the Belgian general population: a cross-sectional survey

Background. Commensal streptococci are common inhabitants of the oral microbiome and regulate its structure and function in beneficial ways for human health. They can, however, also be opportunistic pathogens and act as a reservoir of resistance genes that can be passed on to other bacteria, including pathogens. Little is known about the prevalence of these commensals in parents and their children and their antimicrobial susceptibilities in the Belgian general population. Gap Statement. The macrolide susceptibility of commensal oral Streptococci in Belgium is unknown. Methods. We assessed the prevalence and azithromycin susceptibility of commensal streptococcal species in the parents (n=38) and children (n=50) of 35 families in Belgium. Results. The most frequently detected taxonomic grouping was Streptococcus mitis/oralis, which was detected in 78/181 (43.1%) of the children’s isolates and 66/128 (51.6%) of the parents’ isolates. Of the 311 isolates collected in this study, 282 isolates (90.7%) had an azithromycin MIC value greater than the breakpoint of 0.25 mg l−1 and 146 isolates (46.9%) had azithromycin MICs greater than 2 mg l−1. There was no difference in the azithromycin MIC distribution of all streptococcal isolates between children and parents. All individuals were colonized by streptococci with azithromycin MICs greater than 0.25 mg l−1, and 87.5% of individuals had streptococci with MICs greater than 2 mg l−1. Interpretation. The most prevalent species identified in both age groups was S. mitis/oralis. All individuals harboured streptococci with macrolide resistance. This highlights the need for additional antimicrobial stewardship initiatives to reduce the consumption of macrolides in the general population.

Microbial Trends and their Drug Resistance Responsible for Bloodstream Infections in a Superspeciality Transplant Hospital

Background & Objective: Bloodstream infections (BSIs) are critical healthcare-associated infections that lead to high morbidity and mortality, requiring rapid diagnosis and effective antimicrobial treatment. The increasing prevalence of multidrug-resistant organisms (MDROs) exacerbates this issue, particularly in developing countries. The purpose of this study is to assess the bacteriological profile and antimicrobial susceptibility trends of BSIs to establish an antibiogram for effective empirical treatment. Materials and Methods: This study was conducted retrospectively on 3,300 blood culture samples from a multispecialty hospital over 15 months. Cultures were performed using Bactec FX and identification and antibiotic susceptibility determined by Vitek2 and Kirby-Bauer methods following CLSI guidelines. Results: Overall, the positivity rate was (14.3%) with 473 isolates: (400 bacterial and 73 fungal). Gram-negative bacteria were predominant, led by Klebsiella pneumoniae (113 isolates) and Escherichia coli (100 isolates). Among the Gram-negative bacteria, antimicrobial susceptibility was found to be low for Cephalosporins (21%sensitivity) and Fluoroquinolones (19.3% sensitivity), with moderate susceptibility to Carbapenems (51.3%). Sensitivity was high for Colistin (98.9%), Amikacin (91.05%), Tigecycline (100%), Fosfomycin (100%) and Ceftazidime-avibactum Aztreonam (97.7%). Among Gram-positive bacteria, Coagulase-negative Staphylococcal Species (CONS) and Staphylococcus aureus were the most common. The overall sensitivity of Gram-positive bacteria to antibiotics tested was high compared to the Gram-negative bacteria. Sensitivity to antibiotics such as Linezolid was found to be 94.5% and Vancomycin was found to be 93.5%. Conclusion: The high incidence of MDROs especially among the Gram-negative bacteria highlights the need for continuous monitoring and antibiotic stewardship programs. Empirical therapy must consider local resistance patterns, and a multidisciplinary approach is essential to mitigate antimicrobial resistance.

Improved use of antibiotics following implementation of antimicrobial stewardship in a neonatal intensive care unit

Abstract Introduction: Inappropriate antibiotic use in infants can have multiple adverse effects and contribute to the development of bacteria resistant to antimicrobials. Antimicrobial stewardship programs can reduce unnecessary antibiotic use in children. The aim of this study was to evaluate the effect of an antimicrobial stewardship program implemented in 2017 in the Neonatal Intensive Care Unit (NICU) at The Children’s Hospital Iceland. Materials and methods: The study included all infants who were admitted to the NICU during the study period (January 1st 2012–October 31st 2020). Data was collected from hospital records. Three periods were defined: preimplementation (2012–2014), peri-implementation (2015–2016) and postimplementation (2017–October 2020). Antibiotic use was quantified using days of therapy (DOT) per 1000 bed days (BD). For statistical analysis the pre- and postimplementation periods were compared. Results: Antibiotics were administered in 38.6% (1372) of admissions to the NICU during the study period. Antimicrobial use per year decreased from 584.6 to 317.1 DOT/1000 BD per year (P < 0.001). Use of broad-spectrum antibiotics decreased significantly. The average number of BD per month decreased from 297.8 to 220.9 BD/month (P = 0.0096). There were no significant changes in the length of stay for each infant or the proportion of readmissions or retreatment. Conclusion: Increased awareness of appropriate use of antimicrobials in the NICU led to shorter treatments and less use of broad-spectrum antibiotics. No increase in adverse effects such as readmissions or retreatment was observed.

Antimicrobial stewardship to reduce overtreatment of asymptomatic bacteriuria in critical access hospitals: measuring a quality improvement intervention

Abstract Background: Asymptomatic bacteriuria (ASB) treatment is a common form of antibiotic overuse and diagnostic error. Antibiotic stewardship using the inappropriate diagnosis of urinary tract infection (ID-UTI) measure has reduced ASB treatment in diverse hospitals. However, critical access hospitals (CAHs) have differing resources that could impede stewardship. We aimed to determine if stewardship including the ID-UTI measure could reduce ASB treatment in CAHs. Methods: From October 2022 to July 2023, ten CAHs participated in an Intensive Quality Improvement Cohort (IQIC) program including 3 interventions to reduce ASB treatment: 1) learning labs (ie, didactics with shared learning), 2) mentoring, and 3) data-driven performance reports including hospital peer comparison based on the ID-UTI measure. To assess effectiveness of the IQIC program, change in the ID-UTI measure (ie, percentage of patients treated for a UTI who had ASB) was compared to two non-equivalent control outcomes (antibiotic duration and unjustified fluoroquinolone use). Results: Ten CAHs abstracted a total of 608 positive urine culture cases. Over the cohort period, the percentage of patients treated for a UTI who had ASB declined (aOR per month = 0.935, 95% CI: 0.873, 1.001, P = 0.055) from 28.4% (range across hospitals, 0%-63%) in the first to 18.6% (range, 0%-33%) in the final month. In contrast, antibiotic duration and unjustified fluoroquinolone use were unchanged (P = 0.768 and 0.567, respectively). Conclusions: The IQIC intervention, including learning labs, mentoring, and performance reports using the ID-UTI measure, was associated with a non-significant decrease in treatment of ASB, while control outcomes (duration and unjustified fluoroquinolone use) did not change.

Potential Impact of Rapid Molecular Microbiologic Diagnosis for Mechanically Ventilated Children in Intensive Care With Suspected Pneumonia

Background: Lower respiratory tract infections (LRTIs) remain a leading cause of community-acquired and nosocomial infection in children and a common indication for antimicrobial use and intensive care admission. Determining the causative pathogen for LRTIs is difficult and traditional culture-based methods are labor- and time-intensive. Emerging molecular diagnostic tools may identify pathogens and detect antimicrobial resistance more quickly, to enable earlier targeted antimicrobial therapy. Methods: This is a single-center, prospective observational laboratory study evaluating the use of the Biofire FilmArray pneumonia panel (FA-PP) (BioFire Diagnostics, Salt Lake City, UT) for bronchoalveolar lavage specimens from mechanically ventilated children admitted with suspected or presumed pneumonia. We aimed to determine its feasibility and utility for identifying pathogens, antimicrobial resistance and its potential influence on antibiotic prescribing. Results: We analyzed 50 samples taken from 41 children with a median age of 6 months. Positive agreement between culture and FA-PP was 83% and negative agreement was 76%. Agreement between FA-PP (mecA/C or MREJ) and culture was high for methicillin-resistant Staphylococcus aureus. In 3 cases, extended-spectrum beta-lactamase-producing Gram-negative organisms were detected by culture and not FA-PP. Hypothetically, FA-PP results would have affected antimicrobial prescribing in approximately half the cases (24, 48%). Conclusions: FA-PP is a useful adjunct to traditional culture methods in mechanically ventilated children with LRTIs and may influence clinical decision-making regarding antibiotic escalation or stewardship.

Clinical outcomes following acute sore throat assessment at community pharmacy versus general practice: a retrospective, longitudinal, data linkage study

Abstract Background To date, no research has compared longer-term outcomes (antibiotic provision; re-consultations; hospital admissions for quinsy; cost-effectiveness) following presentation with acute sore throat at general practice (GP) versus newer, pharmacy-led services. Methods A retrospective, longitudinal cohort study of sore throat consultations between 1 November 2018 and 28 February 2020 either with the Wales pharmacy-led sore throat test and treat (STTT) service or with a healthcare professional at GP. Individual-level pharmacy consultation data from the national Choose Pharmacy IT application were securely uploaded to the Secure Anonymised Information Linkage Databank and linked to routinely collected, anonymized, population-scale, individual-level, anonymized health and administrative data. Results Of 72 736 index consultations, 6495 (8.9%) were with STTT and 66 241 (91.1%) with GP. Antibiotic provision at the index consultation was 1382 (21%) with STTT and 25 506 (39%) with GP [adjusted odds ratio (AOR), 0.30; 95% CI, 0.27 to 0.32]. Antibiotic provision within 28 days of index occurred in 1820 (28%) STTT and 26 369 (40%) GP consultations (AOR, 0.44; 95% CI, 0.41 to 0.47). GP re-consultation rate within 28 days of index date was 21% (n = 1389) with STTT compared with 7.4% (n = 4916) with GP (AOR, 3.8; 95% CI, 3.5 to 4.1). Coding limitations may lead to overestimates of GP re-consultations rates in the STTT group. Hospital admissions for quinsy were rare in both STTT (n = 20, 0.31%) and GP (n = 274, 0.41%) (AOR, 0.68; 95% CI, 0.43 to 1.1). STTT was less costly than consultation with GP. Conclusions The pharmacy-led STTT service is safe, cost-effective, and contributes to antimicrobial stewardship.

Assessment of therapeutic response to photodynamic therapy with the Zn-Phthalocyanine RLP068/Cl versus topical Clindamycin in patients affected by Hidradenitis Suppurativa: a comparative clinical pilot study

AbstractHidradenitis suppurativa is a chronic skin disorder characterized by painful inflammatory nodules and abscesses, significantly impacting patients’ quality of life. Current treatment strategies, including topical antibiotics, often yield limited efficacy and pose risks of antibiotic resistance. Photodynamic therapy has emerged as a potential option, with RLP068/Cl (ELKOFAST®, non-sterile formulation) showing promising efficacy due to its broad-spectrum bactericidal activity. We conducted a pilot study assessing the therapeutic response to photodynamic therapy with RLP068/Cl versus topical clindamycin gel in patients affected by hidradenitis suppurativa of Hurley score I, II, and III. Results revealed higher efficacy of photodynamic therapy in combination with RLP068/Cl, particularly in mild cases. Its efficacy remains reliable even in more severe cases when combined with adalimumab. The observed faster lesion improvement and pain relief were ascribed to the bactericidal effects of RLP068/Cl against Gram+ and Gram− bacteria. Furthermore, photoactivated RLP068/Cl was well tolerated with no adverse events reported. Therefore, photodynamic therapy following RLP068/Cl application represents a novel therapeutic option for hidradenitis suppurativa with potential implications for antibiotic stewardship in dermatology. Graphical abstract

Knowledge and attitudes of patients in underserved communities regarding antibiotic resistance, antibiotic stewardship, and pharmacist involvement in antibiotic prescribing: A regional survey

Abstract Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Despite the effectiveness of antibiotic stewardship programs (ASPs) in improving antibiotic prescribing, these are rarely implemented in clinics serving underserved communities. Our objective was to understand patients’ perspectives on the factors that can impact implementation of ASPs and integration of pharmacists in antibiotic prescribing in rural clinics. Methods We conducted a survey using both quantitative questions and an open-ended question. To participate, patients had to receive care from a clinic serving low-income or rural communities and provide verbal consent to be included in the study. We analyzed the quantitative component of the data using descriptive statistics. The Pearson correlation coefficient was used to examine the relationship between respondents’ knowledge of the prevalence of antibiotic resistance and their attitudes toward ASPs and pharmacist integration in antibiotic prescribing. Results Of the 189 respondents who completed a survey, 51.3% were female and 51.3% were Caucasian. In our analysis, over 60% of patients reported knowing their prescribed antibiotics’ names, while less than 30% possessed adequate knowledge of the indication and duration of the prescribed antibiotics. There was a positive correlation between knowledge about antibiotic resistance and being comfortable involving pharmacists in antibiotic prescribing (P < 0.01). Conclusion Many patients supported pharmacist involvement in antibiotic prescribing. Understanding patients’ perceived attitudes will facilitate patient-centered, infrastructure-supported interventions by clinicians to improve antibiotic prescribing in the community.

Effects of Prospective Audit and Feedback in Patients with Extended-Spectrum β-Lactamase-Producing Escherichia coli Bacteremia

Antimicrobial stewardship (AS) Guidelines by the Infectious Diseases Society of America recommend employing prospective audit and feedback (PAF) as an effective intervention in AS programs. Since July 2022, our hospital has implemented PAF for all patients with positive blood cultures, including those with extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (EC) bacteremia. Our study examined the effect of PAF on clinical outcomes in patients with ESBL-EC bacteremia. We enrolled 62 patients diagnosed with ESBL-EC via blood culture who were undergoing antibiotic treatment. The patients were divided into the pre-PAF and post-PAF implementation groups. The rate of antibiotic de-escalation from broad-spectrum antibiotics to narrow-spectrum cefmetazole was significantly higher in the post-PAF group than in the pre-PAF group (80.7% vs. 32.4%, p = 0.0003). The treatment failure rate in the pre-PAF group was higher than that in the post-PAF group (38.7% vs. 12.9%, p = 0.04). The results of this study indicate that the implementation of PAF is advantageous not only in terms of process indicators but also in improved clinical outcomes, including reduced treatment failure rates. We hope that this study will encourage the implementation of PAF in more facilities to instigate a collective effort to reduce the incidence of antimicrobial resistance.

Combatting extensively drug-resistant Salmonella: a global perspective on outbreaks, impacts, and control strategies

ABSTRACT Antibiotic resistance in typhoid fever poses a critical public health problem due to the emergence of extensively drug-resistant (XDR) Salmonella, resulting in prolonged illness and treatment failure. Salmonella enterica serovar Typhi is the most predominant among all serotypes and can acquire resistance. The emergence of XDR Salmonella in various regions globally, particularly Pakistan, presents a concerning trend. However, limited data availability impedes a comprehensive understanding of the outbreaks and hinders the development of real-time solutions. Here, we have provided an updated overview of the current outbreaks of XDR Salmonella in epidemic and endemic regions. Treatments of XDR Salmonella infections are challenging, as there are records of treatment failure in humans and animals. However, intensive prevention techniques can be implemented pending the advent of novel antibiotics. Emphasis on antimicrobial stewardship and frequent surveillance of the pathogen should be made to keep track of potential outbreaks in both human and animal populations. Although progress is being made to combat XDR Salmonella within some regions, a unified and efficient effort on an international scale is required to curtail the XDR outbreak before it escalates and leads us back to the pre-antibiotic era.

Evaluating pediatric antimicrobial dosing of β-lactam antibiotics for upper respiratory tract infections in emergency and primary care settings

Abstract Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Pediatric prescribing is often weight and indication specific and has been associated with high rates of error. The aim of this study was to evaluate outpatient β-lactam suspension dosing practices for pediatric upper respiratory tract infections (URIs), to characterize the rate of error and to describe common error types. Methods This retrospective cohort study was conducted at a community health system with 2 emergency departments and 20 outpatient family medicine practices. Pediatric patients treated from these settings with oral suspension formulations of amoxicillin, amoxicillin/clavulanate, cefdinir, or cephalexin for streptococcal pharyngitis or otitis media between June 1, 2020, and May 31, 2023, were eligible for inclusion. Doses were evaluated against indication-specific best-practice guidelines and assessed for guideline concordance. Results Of the 200 patients evaluated, 100 were treated for streptococcal pharyngitis and 100 were treated for otitis media. Of the prescribed β-lactam doses, 32% were discordant with best-practice guideline recommendations. Dosing errors were more common for pharyngitis than for otitis media (47% vs 17%; P < 0.001). Overdosing was the most frequently observed error in pharyngitis prescriptions (93.6% of errors) and most commonly occurred in patients weighing more than the 20-kg weight associated with the dosing maximum (80.9% of overdosing errors). All patients receiving an inappropriate dose for otitis media were underdosed. Conclusion Outpatient pediatric dosing errors for URI indications are common among both emergency medicine and family medicine prescribers. Patients weighing over the weight corresponding to the dosing maximum are at highest risk for error. Antimicrobial stewardship interventions targeting the point of prescribing are urgently needed to provide safe dosing practices for pediatric patients.

Antimicrobial stewardship in sub-Saharan African community pharmacies: a systematic review of community pharmacists’ knowledge, practice and challenges faced

Abstract Introduction The indiscriminate use of antimicrobials contributes significantly to antimicrobial resistance (AMR). The World Health Organization (WHO) recommends antimicrobial stewardship (AMS) as one of the global sustainable development interventions to tackle AMR. Implementation of AMS interventions have been documented to be successful in high-income countries 1, however, there is paucity of data regarding the implementation and effectiveness of AMS in low-income settings including sub-Sahara Africa (SSA). Community pharmacies in the SSA play a critical role in the dispensing of medicines, including antibiotics. Aim To evaluate community pharmacists' knowledge, practice, and challenges faced in relation to AMS in SSA community pharmacies. Methods The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework guided the review. We searched six electronic databases (PubMed, Web of Science, ProQuest Central, Google Scholar, African Journal Online and Wiley Online library) from January 2010 to December 2022. Reference lists of included articles were screened for additional studies. Studies published in English that described AMS interventions, antibiotic dispensing practices, community pharmacists’ knowledge and perceptions of AMS/AMR were included. Literature reviews and systematic reviews were excluded. AMS in hospital pharmacy and animal studies were also excluded. Two reviewers independently screened the abstracts and full texts according to pre-defined inclusion criteria. Disagreements were resolved through discussion. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the quality of the included studies2. Data were extracted using a standardised form in Microsoft excel and double checked for accuracy. Data were synthesised using narrative synthesis. The review protocol was registered with PROSPERO (CRD42023381320). The study did not require ethical approval because it did not involve conducting primary or secondary research involving human participants. Results The review identified 1972 articles, of which 23 studies met the inclusion criteria. Studies varied in settings, design, and data collection methods. Two broad categories were identified from the narrative synthesis. (1) Community pharmacists’ knowledge, attitude, perception, and dispensing practices (n=20). Studies reported that community pharmacists displayed an understanding of how antibiotics work. They also acknowledged threats posed by AMR. Some studies reported misconceptions on clear guidelines about the practical implementation of AMS, other studies described good adherence to antibiotic dispensing practices, including taking medication histories, assessing symptoms, advising on completion of antibiotic courses and making referrals. One study described the perception of community pharmacists of AMS as crucial for improving patient care. (2). Determinants of non-prescription antibiotic sales (n=3). The studies explored factors influencing the sale of antibiotics without prescription. Studies identified pharmacy owners’ expectations (profitability) and lack of public awareness regarding the risks of non-prescription antibiotic use as contributing factors. Limited patient access to doctors and low economic status in SSA were also cited as determinants. Conclusions Community pharmacists have knowledge of antibiotics, and they also acknowledged the importance of AMS. There were also positive dispensing practices despite existing challenges regarding implementation of AMS and sales of antibiotics without prescription. Further research should prioritize well-designed studies that evaluate the effectiveness of AMS in this setting and address the challenges identified. Heterogeneity of study methods limits the generalisability of findings.

Education on antimicrobial stewardship in community pharmacies to be delivered as a part of a public health campaign

Abstract Introduction Community pharmacies are well-placed to educate the public on antimicrobial stewardship (AMS). Medicines management teams have historically focused on empowering prescribers to practise prudent use of antibiotics; in 2017 there was a lack of education/support to community pharmacy (CP) colleagues on the same topic, although subsequent ESPAUR reports (2) have highlighted the tools and resources that are now available to CP. To address the identified need locally, educational events for CP staff were organised with the aim of increasing knowledge of AMS and increasing confidence in recommending self-care for self-limiting respiratory tract infections (RTIs). Educational material delivered included key AMS messages, an introduction to the local antimicrobial guidelines and a case study. Method In the UK, a Birmingham based commissioning organisation organised a CP public health (PH) campaign promoting AMS. The campaign ran throughout February 2017. All CPs in Birmingham and Sandwell (n=385) were invited to an educational event, with 4 dates through January. The event provided educational presentations on AMS, including fundamentals of antimicrobial resistance (AMR), and management of self-limiting RTIs, with interactive case studies focussing on patients who may initially present to their local pharmacy. Content was delivered by a consultant microbiologist and the antimicrobial lead pharmacist. Learning outcomes included understanding of AMS, AMR, appropriate antibiotic use, and the role of a CP team in raising public awareness. An electronic questionnaire was designed and provided to CP via PharmOutcomes after the campaign, to assess the impact of the events on the knowledge and confidence of the staff in delivering key AMS messages to the public. All responses were completed at the same time after the education session and this may impacted the results. The follow up questionnaire was classed as service evaluation by the organisation as per the NHS Health Research Authority assessment tool and did not require ethical approval. Results There were 226 responses to the questionnaire, from 210 (54.5%) CP. Of the 150 spaces available for the educational events, 144 tickets were reserved. Prior to the session 26% (n/58) of CP staff felt their knowledge of AMS was very good or excellent; after the session this increased to 78% (n/177). Confidence in recommending self-care for self-limiting RTIs also increased, with 79.2% (n/179) rating their confidence as very good or excellent after the session compared to 36.3% (n/82) beforehand. 95% (n/214) of CP staff felt that the education session changed their attitude towards AMS. Discussion / Conclusion This intervention showed a positive outcome of increasing CP knowledge about AMS and confidence in recommending appropriate self-care. The educational events were well attended although not all pharmacies were able to engage with the events and not all the learning outcomes were able to be captured in the evaluation survey. Overall feedback from CP was positive with the majority of staff gaining an increase knowledge and confidence in communicating with the public and recommending self care where appropriate. As the questionnaire was anonymised, we were unable to follow up feedback from individuals, which have useful to inform future sessions.

Barriers and facilitators to implementation of a national antimicrobial stewardship toolkit for inpatient settings

Abstract Introduction Antimicrobial stewardship (AMS) is vital for combating antimicrobial resistance (AMR). The updated 2023 "Start Smart Then Focus" (SSTF) national antimicrobial stewardship (AMS) toolkit1, designed for inpatient settings, supports optimising prescribing of antimicrobials. Aim This project was designed to identify the barriers and facilitators to implementing the national toolkit to improve patient outcomes and reduce AMR. Method An online training workshop was conducted for healthcare professionals across England, focusing on the SSTF toolkit. Before the workshop, participants completed a survey that included consent and gathered information on their roles, familiarity with AMS principles, current practices, and perceived barriers and facilitators to AMS implementation. This information in this survey was used to form basis for the workshop and it was helpful in developing content appropriate for the target audience, which will be delivered during the session. The workshop included discussions on knowledge mobilisation, behavioural science using the COM-B model, and SSTF implementation case studies. Participants engaged in breakout sessions to identify implementation challenges at their organisations. Post-workshop surveys collected feedback on learning outcomes. Collaboration with NHS England AMS leads and UKHSA behavioural scientists was integral. The NHS Health Research Authority tool confirmed the project did not require ethical approval as the surveys were service evaluation. Data were analysed using descriptive statistics for quantitative responses and thematic analysis for qualitative feedback, tailoring workshop content to address specific needs. Results The workshop attracted 57 out of 71 (80%) registered healthcare professionals, including pharmacists (n=45), doctors(n=3), and nurses(n=4). Post-workshop surveys received a 28%(n=16) response rate. Feedback was positive, with 14 out of 16 (88%) of participants expressing high satisfaction. Highlights included SSTF development, e-prescribing implementation, and sessions on barriers and facilitators.Key barriers identified were lack of time, competing priorities, data complexity, insufficient organisational support, and limited resources3. Facilitators included engaging microbiology consultants and the ePMA team, raising awareness through AMS ward rounds, and embedding the SSTF toolkit into guidelines and education. Participants suggested further support from UKHSA and NHSE, including more teaching sessions, workshops, educational materials, and e-learning resources. Practical tools like posters, lanyard cards, infographics, and virtual sessions were recommended to reinforce implementation. The survey responses were analysed using descriptive statistics for quantitative data, such as satisfaction ratings, and thematic analysis for qualitative feedback. This analysis evaluated the workshop's impact on participants' understanding and readiness to implement the toolkit and provided insights for enhancing future training activities. Discussion/Conclusion The workshop identified key facilitators and barriers to SSTF implementation. While the toolkit offers a comprehensive framework for AMS, overcoming barriers requires a multifaceted approach involving education, stakeholder engagement, and continuous support. Clearer role definitions and improved support structures are essential. Limitations include limited participant representation and reliance on self-reported data, which may introduce bias. The study lacks long-term follow-up data to assess sustained impact, and feedback might be influenced by personal experiences or organisational culture, affecting generalisability. Future studies could expand participant diversity, incorporate longitudinal assessments, and explore additional AMS aspects.