Antimicrobial Stewardship Team Research Articles

Prospective audit and feedback implementation by a multidisciplinary antimicrobial stewardship team shortens the time to de-escalation of anti-MRSA agents.

Prospective audit and feedback (PAF) is considered an effective procedure for appropriate antibiotic use. However, its effect on the time to de-escalation is unclear. We aimed to evaluate the effect of daily PAF implementation, focusing on the time to de-escalation of anti-methicillin‐resistant Staphylococcus aureus (MRSA) agents as an outcome measure. To this end, a single-center, retrospective, quasi-experimental study including patients treated with intravenous anti-MRSA agents during pre-PAF (April 1, 2014 to March 31, 2015) and post-PAF (April 1, 2015 to March 31, 2016) periods was conducted. The time to de-escalation was estimated using the Kaplan–Meier method, and Cox proportional hazard analysis was performed to assess the effect of daily PAF implementation on the time to de-escalation. Interrupted time series analysis was used to evaluate the relationship between daily PAF implementation and anti-MRSA agent utilization data converted to defined daily dose (DDD) and days of therapy (DOT) per 1,000 patient days. The median time to de-escalation was significantly shorter in the post-PAF period than in the pre-PAF period (6 days vs. 7 days, P < 0.001). According to multivariate analysis, PAF implementation was independently associated with a shorter time to de-escalation (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.02 to 1.35). There were no significant differences in hospital mortality, 30-day mortality, and length of stay between the two periods. Interrupted time series analysis showed significant reductions in the trends of DDD (trend change, –0.65; 95% CI, –1.20 to –0.11) and DOT (trend change, –0.74; 95% CI, –1.33 to –0.15) between the pre-PAF and post-PAF periods. Daily PAF implementation for patients treated with intravenous anti-MRSA agents led to a shorter time to de-escalation and lower consumption of anti-MRSA agents without worsening the clinically important outcomes.

Impact of collaborative physician-pharmacist stewardship strategies on prophylactic antibiotic practices: a quasi-experimental study

BackgroundAn effective use of surgical antibiotic prophylaxis (SAP) appears essential to prevent the development of infections linked to surgery while inappropriate and excessive prescriptions of prophylactic antibiotics increase the risk of adverse effects, bacterial resistance and Clostridium difficile infections. In this study, we aimed to analyze SAP practices in an acute secondary hospital in Belgium during the years 2016–2021 in order to evaluate the impacts of combined stewardship interventions, implemented thanks to a physician-pharmacist collaboration.MethodsA quasi-experimental study on SAP practices was conducted during 5 years (2016–2021) in a Belgian University Hospital. We first performed a retrospective observational transversal study on a baseline group (2016.1–2016.4). Then, we constituted a group of patients (2017.1–2017.4) to test a combined intervention strategy of stewardship which integrated the central role of a pharmacist in antibiotic stewardship team and in the pre-operative delivery of nominative kits of antibiotics adapted to patient factors. After this test, we collected patient data (2018.1–2018.4) to evaluate the sustained effects of stewardship interventions. Furthermore, we evaluated SAP practices (2019.1–2019.4) after the diffusion of a computerized decision support system. Finally, we analyzed SAP practices in the context of the COVID-19 pandemic (2020.1–2020.4 and 2021.1–2021.4). The groups were compared from year to year in terms of compliance to institutional guidelines, as evaluated from seven criteria (χ2 test).ResultsIn total, 760 surgical interventions were recorded. The observational study within the baseline group showed that true penicillin allergy, certain types of surgery and certain practitioners were associated with non-compliance (p < 0.05). Compared with the baseline group, the compliance was significantly increased in the test group for all seven criteria assessed (p < 0.05). However, the effects were not fully sustained after discontinuation of the active interventions. Following the diffusion of the computerized decision support system, the compliance to guidelines was not significantly improved. Finally, the COVID-19 pandemic did not appear to affect the practices in terms of compliance to guidelines.ConclusionsThis study shows that optimization of SAP practices is achievable within a proactive multidisciplinary approach including real-time pharmaceutical interventions in the operating area and in the care units practicing SAP.

Infections in G6PD-Deficient Hospitalized Patients-Prevalence, Risk Factors, and Related Mortality.

G6PD deficiency is a genetic disease that weakens the immune system and renders affected individuals susceptible to infections. In the Sultanate of Oman resides a high number of recorded G6PD cases due to widespread consanguineous marriage, which may reach 25% of the population. We studied the infection patterns and risk factors for mortality to provide antimicrobial stewardship recommendations for these patients. After obtaining ethical approval, a registry of recorded cases was consulted retrospectively to include G6PD-deficient adult patients admitted to Suhar hospital over 5 years with microbiologically confirmed infections. Patient demographics, health-related information, infection causes, treatment, and clinical outcomes were studied. Data were analyzed to describe infection patterns and risk factors. Several variables, including underlying comorbidities and hospitalization details, such as length of stay, admission to critical care unit, blood transfusion, or exposure to an invasive procedure, were statistically associated with the acquisition of multidrug-resistant and hospital-acquired infections. Meanwhile, these infections were associated with a high mortality rate (28%), significantly associated with the patient’s health status and earlier exposure to antimicrobial treatment due to previous bacterial infection. The high prevalence of G6PD deficiency among the Omani population should alert practitioners to take early action when dealing with such cases during infection that requires hospitalization. Strict infection control measures, Gram-negative empiric coverage, hospital discharge as early as possible, and potent targeted antimicrobial therapy in this patient population can ameliorate the treatment outcomes and should be emphasized by the antimicrobial stewardship team.

Implementation of Clinical Practice Guidelines for Empirical Antibiotic Therapy of Bacteremia, Urinary Tract Infection, and Pneumonia: A Multi-Center Quasi-Experimental Study.

A quasi-experimental study was conducted on the implementation of locally developed clinical practice guidelines (CPGs) for empirical antibiotic (ATB) therapy of common infections (bacteremia, urinary tract infection (UTI), pneumonia) in the hospitals from January 2019 to December 2020. The CPGs were developed using data from patients with these infections at individual hospitals. Relevant CPG data pre- and post-implementation were collected and compared. Of the 1644 patients enrolled in the study, 808 and 836 were in the pre- and post-implementation periods, respectively, and patient outcomes were compared. Significant reductions in the mean durations of intensive care unit stay (3.44 ± 9.08 vs. 2.55 ± 7.89 days; p = 0.035), ventilator use (5.73 ± 12.14 vs. 4.22 ± 10.23 days; p = 0.007), piperacillin/tazobactam administration (0.954 ± 3.159 vs. 0.660 ± 2.217 days, p = 0.029), and cefoperazone/sulbactam administration (0.058 ± 0.737 vs. 0.331 ± 1.803 days, p = 0.0001) occurred. Multivariate analysis demonstrated that CPG-implementation was associated with favorable clinical outcomes (adjusted odds ratio 1.286, 95% confidence interval: 1.004–1.647, p = 0.046). Among patients who provided follow-up cultures (n = 284), favorable microbiological responses were significantly less frequent during the pre-implementation period than the post-implementation period (80.35% vs. 91.89%; p = 0.01). In conclusion, the locally developed CPG implementation is feasible and effective in improving patient outcomes and reducing ATB consumption. Hospital antimicrobial stewardship teams should be able to facilitate CPG development and implementation for antimicrobial therapy for common infections.

Evaluation of antibiotic prescribing for ambulatory patients seeking primary dental care services in a public hospital in Ghana: a clinical audit study.

BackgroundOne in 10 of all antibiotic prescriptions globally are for dental conditions with 80% of them being inappropriate, making it a potential driver of antimicrobial resistance.ObjectivesTo evaluate the appropriateness of antibiotic use among ambulatory patients seeking dental care services in a public hospital in Ghana.MethodsA retrospective clinical audit was conducted by extracting the medical records of all patients seeking dental care at the ambulatory care clinic of Keta Municipal Hospital (KMH) from January 2020 to December 2020 using the hospital’s electronic database. Descriptive statistics, bivariate and multivariate analysis were performed on the data collected.ResultsOverall, 1433 patient medical records were extracted from the database within the study period. The mean age of the patients identified was 39.9 years with almost two-thirds being female. The majority (91.1%, n = 1306) of them were attended to by a dental nurse. In total, 88.6% (n = 1269) of the patients received antibiotics and 87.5% (n = 1254) of antibiotics prescribed were non-compliant with Ghana Standard Treatment Guidelines. Three-quarters of the dental conditions were managed with dual antibiotics comprising amoxicillin and metronidazole. Antibiotic prescription was associated with age, gender, type of prescriber and type of dental condition diagnosed.ConclusionsThere is a high usage of antibiotics for dental conditions managed at the outpatient section of the hospital and most are inappropriate. Development of local guidelines supported by education of dental clinicians on empirical use of antibiotics is a suitable target for the antimicrobial stewardship team to address in KMH.

Antimicrobial Stewardship for the Infusion Nurse.

The consequences of antimicrobial overuse are complex. Censoring overuse requires strategic efforts directed at tailoring antimicrobial prescribing habits. Antimicrobial stewardship combats the negative consequences for patients and society. All members of the health care team can influence stewardship efforts in the patient treated for infectious diseases. Many of the potent antimicrobials used today are given by infusion, providing an exceptional opportunity for the infusion nurse to become a crucial part of the antimicrobial stewardship team. The goal of this article is to explain why antimicrobials are worth caring for and preserving, as well as to define the role of the infusion nurse in the antimicrobial stewardship team.

Antibiotic Consumption and Deviation of Prescribed Daily Dose From the Defined Daily Dose in Critical Care Patients: A Point-Prevalence Study.

Background: The consumption of antibiotics is one of the metrics used to evaluate the impact of antimicrobial stewardship programs (ASP). The aim of this study was to determine the prevalence of antibiotic consumption in Brazilian intensive care units (ICUs) and estimate the deviation of the prescribed daily dose (PDD) from the defined daily dose (DDD). Methods: This is a multicenter, observational, point-prevalence study carried out in adult ICUs of 8 Brazilian hospitals from August 2019, to February 2020. We collected data on the patient’s demographic and clinical characteristics, antibiotic therapy, classification and site of infections. The DU90 (antibiotic accounting for 90% of the volume utilized) was calculated, and the antibiotics were classified by the Anatomical Therapeutic Chemical (ATC) Index and the World Health Organization (WHO) Access, Watch, Reserve (AWaRe) groups. For the most prevalent antibiotics, the deviation of PDD from DDD was determined. Results: Three hundred thirty-two patients from 35 ICUs were analyzed. The prevalence of antibiotic use was 52.4%. The patients in use of antibiotics were predominantly over 60 years of age (81.6%) with pulmonary infections (45.8%). A predominance of empirical regimens was observed (62.6%) among antibiotic therapies. The highest frequencies of prescriptions observed were for piperacillin + tazobactam (16.1%), meropenem (13.3%), amoxicillin + clavulanate (7.2%), azithromycin (7.2%), and teicoplanin (6.1%). The watch (64.2%) and reserve (9.6%) categories of the AWaRe classification accounted for 73.8% of all antibiotics, and they were prescribed alone or in combinations. High variability of doses was observed for the most prescribed antibiotics, and large deviations of PDD from the DDD were observed for meropenem, teicoplanin, and tigecycline. Conclusions: The high prevalence of antibiotic prescription was related to a predominance of empirical regimens and antibiotics belonging to the WHO Watch classification. High variability of doses and large deviations of PDD from DDD for meropenem, teicoplanin, and tigecycline was observed, suggesting that DDD may be insufficient to monitor the consumption of these antibiotics in the ICU population. The variability of doses found for the most prescribed antibiotics suggests the need for monitoring and intervention targets for antibiotic stewardship teams.

Out of sight, out of mind: Impact of an antimicrobial stewardship initiative to reduce fluoroquinolone utilization

AbstractIntroductionIn June 2017, the antimicrobial stewardship team at Wesley Healthcare implemented a combination of strategies aimed at reducing fluoroquinolone usage. The components included suppression of fluoroquinolone susceptibility in Enterobacterales isolates, removal of fluoroquinolones as first‐line options in order sets, and introduction of a respiratory‐specific antibiogram.ObjectivesThe objective was to evaluate the impact of combined stewardship strategies on fluoroquinolone utilization.MethodsThis was a quality improvement study evaluating fluoroquinolone use within a health‐care system. The primary outcome was ciprofloxacin and levofloxacin usage in days of therapy (DOT) per 1000 inpatient days collected at monthly intervals for 24 months before and after the intervention. Overall antibacterial usage in DOT served as a control variable. The secondary outcomes were Escherichia coli and Pseudomonas aeruginosa susceptibility to ciprofloxacin measured at the same time points. An interrupted time series analysis using segmented regression was performed for all variables.ResultsThe mean monthly levofloxacin usage was reduced from 14.1 (95% confidence interval [CI], 12.7‐15.4) to 8.4 (95% CI, 7.6‐9.3) DOT. The mean monthly ciprofloxacin usage was reduced from 26.9 (95% CI, 24.6‐29.4) to 15.8 (95% CI, 14.0‐17.5) DOT. The trend in levofloxacin usage was reduced (P = .035), while a pre‐existing downward trend in ciprofloxacin usage was unchanged (P = .430). Overall antibacterial usage increased (P = .001). There were no differences in Escherichia coli or Pseudomonas aeruginosa susceptibilities observed.ConclusionThe use of combined antimicrobial stewardship strategies may be a viable intervention method to reduce fluoroquinolone usage. The combined strategy was effective in reducing levofloxacin usage, as demonstrated by the reduction of use and the downward usage trend.

P13 Every patient who could have OPAT, should have OPAT—the importance of data

BackgroundOutpatient parenteral antimicrobial therapy (OPAT) has a clear role to play in optimizing antimicrobial stewardship and is listed as one of the Department of Health's five options for antimicrobial prescribing decision options to focus therapy. York and Scarborough Teaching Hospital NHSFT OPAT service has been operational since January 2019, treating over 438 patients and demonstrating year-on-year growth. Growth has been progressive, however a department vision established in 2021 stretched this to seek that ‘Every patient that could have OPAT, should have OPAT’—an ambitious target but not impossible with a robust evaluation of the service and a structured approach to scale.ObjectivesAn in-depth assessment to understand the current OPAT service and to identify pathways for further expansion together with potential efficiency and productivity gains.MethodsWorking in partnership with Baxter Healthcare, a 3 month diagnostic process was undertaken with the multidisciplinary team, using a range of service and quality improvement tools to inform an in-depth assessment. A clear picture of the OPAT current state was developed through: (i) outcomes analysis; (ii) insights: pathway mapping and system flow; (iii) insights: patient experience; and (iv) insights: point of use.ResultsThe assessment of OPAT services provided a clear demonstration of how the service has grown from 8.4 patients per month in 2019 to 20.8 in 2020 and 27.4 in 2021, saving over 10 500 bed-days in line with the department vision and antimicrobial stewardship team goals (Figure 1). Multiple metrics have been included demonstrating clear service expansion opportunities and growth as evidenced from an initial focus on vascular, surgical and orthopaedic patients, to now include provision for patients with diabetic foot infections, bronchiectasis and intra-abdominal infections. The service has significant peaks and troughs, impacted by a number of factors impacting capacity and flow including resource, points of referral and the ability to identify patients. The OPAT Good Practice Recommendation (GPR) Assessment Tool was utilized to review overall compliance with the BSAC OPAT GPRs and to plan further improvement initiatives.Figure 1.York Hospitals OPAT patient numbers, starting 1 January 2019.ConclusionsMoving forward the focus is on predictability for sustainable growth creating a more consistent service, with multiple care pathways optimized to meet individual patient needs across North Yorkshire. The Baxter partnership has offered the Trust an opportunity to understand the service potential and meet their ambitious vision. Ultimately the goal is for 75% of patients in the OPAT service to be on a self-care pathway, thus releasing time to care.

A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial

BackgroundInappropriate antibiotic use can cause harm and promote antimicrobial resistance, which has been declared a major health challenge by the World Health Organization. In Australian residential aged care facilities (RACFs), the most common indications for antibiotic prescribing are for infections of the urinary tract, respiratory tract and skin and soft tissue. Studies indicate that a high proportion of these prescriptions are non-compliant with best prescribing guidelines. To date, a variety of interventions have been reported to address inappropriate prescribing and overuse of antibiotics but with mixed outcomes. This study aims to identify the impact of a set of sustainable, multimodal interventions in residential aged care targeting three common infection types.MethodsThis protocol details a 20-month stepped-wedge cluster-randomised trial conducted across 18 RACFs (as 18 clusters). A multimodal multi-disciplinary set of interventions, the ‘AMS ENGAGEMENT bundle’, will be tailored to meet the identified needs of participating RACFs. The key elements of the intervention bundle include education for nurses and general practitioners, telehealth support and formation of an antimicrobial stewardship team in each facility. Prior to the randomised sequential introduction of the intervention, each site will act as its own control in relation to usual care processes for antibiotic use and stewardship.The primary outcome for this study will be antibiotic consumption measured using defined daily doses (DDDs). Cluster-level rates will be calculated using total occupied bed numbers within each RACF during the observation period as the denominator. Results will be expressed as rates per 1000 occupied bed days. An economic analysis will be conducted to compare the costs associated with the intervention to that of usual care. A comprehensive process evaluation will be conducted using the REAIM Framework, to enable learnings from the trial to inform sustainable improvements in this field.DiscussionA structured AMS model of care, incorporating targeted interventions to optimise antimicrobial use in the RACF setting, is urgently needed and will be delivered by our trial. The trial will aim to empower clinicians, residents and families by providing a robust AMS programme to improve antibiotic-related health outcomes.Trial registrationUS National Library of Medicine Clinical Trials.gov (NCT04705259). Prospectively registered in 12th of January 2021.

A little education goes a long way: Decreasing antibiotics for community-acquired pneumonia in COVID-19 patients

Background: Antibiotic use was common in patients with suspected or confirmed COVID-19 infection; however, data emerged demonstrating low rates of bacterial coinfection (6%–10%). Antimicrobial stewardship best practice was challenged during this time, requiring new strategies and education to limit the inappropriate use of antibiotics. At the Veterans’ Affairs Maryland Healthcare System, we evaluated the use of community acquired pneumonia (CAP) specific antibiotics in COVID-19–positive patients after successive interventions. Methods: We conducted a pre–post evaluation of common CAP antibiotics (ceftriaxone IV/IM, cefpodoxime PO, azithromycin PO/IV, ampicillin/sulbactam IV, amoxicillin-clavulanate PO, levofloxacin) during the COVID-19 pandemic. The preintervention period was April–October 2020 and the postintervention period was November 2020–April 2021. During the preintervention period, intervention A was carried out as follows: (1) inpatient weekly virtual interdisciplinary COVID-19 rounds were led by an antimicrobial stewardship champion, (2) χprocalcitonin was implemented in clinical decision making, and (3) inpatient audit and feedback of active antibiotics was conducted by the antimicrobial stewardship team. In the postintervention period, intervention B was added as follows: (1) weekly educational COVID-19 virtual seminars were conducted for providers, and (2) targeted education was provided to emergency department and hospitalist directors. Comparisons of the proportions of antibiotics prescribed were made between the pre- and postintervention periods using X2 statistic, and data were stratified by location. The rates of CAP antibiotic prescription per 100 COVID-19–positive patients were also compared using Poisson distribution. Results: During the study period, 814 unique patients had COVID-19 infection: 182 (22.4%) patients admitted to the acute-care center, 66 (8.1%) long-term care residents, and 566 (69.5%) were managed outside the hospital. Of these 814 patients, 211 (25%) were prescribed a CAP antibiotic. Of the antibiotics prescribed, 223 (61%) were ceftriaxone, cefpodoxime, amoxicillin-clavulanate, or ampicillin-sulbactam; 123 (34%) were azithromycin; and 16 (4.4%) were levofloxacin. We observed a decrease in the frequency of all antibiotic prescriptions after intervention B was added: 32% (86 of 273) vs 23% (125 of 541) (P = .01). Decreases in antibiotic prescriptions were observed in all locations: acute care (57% vs 44%), long-term care (53% vs 41%) and outpatient care (19% vs 15%). The rates of CAP antibiotic prescribing per 100 COVID-19–positive patients were 114 in the preintervention period and 45 in the postintervention period, a rate difference of −70 antibiotics per 100 COVID-19–positive patients (pConclusions: Curbing antibiotic use for CAP indication during the COVID-19 pandemic was a challenge. A multifaceted approach focusing on education was an impactful intervention leading to significant decreases in antibiotic prescribing despite COVID-19 cases increasing.Funding: NoneDisclosures: None

Clostridioides difficile: A diagnostic intervention

Background:Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated infection and is associated with increased morbidity and mortality. Multiple strategies have been implemented to optimize the diagnostic accuracy of CDI testing algorithms. However, overdiagnosis of C. difficile colonization remains a challenge especially in the era of highly sensitive Nucleic acid amplification testing (NAAT). We implemented 2 interventions to reduce the rates of inappropriate C. difficile orders and tests. Methods: We performed a quasi-experimental retrospective study to examine the rates of all inpatient C. difficile test orders and results relative to 2 interventions between January 2018 and February 2021. We defined 3 periods: preintervention, after the first intervention, and after the second intervention. The first intervention, implemented May 2019, was a clinical decision support system (CDSS) tool to guide clinicians to order testing only if CDI criteria were met. The second intervention, implemented July 2020, was the requirement of mandatory antimicrobial team approval of PCR reflex testing for indeterminate toxin or antigen test results. This intervention included a discussion between clinicians and members of stewardship team prior to approval. To evaluate the impact of interventions on ordering appropriateness, chart review was conducted on a random subsample of 100 orders from each period. Hospital-onset CDI (HO-CDI) was calculated using CDC criteria. Results: In total, 3,004 C. difficile test orders were placed during the study period. The rates of reportable HO-CDI were significantly reduced by 57.1% (P = .003). We detected a significant reduction in the number of tests ordered over time from 11.6 to 7.51 per 1,000 patient days. (p Conclusions: CDSS tools target patients at high pretest probability of CDI. The restriction of PCR-reflex testing to the antimicrobial stewardship team is a novel effective measure to minimize the misdiagnosis of CDI. The incorporation of multiple strategies is necessary to improve the diagnostic accuracy of C. difficile testing.Funding: NoneDisclosures: None

Rational use of antibiotics for major elective gynaecological and obstetrical surgical procedures: quality improvement journey from a tertiary care public facility

BackgroundAntibiotic resistance is a global problem. Irrational use of antibiotics is rampant. Guidelines recommend administration of single dose of antibiotic for surgical antimicrobial prophylaxis (SSAP) for elective obstetrical and gynaecological...

Characteristics of antimicrobial stewardship programmes in hospitals of Uganda.

While interest in antimicrobial stewardship programmes (ASPs) is growing in most low- and middle-income countries (LMICs), there is a paucity of information on their adoption or implementation in Africa, particularly Uganda. The study assessed the presence and characteristics of ASPs, implemented antimicrobial stewardship (AMS) strategies and the challenges to their implementation in hospitals in Uganda. We conducted a cross-sectional study among heads of infection prevention committees (IPCs) in regional referral hospitals, general hospitals, and private-not-for-profit (PNFP) hospitals from November 2019 to February 2020. An interviewer-administered questionnaire was used to collect data. We analysed data using descriptive statistics. A total of 32 heads of IPCs were enrolled in the study. Of these, eight were from regional referral hospitals, 21 were from general hospitals, and three were from PNFPs. Most heads of IPC were pharmacists (17/32, 53.1%) with a mean age and standard deviation (sd) of 36.1 (±1.1) years. A formal ASP was adopted or implemented in 14 out of the 32 (44%, 95% CI 26-62) studied hospitals. Thirty out of 32 hospitals implemented at least one type of AMS strategy. Sixty-eight percent (22/32) of the hospitals implemented pre-authorisation and approval as their primary AMS core strategy to optimise antibacterial use. The most commonly reported challenges to the implementation of ASP across all 32 hospitals (with or without ASP) were lack of time for the ASP team (29/32, 90.6%) and lack of allocated funding for antimicrobial stewardship team (29/32, 90.6%). In this study, most hospitals in Uganda implemented at least one AMS strategy despite the low implementation of ASPs in hospitals. The ministry of health needs to sensitise and support the establishment of ASP in hospitals across the country.

Impact of the Antimicrobial Stewardship Team Intervention Focusing on Changes in Prescribing Trends and the Rate of Carbapenem-resistant P. aeruginosa

Antimicrobial stewardship (AS) intervention strategy is a critical process in promoting appropriate antibiotic use, thus preventing unnecessarily prolonged therapy and reducing antimicrobial resistance (AMR). Although limiting unnecessary carbapenem use by AS intervention is speculated to reduce AMR, there is a lack of specific data on the efficacy of AS team (AST) intervention regarding carbapenem-resistant Pseudomonas aeruginosa (CRPA). Consequently, this study aimed to evaluate the impact of our AS strategy on carbapenem use and CRPA. The AS intervention strategy was launched in July 2017 and consisted of daily audits and feedback on carbapenem use. We evaluated the 4-year prescription trend, including the rate of switching to other antimicrobials, and the rate of CRPA and the days of therapy required prior to and after the beginning of the AST intervention. The rate of switching to narrow-spectrum antibiotics and the discontinuation of carbapenem treatment were significantly higher in the pre-intervention period compared with the post-intervention period. (7.0% vs. 14.5%; p<0.001; 54.1% vs. 50.9%; p=0.027). However, there were no significant differences in the rate of CRPA prior to and after the beginning of the AST intervention. Furthermore, there was no correlation found between consumption and resistance rate (Pearson's r=0.123). Our results suggest that it is extremely important for AST to promote de-escalation and reduce unnecessary use, while the combination of process and outcome indicators other than antimicrobial consumption and resistance rate are required for the evaluation of the AS programs.

KNOWLEDGE, ATTITUDES, AND PRACTICES OF NURSES REGARDING ANTIBIOTIC STEWARDSHIP IN NORTH LEBANON: A CROSS-SECTIONAL STUDY

Background: Antimicrobial resistance is an urgent global issue. Several associations are supporting the implementation of antibiotic stewardship programs in all hospitals. This program is multidisciplinary in its nature however, nurses are often not included in the antibiotic stewardship team. The role of nurses in antibiotic stewardship needs further development, and additional information is needed regarding gaps in nurses’ knowledge and attitudes toward antibiotic stewardship. Hence, this study was conducted to assess the knowledge, attitudes, and practices of nursing staff regarding antibiotic stewardship in North Lebanon and identify the barriers that prevent their participation. Methods: A descriptive cross-sectional study was performed using a self-administered questionnaire distributed to 120 nurses working in four hospitals in North Lebanon. The survey included 29 questions addressing (1) demographic and professional characteristics; (2) knowledge and attitude about antibiotic stewardship; (3) delivery of antimicrobials; (4) knowledge and attitude about antimicrobial use, (5) and knowledge and attitude about antimicrobial resistance. Results: In total, 100 staff nurses (33.3%) responded to the survey. 60% of the nurses were familiar with the term antibiotic stewardship and 57% received training in this subject, however, gaps in their knowledge were recorded. Almost all nurses (97%) believed they should be involved in antibiotic stewardship interventions. There was no association between years of experience or level of education with being familiar with ASP. Conclusion: This study showed that although many nurses are familiar with the term antibiotic stewardship, their overall knowledge of core elements and their potential roles in AS were limited. In addition, nurses stated that concerns over physician pushback and knowledge of antibiotics as barriers to their participation in the program. The results highlight the need for further education to fill the gaps in their knowledge.

The impact of diagnostic stewardship interventions on Clostridiodes difficile test ordering practices and results

Clostridiodes difficile infection (CDI) is a leading cause of healthcare associated infection and is associated with increased morbidity and mortality. Diagnostic stewardship is critical in optimizing testing accuracy for CDI. Multiple algorithms have been used for testing combining toxin A/B, glutamate dehydrogenase antigen and nucleic acid amplification test (NAAT) to enhance sensitivity. This study evaluated the effectiveness of two interventions on the rates and appropriateness of Clostridiodes difficile test orders and hospital-onset (HO) CDI. All Clostridiodes difficile orders and results in the study period (1/2018–2/2021) were included. To evaluate ordering appropriateness, we reviewed the medical charts of a random subsample of 100 orders that were collected from three periods within the study: pre-intervention and following each intervention. The first intervention was a clinical decision support system (CDSS) tool guiding providers to order testing only if CDI clinical criteria were met. The second intervention eliminated automatic NAAT reflex for indeterminate results and required antimicrobial stewardship team approval. A total of 3004 orders were registered during the study period. There was a 33% reduction in the rates of Clostridiodes difficile orders by the end of the study period (p < 0.001). The rates of reportable HO-CDI were significantly reduced by 57.1% (p = 0.003). We also noted a trend of increased appropriateness of testing overtime. In conclusion, combining CDSS intervention with NAAT reflex restriction was an effective tool to reduce inappropriate Clostridiodes difficile orders and decrease the rates of reportable HO-CDI.

Practice-guided Presentation of the German S3 Guideline "Strategies to Warrant Rational In-hospital Use of Antibiotics"

The current S3 guideline entitled "Strategies to warrant rational in-hospital use of antibiotics" summarizes evidence-based antibiotic stewardship (ABS) measures that aim to improve clinical outcomes and prevent development and spread of microbial resistance in German hospitals. Most important prerequisite for efficiency and safety of ABS programs is sufficient staffing capacity as well as reliably operating surveillance of (i) pathogens, (ii) antimicrobial resistance and (iii) consumption of antimicrobials. ABS teams require authorization by hospital institutions as units exclusively responsible for antimicrobial audits and implementation of anti-infective interventions. Clinicians should be regularly granted access to in-hospital training programs delivered by ABS experts. Finally yet importantly, the current S3 guideline also highlights future goals, e.g., the structured involvement for nurses in ABS-guided infection management or the promotion of ABS programs in the outpatient sector and in veterinary medicine.

Antimicrobial stewardship in high-risk febrile neutropenia patients

BackgroundThe 2011 4th European Conference on Infections in Leukemia (ECIL4) guidelines recommend antibiotics de-escalation/discontinuation in selected febrile neutropenia (FN) patients. We aimed to assess the impact of an antimicrobial stewardship (AMS) program based on these guidelines on antibiotics use and clinical outcomes in high-risk FN patients.MethodsWe conducted an observational study in the hematology department of Cochin University Hospital in Paris, France. An ECIL4-based antibiotics de-escalation and discontinuation strategy was implemented jointly by the hematologists and the AMS team. The pre-intervention (January–October 2018) and post-intervention (January-October 2019) periods were compared. We retrospectively collected clinical and microbiological data. We compiled antibiotics consumptions via hospital pharmacy data and standardized them by calculating defined daily doses per 1000 patient-days. We analyzed the two-monthly antibiotic consumption using an interrupted time series method and built a composite endpoint for clinical outcomes based on transfer to the intensive care unit (ICU) and/or hospital death.ResultsOverall, 273 hospital stays (164 patients) in the pre-intervention and 217 (148 patients) in the post-intervention periods were analyzed. Patients were mainly hospitalized for intensive chemotherapy for acute leukemia or autologous stem-cell transplant for myeloma. Patients were slightly younger in the pre-intervention compared to the post-intervention period (median age 60.4 vs 65.2 years, p = 0.049), but otherwise comparable. After implementation of the AMS program, glycopeptide and carbapenem use decreased by 85% (p = 0.03) and 72% (p = 0.04), respectively. After adjustment on confounders, the risk of transfer to the ICU/death decreased significantly after implementation of the AMS program (post-intervention period: odds-ratio = 0.29, 95% Confidence Interval: 0.15–0.53, p < 0.001).ConclusionImplementation of a multidisciplinary AMS program for high-risk neutropenic patients was associated with lower carbapenem and glycopeptide use and improved clinical outcomes.

Efficacy and safety of antimicrobial stewardship prospective audit and feedback in patients hospitalized with COVID-19: A protocol for a pragmatic clinical trial

The use of broad-spectrum antibiotics is widespread in patients with COVID-19 despite a low prevalence of bacterial co-infection, raising concerns for the accelerated development of antimicrobial resistance. Antimicrobial stewardship (AMS) is vital but there are limited randomized clinical trial data supporting AMS interventions such as prospective audit and feedback (PAF). High quality data to demonstrate safety and efficacy of AMS PAF in hospitalized COVID-19 patients are needed. This is a prospective, multi-center, non-inferiority, pragmatic randomized clinical trial evaluating AMS PAF intervention plus standard of care (SOC) versus SOC alone. We include patients with microbiologically confirmed SARS-CoV-2 infection requiring hospital admission for severe COVID-19 pneumonia. Eligible ward beds and critical care unit beds will be randomized prior to study commencement at each participating site by computer-generated allocation sequence stratified by intensive care unit versus conventional ward in a 1:1 fashion. PAF intervention consists of real time review of antibacterial prescriptions and immediate written and verbal feedback to attending teams, performed by site-based AMS teams comprised of an AMS pharmacist and physician. The primary outcome is clinical status at post-admission day 15 measured using a 7-point ordinal scale. Patients will be followed for secondary outcomes out to 30 days. A total of 530 patients are needed to show a statistically significant non-inferiority, with 80% power and 2.5% one-sided alpha assuming standard deviation of 2 and the non-inferiority margin of 0.5. This study protocol presents a pragmatic clinical trial design with small unit cluster randomization for AMS intervention in hospitalized COVID-19 that will provide high-level evidence and may be adopted in other clinical situations. This study is being performed at the University of Alberta and is registered at ClinicalTrials.gov (NCT04896866) on May 17, 2021.