Antimicrobial Stewardship Guidelines Research Articles

European society of clinical microbiology and infectious diseases guidelines for antimicrobial stewardship in emergency departments (endorsed by European association of hospital pharmacists)

ScopeThis European Society of Clinical Microbiology and Infectious Diseases guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are (a) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? (b) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? (c) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? (d) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing? MethodsAn expert panel was convened by European Society of Clinical Microbiology and Infectious Diseases and the guideline chair. The panel selected in consensus the four most relevant antimicrobial stewardship topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes and stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively. RecommendationsThe recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e. withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very low and low certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.

Effect of institutional antimicrobial stewardship guidelines on prescription of critically important antimicrobials for dogs and cats.

Veterinary hospital antimicrobial stewardship (AMS) guidelines might help combat antimicrobial resistance (AMR). Determine the conditions and types of infection for which antimicrobial drugs (AMDs) deemed critically important (CIA) by the World Health Organization (WHO) were prescribed and assess the effect of hospital AMS guidelines on adherence to International Society for Companion Animal Infectious Diseases published guidelines for the treatment of superficial bacterial folliculitis, respiratory tract disease and urinary tract infection in these cases. Dogs and cats managed at an academic veterinary hospital from 1/21 to 6/21 and 9/21 to 6/22. Prescriptions of cephalosporins (third or fourth generation), glycopeptides, macrolides/ketolides, polymyxins, and quinolones were identified. Data on culture and susceptibility (C/S) testing and previous AMD exposure were collected. Frequencies were compared between time periods using Fisher's exact test with Bonferroni corrections. In animals prescribed ≥1 WHO-CIA AMD, fluoroquinolones were the most frequently prescribed WHO-CIA class in dogs (567/1724, 32.9%) and cats (192/450, 42.7%). No animals were prescribed carbapenems, dihydrofolate reductase inhibitors/sulfonamides, or polymyxins. No cats were prescribed aminoglycosides or amphenicols. Institutional guidelines were followed in 57.8% (324/561) cases. The most frequent causes of nonadherence were failure to perform C/S testing 46.0% (109/237) and unnecessary use of a higher-tier AMD 43.0% (102/237). Bacterial C/S testing was more frequently performed after AMS guideline institution (59.7% vs. 46.8%, P = 0.0006). Adherence to published guidelines remained poor despite an increase in C/S testing. There were no changes in the frequencies of confirmed infections, positive cultures or AMD resistance between time periods.

Application of a multiplex molecular pneumonia panel and real-world impact on antimicrobial stewardship among patients with hospital-acquired and ventilator-associated pneumonia in intensive care units

BackgroundThe optimal timing for applying the BioFire FilmArray Pneumonia Panel (FAPP) in intensive care unit (ICU) patients with hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP) remains undefined, and there are limited data on its impact on antimicrobial stewardship. MethodsThis retrospective study was conducted at a referral hospital in Taiwan from November 2019 to October 2022. Adult ICU patients with HAP/VAP who underwent FAPP testing were enrolled. Patient data, FAPP results, conventional microbiological testing results, and the real-world impact of FAPP results on antimicrobial therapy adjustments were assessed. Logistic regression was used to determine the predictive factors for bacterial detection by FAPP. ResultsAmong 592 respiratory specimens, including 564 (95.3%) endotracheal aspirate specimens, 19 (3.2%) expectorated sputum specimens and 9 (1.5%) bronchoalveolar lavage specimens, from 467 patients with HAP/VAP, FAPP testing yielded 368 (62.2%) positive results. Independent predictors for positive bacterial detection by FAPP included prolonged hospital stay (odds ratio [OR], 3.14), recent admissions (OR, 1.59), elevated C-reactive protein levels (OR, 1.85), Acute Physiology and Chronic Health Evaluation II scores (OR, 1.58), and septic shock (OR, 1.79). Approximately 50% of antimicrobial therapy for infections caused by Gram-negative bacteria and 58.4% for Gram-positive bacteria were adjusted or confirmed after obtaining FAPP results. ConclusionsThis study identified several factors predicting bacterial detection by FAPP in critically ill patients with HAP/VAP. More than 50% real-world clinical practices were adjusted or confirmed based on the FAPP results. Clinical algorithms for the use of FAPP and antimicrobial stewardship guidelines may further enhance its benefits.

Antibiotic Stewardship: A Handshaking Strategy Among Physicians and Pharmacists to Improve therapeutic Outcomes in Hematology-Oncology.

Background: Infections are highly susceptible in patients with hematological malignancies due to immune suppression, immunosuppressive therapies and disease progression. Rational use of antibiotics following Antimicrobial Stewardship (AMS) guidelines in early detection and response to infection is significant to improve patient care. Objectives: The present study was conducted to determine the impact of clinical pharmacists' interventions (PIs) on antibiotics usage in hematology-oncology set up in Karachi, Pakistan. Methodology: An observational prospective study was conducted for a period of 4 months in a well-known 75-bed teaching hospital, specializing in bone marrow transplantation in Karachi, Pakistan without a structured Antimicrobial stewardship programs (ASPs). The information was gathered from patient medical histories, laboratory, and microbiological records. Results: A total of 876 PIs (1 to 5 per patient) were implemented. Dose modifications or interval changes accounted for the major interventions (n = 190, 21.6%). The majority of all recommendations were related to antipseudomonal β-lactams, aminoglycosides, sulfamethoxazole-trimethoprim and vancomycin. Overall, 94.3% (n = 876) of the 928 PIs were accepted. Conclusion: The PIs and the high physician acceptance rate may be useful for improving the safe use of antibiotics, lowering their toxicity, lowering the need for special-vigilance medications and potentially improving patient care.

1176. Assessing the Impact of Collaborative Antimicrobial Stewardship Guidelines on the Use of Antibiotics in Hospitalized Veterans with COVID-19 from Five Veterans Health Administration (VHA) Hospitals

Abstract Background Limited data and resources drove collaboration among healthcare providers treating COVID-19. In July 2021 a multi-disciplinary committee representing all facilities in Veterans Integrated Service Network (VISN) 9 developed COVID-19 guidelines for bacterial co-infection in hospitalized COVID-19 patients. We assessed the impact of these guidelines on appropriate antibiotic utilization (AU) in admissions for COVID-19. Methods AU in COVID-19 admissions to VISN 9 facilities from 08/01/20 to 08/31/21 (pre-guidelines) were reviewed and compared to 11/01/21 to 11/30/22 (post-guidelines). COVID-19 positivity, hospitalization, and AU data were pulled from the Corporate Data Warehouse. COVID-19-specific antibiotic stewardship (AS) interventions and guideline distribution plans were collected for each facility. A weighted random sample of patients from each facility who received antibiotics was chart reviewed for appropriateness of AU. AU for non-respiratory indications were excluded from analysis (Table 1). AU was considered appropriate if at least one guideline criteria was met (Table 2). Antibiotic appropriateness was compared before and after guideline distribution for each site using t-test. The odds of appropriate antibiotic prescribing in the VISN after guidance distribution was determined by logistic regression adjusted for site. Results Initial rates of antibiotic use varied among facilities both pre and post guideline distribution (Table 1). Facility-specific interventions and guideline distribution also varied (Table 3). There was no significant change in the frequency of appropriateness for any individual site. Similarly, the odds of AU appropriateness for the VISN was not significantly changed in the post-guideline period (p=0.7) (Table 4). Conclusion AU appropriateness did not change significantly after guidance distribution, likely due to a myriad of reasons. Reprioritization of AS programs’ focus in the post-guidance period may have shifted resources away from initiatives targeting AU in COVID-19 patients. Additionally, guidance was distributed mid-2021 potentially missing the window for largest impact. Collaboration can fill in gaps for many ASPs; but the success of any intervention is multifactorial. Disclosures Milner Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds

A multinational survey of companion animal veterinary clinicians: How can antimicrobial stewardship guidelines be optimised for the target stakeholder?

Antimicrobial stewardship initiatives are widely regarded as a cornerstone for ameliorating the global health impact of antimicrobial resistance. Within companion animal health, such efforts have largely focused on development and dissemination of antimicrobial stewardship guidelines (ASGs). However, there have been few attempts to understand veterinarian attitudes towards and knowledge of ASGs or to determine how awareness regarding ASGs might best be increased. An online survey regarding ASGs was formulated for veterinarians who treat companion animals. The survey was distributed across 46 European and associated countries between 12 January and 30 June, 2022. In total, 2271 surveys were completed, with 64.9% of respondents (n = 1474) reporting awareness and usage of at least one ASG. Respondents from countries with greater awareness of ASGs tended to report more appropriate use of antimicrobials (Spearman's rank coefficient = 0.6084, P ≤ 0.001), with respondents from countries with country-specific ASGs tending to score highest across both awareness and appropriate use domains. Respondents prioritised guidance around antimicrobial choice (82.0%, n = 1863), duration of treatment (66.0%, n = 1499), and dosage (51.9%, n = 1179) for inclusion in future ASGs, with 78.0% (n = 1776) of respondents preferring ASGs to be integrated into their patient management system. Awareness of ASGs and their use in companion animal veterinary practice appears to be greater than previously reported, with respondents tending to report antimicrobial prescription decision making broadly in line with current clinical recommendations. However, further initiatives aimed at maximising accessibility to ASGs both within countries and individual veterinary practices are recommended.

Study of prevalence and antimicrobial susceptibility pattern of blood culture isolates from a tertiary care hospital in South India

Bloodstream infections progress rapidly to life threatening septicemia and sepsis and hence appropriate rapid management is crucial. A prospective study was carried out in the department of microbiology where patients with clinical suspension of bacteremia were enrolled and blood culture was performed. The isolates were identified by phenotypic characters and antimicrobial susceptibility performed. A total of 1200 blood samples were collected out of which 279 were positive for aerobic bacterial growth. was the most commonly isolated organism followed by and . Gentamicin (81.6%), Levofloxacin (75%), Meropenem (88.5%) and (93.8%) showed higher sensitivities when compared to Cephalosporins (55%-68%) and penicillin. Gram-negative bacteria have high resistance rates and discordant antibiotic treatment can lead to multi-organ involvement. Proper timely institution of empirical treatment and adherence to antimicrobial stewardship guidelines coupled with aggressive management is crucial in saving lives.

Decision making on antimicrobial use: Cat and dog owners' knowledge and preferences for veterinary communication.

Veterinarians' understanding of cat and dog owners' perceptions about antimicrobial use will enhance their ability to communicate with clients to uphold antimicrobial stewardship guidelines. A total of 571 cat and dog owners were surveyed via an online platform to understand their antimicrobial knowledge and preferences for veterinary communication in antimicrobial use decision making. Data were analysed descriptively and inferentially to determine relationships between variables. Cat and dog owners' backgrounds had an impact their antimicrobial knowledge. Women, individuals with a university degree, those with a health/science background and those identifying as white had a higher level of knowledge of antibiotics and antibiotic resistance. Owners' trust in veterinarians positively impacts adherence to recommendations. Where there was a strong preference for one type of messaging regarding antimicrobial use and stewardship, the owner's background was not predictive of a difference in response. The study population was mostly white, which reflects the US population and the reported distribution of pet owners who own dogs and cats. Respondents may have been susceptible to recall bias and/or social desirability bias. Veterinarians should tailor their communication to meet clients' level of knowledge and rely on competent communication to enhance understanding and facilitate adherence to antimicrobial stewardship guidelines.

Antimicrobial stewardship: Prescribing across the primary care health professions.

We examined the patterns of antibiotic prescribing by medical and non-medical prescribers (dentists, nurse practitioners, and midwives) in Australia. We explored trends in the dispensed use of antibiotics (scripts and defined daily dose [DDD] per 1000 population/day) by Australian prescribers over the 12-year period, 2005-2016. We obtained data on dispensed prescriptions of antibiotics from registered health professionals subsidized on the Pharmaceutical Benefits Scheme (PBS). There were 216.2 million medical and 7.1 million non-medical dispensed prescriptions for antibiotics over 12 years. The top four antibiotics for medical prescribers were doxycycline; amoxicillin, amoxicillin plus clavulanic acid, and cefalexin, constituting 80% of top 10 use in 2005 and 2016; the top three for non-medical were amoxicillin, amoxicillin plus clavulanic acid and metronidazole (84% of top 10 use in 2016). The proportional increase in antibiotic use was higher for non-medical than medical prescribers. While medical prescribers preferentially prescribed broad-spectrum and non-medical prescribers moderate-spectrum antibiotics, there was a large increase in the use of broad-spectrum antibiotics over time by all prescribers. One in four medical prescriptions were repeats. Overprescribing of broad-spectrum antibiotics conflicts with national antimicrobial stewardship initiatives and guidelines. The proportional higher increase in antibiotic use by non-medical prescribers is a concern. To reduce inappropriate use of antibiotics and antimicrobial resistance, educational strategies targeted at all medical and non-medical prescribers are needed to align prescribing with current best practice within the scope of practice of respective prescribers.

Antimicrobial stewardship during COVID-19: An analysis of culture negative patients receiving extended antimicrobial agents

Background: COVID-19 is associated with symptoms, clinical findings, and laboratory abnormalities that raise concern for secondary infections. Excess antimicrobial use despite low rates of secondary infections has been reported and presents a continuing challenge for antimicrobial stewardship programs (ASPs), particularly during COVID-19 surges. The objective of this study was to analyze the appropriateness of antimicrobial use in patients with extended antimicrobial therapy during 2 distinct COVID-19 hospital surges. Methods: We conducted an observational, retrospective, cohort study of COVID-19 patients admitted to our 548-bed community teaching hospital between November and December 2021 (ie, the SARS-CoV-2 delta-variant predominant phase) and January–February 2022 (ie, the SARS-CoV-2 omicron-variant predominant phase) and who received antibiotics for >4 days without positive cultures. Demographic and clinical data were obtained from the institutional data warehouse. Infectious diseases–trained researchers evaluated the appropriateness of antimicrobials based on diagnostic and clinical reporting and institutional antimicrobial stewardship guidelines. Patients were considered to have probable secondary bacterial infection if they had 2 of the following symptoms: fever, unexplained leukocytosis, worsening secretions, or hypoxia and/or imaging. The outcomes of interest included confirmed infections and excess antimicrobial days. Categorical and continuous variables were analyzed using χ2 tests, Fisher exact tests, and Mann-Whitney U tests, respectively. Statistical significance was defined as P ≤ .05. Results: In total, 87 patients were included in the study. Moreover, 56 patients were identified in the SARS-CoV-2 delta-variant predominant phase and 31 patients were identified in the SARS-CoV-2 omicron-variant predominant phase. The groups were similar, with higher vaccination rates in the SARS-CoV-2 omicron-variant predominant group (37.5% vs 64.5%; P = .016). Patients in the SARS-CoV-2 omicron-variant predominant group required less mechanical ventilation (39.3% vs 16.1%; P = .025). There were no significant differences in infectious diseases consultation, immunomodulator or remdesivir use, antimicrobials classes prescribed, or antimicrobial days of therapy or duration between cohorts. There were no significant differences in length of stay, 30-day mortality, or 30-day readmissions. Infections were confirmed in 78.6% in the delta-variant group versus 83.9% in the omicron-variant group (P = .55). Pneumonias accounted for 60.7% in the delta-variant group and 40.9%, in the omicron-variant group. Excess antibiotic use occurred in 14.3% of patients in the delta-variant group and in 3.1% of patients in the omicron-variant group (P = .149). There was no significant difference in the duration of inappropriate antimicrobial use between groups in patients without infections: 5 days in the delta-variant group versus 5 days in the omicron-variant group (P = .24). Conclusions: Results demonstrated that most antimicrobial use was appropriate in a challenging patient population lacking positive cultures to guide therapy. Inappropriate antimicrobial utilization occurred demonstrating continued opportunities for our institutional ASP.Disclosures: None

Veterinary Students' Knowledge and Awareness of Antimicrobial Stewardship before and after Clinical Rotations.

Given the global threat of antimicrobial resistance, it is imperative that veterinary graduates are effective antimicrobial stewards. Veterinary students learn the principles of antimicrobial stewardship explicitly, through pre-clinical coursework, and implicitly, through the cases they each encounter on clinical rotations. We aimed to understand the influence of pre-clinical versus clinical learning on veterinary students' knowledge and awareness of antimicrobial concepts to guide efforts to improve instruction in these areas. To assess knowledge acquisition and to explore student perceptions of antimicrobial stewardship, a standardized online survey was administered to Cornell University veterinary students at two timepoints: in August 2020 before clinical rotations (N = 26 complete responses and N = 24 partial responses) and again in May 2021 after their clinical rotations (N = 17 complete responses and N = 6 partial responses). Overall and section-specific confidence and knowledge scores were calculated, using pairwise deletion for incomplete responses. Students generally had low confidence in antimicrobial topics and correctly answered only half of knowledge questions correctly; they performed the best on antimicrobial resistance knowledge questions. There were no significant differences in knowledge or confidence after clinical rotations. On average, students had only read one antimicrobial stewardship guideline. Students reported that human health care providers contributed more to antimicrobial resistance than veterinarians. In conclusion, graduating veterinary students at our institution have significant knowledge gaps in critical principles that are essential to become antimicrobial stewards. Explicit instruction in antimicrobial stewardship is necessary in the pre-clinical and clinical coursework, and the practical use of antimicrobial stewardship guidelines should be emphasized.

A retrospective case series of the postoperative outcome for 30 dogs with inflammatory interdigital nodules, surgically treated with carbon dioxide laser and a nonantimicrobial wound-healing protocol.

Inflammatory interdigital nodules (IIN) affecting the paws of dogs is a multifactorial and painful condition. Surgery using carbon dioxide (CO 2 ) laser has been shown to be helpful in the management. To assess a postoperative treatment protocol without use of antibiotics following CO2 laser surgery for IIN treatment. Forty-seven paws, in 30 client-owned dogs, with IINs affecting the interdigital web between the 4th and 5th digits of the forepaws, surgically treated using CO2 laser, were included. Medical records were reviewed for demographic details, medication use and wound healing using a set wound care protocol. Time to resolution of the surgical wounds and the postoperative outcome were assessed. The mean healing time was 34 days. Resolution was seen in 42 of 47 paws with complications in five paws (11%), including development of new fistulae or nonhealing granulation tissue. Surgery was repeated in those five cases. Relapse occurred during the follow-up period of five-19 months in six paws (13%). This study shows that surgical treatment with CO2 laser for interdigital nodules is successful in most cases. The postoperative outcome using a wound-healing protocol avoiding use of antimicrobials can be used without compromising patient care whilst following antimicrobial stewardship guidelines.

Recurrent Urinary Tract Infection in Living Donor Renal Transplant Recipients and the Role of Behavioral Education Program in Management: A Single-Center Experience

Urinary tract infections (UTIs) are the most prevalent type of kidney transplant (KT) recipients. We aimed to investigate the incidence, causes, and clinical impact of early recurrent UTI post-living donor KT and to examine the role of behavioral education program in management. This retrospective cohort chart-review study included all KT recipients with recurrent UTI necessitating hospital admission between September 2017 and August 2021. All patients with recurrent UTI were subjected to behavioral education for a month. UTI was found in 14 of 145 patients (9.6%), with recurrent UTI in 11 (7.6%). A total of 93% of UTIs occurred during the first 6 months post-transplant and represented 52% of KT readmissions during the same period. A total of 64.3% of patients were older than 50 years. The mean (SD) length of hospital stay was 5 (2.5) days, with an equal incidence in both sexes. The most common bacterial isolates in early recurrent UTI were Escherichia coli in 80.9%. Both Extended-spectrum beta-lactamases and multidrug-resistant organisms (resistance in ≥3 drugs) were seen in 82.4% of isolates. Furthermore, the most effective antibiotic was meropenem, with 86.7% effectiveness. A total of 65% of UTIs were managed with a single antibacterial course. A total of 64.3% of patients were older than 50 years. In patients who developed UTI, the mean (SD) serum creatinine was 1.31 (0.52) mg/dL, with a mean increase in serum creatinine of 0.19 mg/dL on having the episodes; at 1 year post-transplant, serum creatinine declined to 1.23 (0.43) mg/dL. Four patients (36%) had no recurrence of UTI after behavioral education. The multidrug-resistant bacterial isolates account for 82.4% of the UTIs. Therefore, antibiotic prescription should follow the antimicrobial stewardship guidelines. Behavioral education significantly reduced the incidence of recurrent UTI.

1751. Evaluation of Antimicrobial Stewardship Interventions in Primary Care Clinics

Abstract Background The goal of antimicrobial stewardship is to optimize antimicrobial therapy and clinical outcomes while minimizing the unintended consequences of antimicrobial use. With the majority of antibiotics prescribed in the outpatient setting, optimizing antimicrobial prescribing across the care continuum is necessary. We aimed to evaluate the effect of antimicrobial stewardship interventions on the rate of inappropriate antibiotic prescribing in three adult primary care clinics affiliated with a tertiary care hospital. Methods Antibiotic prescriptions were identified by filtering common antibiotics prescribed prior to and post intervention. Prescriptions were excluded if they were prescribed pre-procedure or if the patient had a recent hospitalization within 30 days of the outpatient visit. Appropriateness of antibiotics was determined by indication, agent, dose and duration. Institutional guidelines were created for most common infections treated in the pre-intervention period. Education to outpatient providers was completed in two in-person visits. Results A total of 258 prescriptions were reviewed between the pre- and post-intervention periods. The majority of patients were female (73-76%) and the median age was similar between both cohorts. The most common infection treated during the pre-intervention period was urinary tract infection, whereas skin and soft tissue infection was most common in the post-intervention period. During the baseline period, the inappropriate prescribing rate was 61%. After intervention, the rate was reduced to 55%. Conclusion The use of outpatient antimicrobial stewardship guidelines and provider education to reinforce knowledge demonstrated reductions in inappropriate antibiotic prescribing. Disclosures All Authors: No reported disclosures.

This Month in Adult Urology.

This Month in Adult Urology.

The Norton Healthcare electronic antimicrobial stewardship program: An opt-out approach to antimicrobial stewardship.

To describe the Norton Healthcare electronic antimicrobial stewardship program (E-ASP), a novel prospective audit and feedback approach that leverages the electronic medical record to overcome efficiency barriers. Additionally, to describe an accompanying opt-out antimicrobial stewardship approach that addresses provider nonresponsiveness. Prospective audit and feedback is recommended by antimicrobial stewardship guidelines; however, execution can be difficult due to labor requirements, delays in communication, and provider nonparticipation. The Norton E-ASP was developed to address these issues by reliably identifying target patients, documenting assessments, streamlining recommendation delivery, promoting handoff, and providing automated tracking of recommendation responses. Opt-out stewardship allows recommendations to be implemented if not rejected after 24 hours. A 25% reduction in target antimicrobial use has been achieved and sustained with the program. Use of the Norton E-ASP, including opt-out antimicrobial stewardship, broadened the reach and furthered the impact of infectious diseases pharmacists. Successes of this program justified addition of 3 full-time infectious diseases pharmacist positions at a large community health system. This strategy may serve as a model for tele-antimicrobial stewardship or other pharmacy recommendations.

Antibiotic Resistance during COVID-19: A Systematic Review.

One of the public health issues faced worldwide is antibiotic resistance (AR). During the novel coronavirus (COVID-19) pandemic, AR has increased. Since some studies have stated AR has increased during the COVID-19 pandemic, and others have stated otherwise, this study aimed to explore this impact. Seven databases—PubMed, MEDLINE, EMBASE, Scopus, Cochrane, Web of Science, and CINAHL—were searched using related keywords to identify studies relevant to AR during COVID-19 published from December 2019 to May 2022, according to PRISMA guidelines. Twenty-three studies were included in this review, and the evidence showed that AR has increased during the COVID-19 pandemic. The most commonly reported resistant Gram-negative bacteria was Acinetobacter baumannii, followed by Klebsiella pneumonia, Escherichia coli, and Pseudomonas aeruginosa. A. baumannii and K. pneumonia were highly resistant to tested antibiotics compared with E. coli and P. aeruginosa. Moreover, K. pneumonia showed high resistance to colistin. Commonly reported Gram-positive bacteria were Staphylococcus aureus and Enterococcus faecium. The resistance of E. faecium to ampicillin, erythromycin, and Ciprofloxacin was high. Self-antibiotic medication, empirical antibiotic administration, and antibiotics prescribed by general practitioners were the risk factors of high levels of AR during COVID-19. Antibiotics’ prescription should be strictly implemented, relying on the Antimicrobial Stewardship Program (ASP) and guidelines from the World Health Organization (WHO) or Ministry of Health (MOH).

2022 AAFP/AAHA Antimicrobial Stewardship Guidelines.

2022 AAFP/AAHA Antimicrobial Stewardship Guidelines.

Point-prevalence survey of antibiotic use at three public referral hospitals in Kenya.

Antimicrobial stewardship encourages appropriate antibiotic use, the specific activities of which will vary by institutional context. We investigated regional variation in antibiotic use by surveying three regional public hospitals in Kenya. Hospital-level data for antimicrobial stewardship activities, infection prevention and control, and laboratory diagnostic capacities were collected from hospital administrators, heads of infection prevention and control units, and laboratory directors, respectively. Patient-level antibiotic use data were abstracted from medical records using a modified World Health Organization point-prevalence survey form. Altogether, 1,071 consenting patients were surveyed at Kenyatta National Hospital (KNH, n = 579), Coast Provincial General Hospital (CPGH, n = 229) and Moi Teaching and Referral Hospital (MTRH, n = 263). The majority (67%, 722/1071) were ≥18 years and 53% (563/1071) were female. Forty-six percent (46%, 489/1071) were receiving at least one antibiotic. Antibiotic use was higher among children <5 years (70%, 150/224) than among other age groups (40%, 339/847; P < 0.001). Critical care (82%, 14/17 patients) and pediatric wards (59%, 155/265) had the highest proportion of antibiotic users. Amoxicillin/clavulanate was the most frequently used antibiotic at KNH (17%, 64/383 antibiotic doses), and ceftriaxone was most used at CPGH (29%, 55/189) and MTRH (31%, 57/184). Forty-three percent (326/756) of all antibiotic prescriptions had at least one missed dose recorded. Forty-six percent (204/489) of patients on antibiotics had a specific infectious disease diagnosis, of which 18% (37/204) had soft-tissue infections, 17% (35/204) had clinical sepsis, 15% (31/204) had pneumonia, 13% (27/204) had central nervous system infections and 10% (20/204) had obstetric or gynecological infections. Of these, 27% (56/204) had bacterial culture tests ordered, with culture results available for 68% (38/56) of tests. Missed antibiotic doses, low use of specimen cultures to guide therapy, high rates of antibiotic use, particularly in the pediatric and surgical population, and preference for broad-spectrum antibiotics suggest antibiotic use in these tertiary care hospitals is not optimal. Antimicrobial stewardship programs, policies, and guidelines should be tailored to address these areas.

Impact of outpatient antimicrobial stewardship guideline implementation in an urgent care setting

BackgroundUrgent care medicine is a rapidly growing health care sector where patients are commonly treated for acute infectious diseases–related conditions. However, there are few antimicrobial stewardship interventions described in these settings. ObjectiveThe objective of this study is to determine whether implementing outpatient antimicrobial stewardship guidelines would improve antibiotic prescribing for acute upper respiratory tract infections (ARTIs), skin and soft tissue infections (SSTI), and urinary tract infections (UTI) at a single urgent care site. MethodsThis was a pre-post interventional study comparing antibiotic prescribing patterns for ARTI, SSTI, and UTI at a single urgent care site in the preintervention group (November 2019 to January 2020) with the postintervention group (November 2020 to January 2021) after implementation of outpatient stewardship guidelines. A second urgent care site that did not receive any interventions served as a control. The outpatient stewardship guidelines were implemented in October 2020 via didactic provider education and pocket guide distribution. The primary end point was the rate of total guideline-concordant antibiotic prescribing. Secondary end points included the rates of guideline concordance of each component of the prescription, including antibiotic selection, duration, dose, therapy indication, and patient safety outcomes. ResultsThe primary outcome of total guideline-concordant antibiotic prescribing significantly improved after implementation of outpatient antimicrobial stewardship guidelines at the study site (50% vs. 70%, P < 0.001), which was also reflected when comparing postintervention study site with postperiod control site (70% vs. 48%, P < 0.001). There was a statistically significant improvement in guideline-concordant duration of antibiotic therapy (43% vs. 61%, P = 0.001), driven by a reduction in antibiotic duration for UTI (7 [interquartile range (IQR) 5–7] vs. 5 [IQR 5–7] days, P = 0.007), which was also observed when comparing the postintervention study site with the postperiod control site (61% vs. 48%, P = 0.02). Patient safety outcomes were similar between groups. ConclusionAn antimicrobial stewardship intervention comprising institutional outpatient guideline implementation and provider education significantly improved total guideline-concordant antibiotic prescribing by 20% for ARTI, UTI, and SSTI in an urgent care site.