Antimicrobial Stewardship Program Initiative Research Articles

Guiding antimicrobial stewardship through thoughtful antimicrobial susceptibility testing and reporting strategies: an updated approach in 2023.

Antimicrobial susceptibility test and report guidelines are an important tool for antimicrobial stewardship programs. Since 1972, Tables 1 within the Clinical and Laboratory Standards Institute (CLSI) M100 document have provided a general framework upon which clinical microbiologists and antimicrobial stewardship teams can build algorithms for susceptibility testing and reporting that meet the specific needs of their institution. Many changes were made to Tables 1 in M100-Ed33 to modernize the content to reflect the landscape of current clinical practice, including the growing armamentarium of antimicrobial agents, the emergence of new mechanisms of antimicrobial resistance, the increasing prevalence of infections caused by multidrug-resistant organisms, and updated consensus recommendations for first-choice and alternative agents for treatment. With these items in mind, the CLSI Table 1 ad hoc working group revised Tables 1 with the ultimate goal of supporting institutions in the creation of individualized test and report strategies that support local antimicrobial stewardship program initiatives. These strategies are built on the concepts of selective and cascade reporting. This minireview introduces the concept of CLSI M100-Ed33 Tables 1, describes the changes to Tables 1 introduced in 2023, and provides clinical vignettes that demonstrate how Tables 1 can be used in various scenarios to devise antimicrobial susceptibility test and report strategies.

Development of a provincial interactive antibiogram tool forOntario.

Antimicrobial resistance (AMR) is a public health issue with significant impact on health care. Antibiogram development and deployment is a key strategy for managing and preventing AMR. Our objective was to develop an Ontario antibiogram as part of a larger provincial initiative aimed at advancing antimicrobial stewardship in the province. As part of a voluntary provincial online survey, antibiogram data from 100 of 201 (49.8%) Ontario hospitals were collected and included. All hospitals in Ontario were eligible to participate except those providing only mental health or ambulatory services. Weighted provincial and regional antibiotic susceptibilities (percentages) were conducted using descriptive statistical analyses, and an interactive antibiogram spreadsheet was developed. Respondent-identified barriers to collecting and interpreting antibiogram data are presented descriptively. There was wide regional variability in antimicrobial-resistant organisms across Ontario. Provincial methicillin-resistant Staphylococcus aureus prevalence was 24.6%, ranging from 5.9% to 43.7% regionally. Provincial Escherichia coli resistance to ceftriaxone and ciprofloxacin was 13.8% (regional range 6.0%-25.1%) and 22.5% (regional range 9.8-37.8%), respectively. Klebsiella spp resistance to ceftriaxone and ciprofloxacin was similar across all health regions, with overall provincial rates of 7.5% and 5.6%, respectively. We have demonstrated that integrating hospital AMR tracking and reporting as part of a larger voluntary provincial antimicrobial stewardship program initiative is a feasible approach to capturing AMR data. The provincial antibiogram serves as a benchmark for the current state of AMR provincially and across health regions.

Antimicrobial Stewardship and Its Impact on the Changing Epidemiology of Polymyxin Use in a South Indian Healthcare Setting.

Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens necessitates the implementation of antimicrobial stewardship program (ASP) initiatives to support its rational prescription across healthcare settings. Our study aims to describe the change in the epidemiology of polymyxins and patient outcomes following the implementation of ASP at our institution. The antimicrobial stewardship program initiated in February 2016 at our 1300 bed tertiary care center involved post-prescriptive audits tracking polymyxin consumption and evaluating prescription appropriateness in terms of the right indication, right frequency, right drug, right duration of therapy and administration of the right loading dose (LD) and maintenance dose (MD). Among the 2442 polymyxin prescriptions tracked over the entire study period ranging from February 2016 to January 2020, the number of prescriptions dropped from 772 prescriptions in the pre-implementation period to an average of 417 per year during the post-implementation period, recording a 45% reduction. The quarterly patient survival rates had a significant positive correlation with the quarterly prescription appropriateness rates (r = 0.4774, p = 0.02), right loading dose (r = 0.5228, p = 0.015) and right duration (r = 0.4361, p = 0.04). Our study on the epidemiology of polymyxin use demonstrated favorable effects on the appropriateness of prescriptions and mortality benefits after successful implementation of antimicrobial stewardship in a real-world setting.

151. An Electronic Algorithm to Better Target Antimicrobial Stewardship Program (ASP) Efforts for Children Hospitalized with Community-Acquired Pneumonia (CAP)

BackgroundPediatric antibiotic stewardship programs (ASPs) have been successful in decreasing inappropriate antibiotic use. However, they require considerable time and effort. Approaches to increase ASP efficiency are urgently needed. We developed and validated an electronic algorithm to identify inappropriate antibiotic use in children hospitalized with community-acquired pneumonia (CAP).MethodsAt Children’s Hospital of Philadelphia (CHOP), we used ICD-10 diagnostic codes to identify inpatient patient encounters for pneumonia between 3/15/17 – 3/14/18 for which patients received a systemic antibiotic in the first 48 hours of hospitalization. Exclusion criteria included transfer from another facility, intensive care unit admission or death in first 48 hours, immunocompromising condition, or specific comorbidities. We randomly selected 150 subjects. Inappropriate antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration of therapy were based on established CHOP and IDSA/PIDS guidelines.ResultsOf 148 eligible subjects, median age was 3.8, 48% were female, and 129 (86%) were admitted to a general pediatrics service. On chart review, 147 (99%) subjects were correctly diagnosed with CAP. Of these subjects, the choice of initial antibiotic(s) was appropriate in 133 (90%). Of the 147 subjects, 137 (93%) had an appropriate duration of therapy. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table.ConclusionIn pediatric patients hospitalized with CAP, the electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration was highly accurate. This algorithm could have considerable utility in targeting ASP initiatives. The impact of interventions based on this algorithm should be tested in the futureTest Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration Disclosures All Authors: No reported disclosures

64. Impact of a Duration Bundle on Antimicrobial Use in a Pediatric Hospital

BackgroundLimiting antibiotic durations to the shortest effective duration is a strong recommendation with moderate-quality evidence in the 2016 IDSA Antimicrobial Stewardship Program (ASP) guidelines. An ASP bundle including a decrease in antimicrobial automatic stop dates from 14 days to 10 days along with a guideline for standard durations for 48 specific indications was implemented at a tertiary pediatric hospital in November 2019. The purpose of this review and was to assess the impact of this ASP initiative on patient outcomes and hospital cost-savings by comparison of pre-intervention and post-intervention data.MethodsA set of antimicrobial duration recommendations for pediatric patients was created by the Antimicrobial Stewardship Program, Pediatric Hospital Medicine providers, and Infectious Disease providers specific to indication, agent, or pathogen. After education of medical care providers and distribution of the recommendations, automatic stop dates in the Electronic Medical Record (EMR) were updated from 14 days to 10 days for all antimicrobials. Concomitant advertising campaigns were shown on all hospital screensavers. Data were collected for a one month pre-intervention period of Nov.15 - Dec.15, 2018 including 133 patients and a one month intervention period of Nov.15 - Dec.15, 2019 including 125 patients.ResultsThe average length of stay decreased from an average of 8.3 days pre-implementation to 6.7 days (p=0.043) post implementation. The ratio of actual to recommended duration also decreased from 1.56 to 1.30 (p< 0.001) when comparing pre vs. post initiative. Balancing measures did not change for restarting treatment within 48 hours of stopping or readmission within 30 days for the same infection. The decrease in inpatient therapy translated to more than $10,000 per year in direct drug cost.ConclusionThis intervention lead to a significant reduction in average length of stay per admission and significantly reduced the secondary outcomes of the total duration of antimicrobial therapy and the ratio of actual duration compared to recommended duration. This lead to cost savings and decreased inappropriate antibiotic exposure.Disclosures All Authors: No reported disclosures

Clinical impact of a pharmacist-led antimicrobial stewardship initiative evaluating patients with Clostridioides difficile colitis

Clostridioides difficile is the most common cause of healthcare-associated infection and gastroenteritis-associated death in the USA. Adherence to guideline recommendations for treatment of severe C. difficile infection (CDI) is associated...

Reduction of Inappropriate Antimicrobial Prescriptions in a Tertiary Neonatal Intensive Care Unit After Antimicrobial Stewardship Care Bundle Implementation.

Our objective was to evaluate the appropriateness of antibiotic prescriptions in the neonatal intensive care unit using standardized criteria and determine the effects of an antimicrobial stewardship program (ASP) on patterns of antibiotic usage. A retrospective audit of antibiotic use from July 2010 to June 2013 was conducted, focusing on prescriptions of vancomycin, cefotaxime, meropenem and linezolid for >3 calendar-days. We evaluated the appropriateness of each course of antibiotic treatment based on the Centers for Disease Control and Prevention 12-Step Guidelines to Prevent Antimicrobial Resistance (steps 4, 6 and 9). An ASP was introduced in August 2014, and the same audit criteria were applied to review antimicrobial use in the subsequent 12 months. In the pre-ASP era, 26.3%, 12.1%, 11.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The most common instance of inappropriate utilization included failure to use narrow-spectrum antimicrobials when appropriate. After the introduction of ASP program, 22.2%, 7.5%, 5.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The numbers of inappropriate antibiotic-days/1000 days of therapy with meropenem, cefotaxime and vancomycin changed from 1.89 to 1.96 [rate ratio (RR), 1.04 (0.70-1.52)], 3.56 to 1.73 [RR, 0.49 (0.33-0.71)] and 2.70 to 1.01 [RR, 0.37 (0.22-0.60)], respectively. In subgroup analysis, very low birth weight infants (birth weight, <1500 g) showed no improvement in the rates of inappropriate antibiotic prescriptions. In this study, we found that ASP initiatives can be applied in neonatal populations to reduce inappropriate antimicrobial prescriptions, though a different approach may be needed among very low birth weight infants.

Pharmacist-driven initiative for management of Staphylococcus aureus bacteremia using a clinical decision support system.

The development and implementation of a clinical decision support system (CDSS) for pharmacists to use for identification of and intervention on patients with Staphylococcus aureus bacteremia (SAB) are described. A project team consisting of 3 informatics pharmacists and 2 infectious diseases (ID) pharmacists was formed to develop the CDSS. The primary CDSS component was a scoring system that generates a score in real time for a patient with a positive blood culture for S. aureus. In addition, 4 tools were configured in the CDSS to facilitate pharmacists' workflow and documentation tasks: a patient list, a patient list report, a handoff note, and a standardized progress note. Pharmacists are required to evaluate the patient list at least once per shift to identify newly listed patients with a blood culture positive for S. aureus and provide recommendations if necessary. The CDSS was implemented over a period of 2.5 months, with a pharmacy informatics resident dedicating approximately 200 hours in total. An audit showed that the standardized progress note was completed for 100% of the patients, with a mean time to completion of 8.5 hours. Importantly, this initiative can be implemented in hospitals without specialty-trained ID pharmacists. This study provides a framework for future antimicrobial stewardship program initiatives to incorporate pharmacists into the process of providing real-time recommendations. A pharmacist-driven patient scoring system was successfully used to improve adherence to quality performance measures for management of SAB. A pharmacist-driven CDSS can be utilized to assist in the management of SAB.

Dramatic effects of a new antimicrobial stewardship program in a rural community hospital

New Joint Commission antimicrobial stewardship requirements took effect on January 1, 2017, promoted as a central strategy for coping with the emerging problems of antimicrobial resistance and Clostridium difficile infection. Our objective was to measure the effects of a new antimicrobial stewardship program (ASP) in a rural community hospital with no prior ASP, in the context of having a new infectious disease specialist on staff. An ASP team was formed to implement a prospective audit with health care provider feedback and targeting 12 antimicrobial agents in a rural hospital in Georgia. An educational grand rounds lecture series was provided before implementation of the ASP to all prescribers. After implementation, algorithms to aid the selection of empirical antibiotics for specific infectious disease syndromes based on local antibiograms were provided to prescribers to improve this selection. Rates of C difficile infections, total targeted antimicrobial costs, and drug utilization rates were calculated for 1 year pre-ASP implementation (2013) and 1 year post-ASP implementation (October 2014-December 2015). The patient safety metric of C difficile infections decreased from 3.35 cases per 1,000 occupied bed days (OBDs) in 2013 to 1.35 cases per 1,000 OBDs in 2015. Total targeted antimicrobial costs decreased 50% from $16.93 per patient day in 2013 to $8.44 per patient day in 2015. Overall antimicrobial use decreased 10% from before the ASP initiative to 1 year after it. Annualized savings were $280,000 in 1 year, based on drug savings only. Judicious use of antimicrobials and resources can improve a patient safety metric and decrease costs dramatically in rural institutions where the average hospital census is <100 patients per day. The savings would allow the institutions to spend better while improving the use of antimicrobials.

Eight Years of Antimicrobial Stewardship Program (ASP) at a Large Academic Medical Center: Antibiotic Utilization, Hospital-onset Clostridium difficile infection (HO-CDI) and Resistance Trends

BackgroundAntibiotic (ABX) use and outcome measures (rate of HO-CDI, local antimicrobial resistance) are recommended ASP metrics. These metrics can be used for internal benchmarking to assess ASP performance within an institution over time.MethodsAn adult ASP at our 750-bed academic medical center was implemented in 2008. ASP interventions include prospective audit and feedback, prior authorization with fluoroquinolone (FLQ) restriction as an ASP target and implementation of facility-specific guidelines for common infections. Newer ASP initiatives were Cepheid/Xpert for blood cultures with Gram-positive cocci in pairs and clusters with daily real-time ASP interventions (11/2014), oral vancomycin secondary prophylaxis for patients with prior CDI (4/2014) and optimization of β-lactam (BL) dosing (piperacillin-tazobactam [PTZ] extended infusion hospital-wide 4/2013; cefepime [CEF] 4/2015 and meropenem 7/2015 protocols). ABX use is measured in days of therapy per 1000 patient-days (DOT/1000 PD) and length of therapy/admission when ABX were administered (LOT/ADM). NHSN definition is used for HO-CDI. For resistance trends the first unique isolate/patient/year regardless of source or susceptibility profile was included. Statistical analysis of trends during 8-years period 2009–2016 was performed by Poisson (SAS).ResultsMajor shifts in ABX use include decrease in FLQ use (-17%, P < 0.01) with compensatory increase in ceftriaxone (CTX, +12%, P < 0.01), antipseudomonal BL (+3%, P < 0.01) and no change in carbapenem (+0.6%, P=0.5) as well as an increase in nafcillin and oxacillin (+7%, P < 0.01) use. There was a decrease in aggregate LOT/ADM (-4%, P < 0.01) with no change in DOT/1000 PD. We observed a decrease in HO-CDI rate (-17%, P < 0.01). Major resistance trends include reduction in Enterobacteriaceae spp. and Pseudomonas aeruginosa isolates nonsusceptible (NS) to FLQ (-4%, P < 0.01; -10%, P < 0.01, respectively) with increase in Enterobacteriaceae spp. NS to ceftriaxone, (+3%, P < 0.01). A decrease in P. aeruginosa NS to PTZ (-11%, P < 0.01) and no change for CEF was reported. There was no difference in Enterobacteriaceae spp. NS to PTZ or CEF.ConclusionOverall, reported trends aligned with ASP initiatives. Increased CTX NS is of concern and warrants an ASP-led strategy to decrease CTX use.Disclosures All authors: No reported disclosures.

Social media as a tool for antimicrobial stewardship.

To increase the reach of our antimicrobial stewardship program (ASP), social media platforms, Facebook and Twitter, were used to increase internal medicine residents' (IMRs') antibiotic (Abx) knowledge and awareness of ASP resources. Fifty-five of 110 (50%) IMRs consented to participate; 39 (71%) completed both pre- and postintervention surveys and followed our ASP on social media. Along with 20 basic Abx and infectious diseases (IDs) questions, this survey assessed IMR awareness of ASP initiatives, social media usage, and attitudes and beliefs surrounding Abx resistance. Over 6 months, IMRs received posts and Tweets of basic Abx/IDs trivia while promoting use of educational tools and clinical pathways on our ASP Web site. To compare pre- and postsurvey responses, McNemar test or Stuart-Maxwell test was used for categorical variables, and paired t test or Wilcoxon signed-rank test was used for continuous variables, as appropriate. Of the IMRs, 98% and 58% use Facebook and Twitter, respectively. To compare pre- and postintervention, median scores for Abx knowledge increased from 12 (interquartile range, 8-13) to 13 (interquartile range, 11-15; P = .048); IMRs knowing how to access the ASP Web site increased from 70% to 94%. More IMRs indicated that they used the clinical pathways "sometimes, frequently, or always" after the intervention (33% vs 61%, P = .004). Social media is a valuable tool to reinforce ASP initiatives while encouraging the use of ASP resources to promote antimicrobial mindfulness.

Evaluation of Management of Community Acquired Pneumonia Prior to Implementation of an Antimicrobial Stewardship Program Initiative: A Retrospective Assessment

Evaluation of Management of Community Acquired Pneumonia Prior to Implementation of an Antimicrobial Stewardship Program Initiative: A Retrospective Assessment

Evaluation of the Impact of an Antimicrobial Stewardship Program Initiative in Patients With Uncomplicated Acute Bacterial Skin and Skin Structure Infections

Evaluation of the Impact of an Antimicrobial Stewardship Program Initiative in Patients With Uncomplicated Acute Bacterial Skin and Skin Structure Infections

An antimicrobial stewardship program initiative: a qualitative study on prescribing practices among hospital doctors.

BackgroundNorway has a low, but increasing prevalence of resistance and few antimicrobial stewardship initiatives. When developing stewardship interventions, an understanding of the determinants of antimicrobial prescribing is needed. We report on the first qualitative study investigating factors influencing doctors’ antimicrobial prescribing practices in Norwegian hospitals.MethodsQualitative semi-structured interviews were conducted with 15 Norwegian hospital doctors prescribing antimicrobials to adult patients. Interviews were transcribed verbatim and thematic analysis was applied to analyse the data.ResultsColleagues, in particular infectious disease specialists, microbiology test results and the newly published national guideline on antimicrobials were identified as key factors influencing antimicrobial prescribing practices. Delayed availability was a barrier for the utilization of microbiology test results and increasing clinical experience overrides the influence of the national guideline.Patient assessment, informal training by experienced colleagues, and infectious disease specialists replacing managers in promoting prudent prescribing policies, also influenced prescribing practices.ConclusionThis study identified the following contextual factors that need to be addressed when developing antimicrobial stewardship programs in Norway: a common work practice for seeking collegial advice, logistics of microbiology test results, and formal leadership and systematic training on prudence. Other countries initiating stewardship programmes may benefit from performing a similar mapping of facilitators and barriers, to identify important stakeholders and organisational obstacles, before developing sustainable and tailored antimicrobial stewardship interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/s13756-015-0065-4) contains supplementary material, which is available to authorized users.

MALDI-TOF and Antimicrobial Stewardship

The emergence of rapid diagnostic tests for use in clinical microbiology laboratories is revolutionizing the ability to efficiently identify pathogens and resistance mechanisms. Optimizing time to appropriate therapy is crucial and linked to significant improvements in mortality. Matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) utilizes mass spectrometry to provide rapid and reliable identification of organisms 1–1.5 days sooner than traditional methods. Further, the literature suggests that involvement of antimicrobial stewardship program initiatives in combination with MALDI-TOF facilitates timely antibiotic adjustments and optimizes clinical outcomes. MALDI-TOF combined with antimicrobial stewardship review and intervention has been associated with improvements in patient care, including improving time to appropriate antibiotic therapy, reduced mortality rates, decreased length of hospitalization, and decreased hospital costs. Antimicrobial stewardship programs (ASPs) can use rapid pathogen identification data to tailor antibiotic therapy to the individual patient through knowledge of local antibiogram data, applying known risk factors for antibiotic resistance and evaluating the patient’s past medical history. Furthermore, a significant economic advantage is possible as studies reveal impressive decreases in total hospital costs when MALDI-TOF was coupled with ASP intervention. Finally, studies evaluating novel uses of MALDI-TOF such as for the detection of antimicrobial resistance and strain typing for epidemiological investigations are underway. These applications will only further expand the range of possible ASP interventions.

Antimicrobial stewardship: philosophy versus practice.

To promote the judicious use of antimicrobials and preserve their usefulness in the setting of growing resistance, a number of policy-making bodies and professional societies have advocated the development of antimicrobial stewardship programs. Although these programs have been implemented at many institutions in the United States, their impact has been difficult to measure. Current recommendations advocate the use of both outcome and process measures as metrics for antimicrobial stewardship. Although patient outcome metrics have the greatest impact on the quality of care, the literature shows that antimicrobial use and costs are the indicators measured most frequently by institutions to justify the effectiveness of antimicrobial stewardship programs. The measurement of more meaningful outcomes has been constrained by difficulties inherent to these measures, lack of funding and resources, and inadequate study designs. Antimicrobial stewardship can be made more credible by refocusing the antimicrobial review process to target specific disease states, reassessing the usefulness of current metrics, and integrating antimicrobial stewardship program initiatives into institutional quality and safety efforts.