Effective Antimicrobial Stewardship Programs Research Articles

Short-term effects of antimicrobial stewardship programs on antibiotics usage, clinical outcomes, and multidrug resistant organisms in the post COVID-19 era

BackgroundAntimicrobial resistance is associated with increasing mortality rates and the emergence of multidrug-resistant (MDR) organisms. There is scarcity of data on the short-term impact of Antimicrobial Stewardship Programs (ASP) on antibiotic usage, clinical outcome and MDR organisms’ pattern following the COVID-19 pandemic. This study evaluated the short-term effects of ASP on antibiotic usage, clinical outcomes and MDR organisms’ pattern in the post COVID-19 era. MethodsConducted at a tertiary academic health center, this observational study involved adult patients (≥18 years) in the general medical unit, treated with oral or intravenous antibiotics from May 1, 2021, to April 30, 2022. The applied ASP strategy was a prospective audit and feedback where a weekly meeting was held to discuss the antimicrobial therapy of admitted patient, after which recommendations were made regarding antimicrobial use. ResultsThe study included 301 patients with 166 (55.1%) pre-ASP and 135 (44.9%) post-ASP. The median (IQR) age was 69 (55−77) years with 56.1% were female. Antibiotic usage dropped by 25.2% post-ASP. The length of hospital stay (LOS) was longer post-ASP (7 days vs. 7.9 days, p = 0.001), with MDR infections being a significant predictor (OR: 0.486, p < 0.001). There were no significant differences in 28-day readmission, recurrence of infections and all-cause mortality. Post-ASP, MDR pathogens increased (17.0% vs. 6.6%, p = 0.013), however, after separating post-ASP into two three-months periods, MDROs numbers decreased slightly (13 vs. 10). ConclusionShort-term ASP implementation post COVID-19 reduced antibiotic usage while other clinical outcomes remained unchanged. Nonetheless an increase in MDR pathogens and LOS was observed. Further research is required to assess ASP’s long-term impact on MDR infections rates and specific patient group outcomes.

A descriptive model featuring expansive clinical microbiology approaches and antimicrobial stewardship to control antimicrobial resistance in low- and middle-income countries

The upsurge and escalation of antimicrobial resistance (AMR) poses a major worry on the global scene. Effective antimicrobial stewardship (AMS) programs are critical to combat this challenge, and applied knowledge in clinical microbiology serves as the cornerstone for the successful implementation. Despite technological advances, many low- and middle-income countries (LMICs) still adopt traditional phenotypic techniques in clinical microbiology laboratories. An expansive implementation of clinical microbiology approaches can bridge this apparent gap. Good laboratory assessment, hospital epidemiology, and infection prevention and control, which are the sub-divisions of the expansive clinical microbiology approaches, can be deployed to implement AMS appropriately in LMICs. In this paper, we describe a model featuring a functional AMS equipped with expansive clinical microbiology approaches to control AMR in LMICs. &amp;nbsp;

Point prevalence of antibiotic use: a systematic review (2021-2023)

Point prevalence surveys (PPSs) provide valuable insights into several aspects of hospital prescription trends, specifically regarding antibiotic usage. Hence, this review was conducted to investigate the point prevalence of antibiotic use. This was an updated systematic review of the previous two years addressing studies conducted between the years 2021 and 2023 regarding the point prevalence of antibiotic use. Studies regarding the current topic were examined using the PubMed, Cochrane, Web of Science, and Google Scholar databases. The terms were employed in different combinations including the \&amp;quot;Point prevalence, survey, antibiotics use, antimicrobial prescribing, antimicrobial resistance, antimicrobial stewardship; surveillance, hospital, private sector, global health security\&amp;quot;. Publications in full text were used as the inclusion criterion. Out of the 85 acquired articles, only nine were deemed suitable for inclusion. The analysis encompassed more than 10,331 hospitalized patients in different regions. This systematic review demonstrated a high point prevalence of antibiotic use in hospitals. The most prevalent clinical indications were pneumonia, skin and soft tissue infections, sepsis, and community-acquired infections. Ceftriaxones were the predominant antibiotics provided to patients. These hospitals have a high incidence of use of antibiotics, but they lack institutional frameworks and protocols to ensure optimal antibiotic use. The study furnishes the requisite data for enhancing forthcoming antibiotic utilization in hospitals and mitigating antimicrobial resistance. These findings emphasize the importance of ongoing efforts to improve the responsible use of antibiotics by implementing effective antimicrobial stewardship programs in hospitals, ultimately leading to decreased antimicrobial resistance in the country.

Point-prevalence survey of antimicrobial use in intensive care units in Nepal.

This study aimed to investigate the prevalence and practices of antibiotic use in intensive care units (ICUs) in Nepal and to identify potential areas for implementing antimicrobial stewardship programs. A point prevalence survey was conducted to characterize and quantify the antimicrobial utilization in level III ICUs of Nepal. Data on antibiotic prescription rates, reasons for prescribing antibiotics, and prescribing practices were collected and analyzed. The prevalence of antimicrobial resistance was also assessed. The antibiotic prescribing rate was found to be very high, with 92.85% of patients in ICU on antibiotics. Prolonged surgical prophylaxis was the most common reason for prescribing antibiotics. Empirical therapy accounted for 67.5% of all antibiotic prescriptions. Prescribing practices were poor, with low adherence to guidelines and best practices. Broad-spectrum antibiotics were commonly used even for surgical prophylaxis or community-acquired infections. High resistance was observed against commonly used antibiotics. The study underscores the urgent need for effective antimicrobial stewardship programs in ICUs of Nepal. Implementing robust stewardship programs could help optimize antibiotic utilization, improve patient outcomes, and combat the global threat of antimicrobial resistance. The findings serve as a stepping stone toward understanding and improving antibiotic prescribing practices in ICUs of Nepal.

Development of quality indicators for antimicrobial stewardship in Belgian hospitals: a RAND – modified Delphi procedure

ABSTRACT Introduction Inappropriate antibiotic use is a major cause of antibiotic resistance. Therefore, optimizing antibiotic usage is essential. In Belgium, optimization of antimicrobials for the fight against multidrug resistant organisms (MDROs) is followed up by national surveillance by public health authorities. To improve appropriate antimicrobial use in hospitals, an effective national Antimicrobial Stewardship (AMS) program should include indicators for measuring both the quantity and quality of antibiotic use. Objectives The aim of this study was to develop a set of process quality indicators (QIs) to evaluate and improve AMS in hospitals. Methods A RAND-modified Delphi procedure was used. The procedure consisted of a structured narrative literature review to select the QIs, followed by two online questionnaires and an intermediate multidisciplinary panel discussion with experts in infectious diseases from general and teaching hospitals in Belgium. Results A total of 38 QIs were selected after the RAND-modified Delphi procedure, from which 11 QIs were selected unanimously. These QIs address compliancy of antibiotic therapy and prophylaxis with local guidelines, documentation of the rationale for antibiotic treatment in the medical record, the availability of AMS Programs and Outpatient Parenteral Antibiotic Therapy, resistance patterns and antimicrobial prescribing during focused ward rounds. Conclusion Our study selected 38 relevant process QIs, from which 11 were unanimously selected. The QIs can contribute to the improvement of quality of antibiotic use by stimulating hospitals to present better outcomes and by providing a focus on how to intervene and to improve prescribing of antimicrobials.

Antibiotic Use Awareness and Practices in the Indian Community During Later Stages of COVID-19 Pandemic: A Cross-Sectional Survey

BACKGROUND: Irrational prescription of, and self medication with antibiotics is a rampant problem in LMIC'S like India. The prescription of antibiotics for symptoms similar to Covid-19 infection has aggravated the problem of antibiotic overuse, further worsening antimicrobial resistance. This study aims at understanding not only the extent of overuse, but also the social patterns and causes of overprescription or self medication of antibiotics in India. METHODS: A cross-sectional survey of the knowledge, attitude and practices on antibiotic use was conducted from September to October, 2022, using a Google form questionnaire. A virtual snowball technique was used to recruit respondents. RESULTS: A total of 309 responses were received (56% female and 44% male). 59.5% of the respondents were between 15 to 30 years. Surprisingly, inspite of a majority of respondents (around 70%) having a health sciences background, 67.8% of respondents falsely believe that antibiotics speed up recovery from most coughs and colds. 94.8% of respondents had used antibiotics in the last one year.17.2% of respondents had taken antibiotics without the prescription of a doctor. The most common antibiotic used on prescription and self medication was Azithromycin. Only 20.7% of respondents took antibiotics on suspicion of having Covid-19, with the most common one being Azithromycin. CONCLUSION: The study brings to light trends in the awareness and usage of antibiotics with greater emphasis on the Indian medical community. The findings of this study can be used to formulate a more effective Antimicrobial Stewardship Programs to curb antibiotic overuse. The use of antibiotics for self-limiting indications like cough, cold and sore throat needs to be restricted through stricter regulations. The study highlights that a greater knowledge on antibiotic use does not necessitate better attitude towards their cautious and rational use, nor does it guarantee a supportive attitude towards regulations on antibiotic dispensing. In spite of it's significant cardiovascular adverse drug reactions, Azithromycin was found to be the most commonly used antibiotic in our study. Relatively lower rate of self-medication with antibiotics was seen in our study, which might be due to a greater percentage of respondents with a healthcare background, thus exhibiting positive behavior practices on antibiotic use.

Bacteriological profile and antibiotic susceptibility pattern of septicemia in neonatal intensive care units in Palestine: A retrospective study

ObjectivesThe aim of this study was to identify the prevalent pathogens that caused neonatal septicemia and their corresponding antimicrobial sensitivities in the neonatal intensive care unit (NICU) in the West Bank. MethodsIn this retrospective study, we extracted records of neonates with suspected neonatal sepsis (NS) admitted to three NICUs in the West Bank between 2019 and 2021 from the Ministry of Health's electronic database. ResultsOut of 6090 suspected episodes of NS, 884 tested positive for blood cultures, and 554 were primary cases; 59.5% were male, 26.6% were preterm, and 52.7% were aged 0-7 days. Moreover, 29% of 884 positive cultures were contributed by multidrug-resistant organisms (MDRO). Only 14.6% of episodes aligned with both Word Health Organization-recommended antibiotic regimens, 5.2% matched with one regimen, and 80.3% did not match either regimen. Specifically, 19.6% of cases matched with ampicillin-gentamicin, and 14.7% matched with ampicillin-cefotaxime. The likelihood of a match between early-onset sepsis and empiric antibiotic regimens was greater than late-onset sepsis (odds ratio = 2.549, [95% confidence interval: 1.276-5.092]). MDRO was more likely than non-MDRO to match with one antibiotic regimen (odds ratio = 4.142 [95% confidence interval: 1.913-8.966]). ConclusionThere is an alarming prevalence of MDRO among Palestinian neonates in the NICU of the West Bank. The study highlights the urgent need for implementation of effective infection control measures and antimicrobial stewardship programs in the NICUs of hospitals in the West Bank to reduce the prevalence of MDRO and improve neonatal health outcomes.

Monitoring the battleground: exploring antimicrobial resistance and virulence factors in wound bacterial isolates

Antibiotic resistance poses a grave global public health threat, exacerbated by widespread and often inappropriate antibiotic usage. Vigilant surveillance of antibiotic utilization and emergence of antimicrobial resistance (AMR) is essential. Of particular concern in the era of AMR is the persistent issue of chronic wound infections. To address this, we conducted a comprehensive evaluation of wound isolates from chronic wounds at Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) in Kenya, to identify relevant bacteria and assess their drug resistance patterns.Wound samples were collected and processed using standard microbiological methods. Bacterial isolates were identified and assessed for their susceptibility to a panel of antibiotics using the Kirby-Bauer disk diffusion method. A total of 103 bacterial isolates were obtained from the wound samples, with a higher prevalence in male patients (59%). Staphylococcus aureus (20.7 %) emerged as the most predominant pathogen, followed by Klebsiella spp. (14.8 %), Pseudomonas aeruginosa spp. (14.8 %) and Escherichia coli (4.4 %) in wound samples. High levels of antibiotic resistance were observed among the isolates, with the highest resistance rates reported for cotrimoxazole (48.1 %), clindamycin (25.9 %) and erythromycin (25.9 %). Furthermore, among the isolates, 75 % produced haemolysin and protease, while 50 % produced lipase and phospholipase, factors that enhance virulence and survival. The findings of this study highlight the alarmingly high prevalence of antibiotic resistance among bacterial pathogens isolated from chronic wounds in Kenya. This poses a major challenge to the effective management of chronic wound infections. There is an urgent need to implement effective antimicrobial stewardship programs and develop new antibiotics to combat the growing threat of antibiotic resistance.

The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department.

Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.

The prevalence of Carbapenem Resistance Gram negative pathogens in a Tertiary Teaching Hospital in Jordan

BackgroundWith the absence of new antimicrobial drugs being developed to replace those facing resistance, bacterial resistance continues to grow. Despite previous studies conducted in various countries, there is a lack of comprehensive local reporting on the occurrence of carbapenem resistance among gram-negative bacteria.ObjectiveThis study aims to identify the prevalence of carbapenem-resistant gram-negative bacterial isolates.MethodA retrospective cross-sectional study was conducted at an academic hospital in Jordan over an eight-month period, spanning from November 2021 to June 2022. The study involved screening electronic medical records to identify patients with clinical cultures showing the growth of Gram-negative bacteria. Antimicrobial susceptibility results of the Gram-negative isolates were recorded.ResultsA total of 1,043 isolated Gram-negative bacteria were analyzed for carbapenem susceptibility. Among the species tested, the most common carbapenem-resistant bacteria were Acinetobacter baumannii (153/164, 93.3%), followed by Klebsiella pneumonia (184/311, 59.2%), and Pseudomonas aeruginosa (67/160, 41.9%). The least commonly isolated species resistant to carbapenem were Escherichia coli (25/361, 6.9%) and Proteus mirabilis (1/30, 3.3%). None of Serratia marcescens or Proteus vulgaris isolates were resistant to carbapenem (0%). Overall, the prevalence of carbapenem-resistance gram-negative isolates was 41.2% (430 out of 1,043).ConclusionThis study provides population-specific data that are crucial for guiding empirical antimicrobial treatment decisions not only within the participating hospital but also in other nearby healthcare facilities. The results underscore the urgent need for coordinated efforts to address antibiotic resistance in Jordan. Comprehensive measures such as strict infection control methods, annual nationwide surveillance programs, and effective antimicrobial stewardship programs at the national level are imperative to reduce the overuse of broad-spectrum antibiotics.

Excess mortality and long-term disability from healthcare-associated carbapenem-resistant Acinetobacter baumannii infections: A nationwide population-based matched cohort study.

Carbapenem resistance is perceived as a clinical challenge in the management of debilitated and immunocompromised patients who eventually will die from underlying diseases. We aimed to examine whether carbapenem resistance per se, rather than the underlying diseases, negatively affect outcomes, by comparing the excess mortality and morbidity from healthcare-associated infections (HAIs) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-susceptible A. baumannii (CSAB). This was a nationwide retrospective matched cohort study of hospitalized patients in 96 hospitals which participated in Taiwan Nosocomial Infection Surveillance (TNIS). A total of 2,213 patients with A. baumannii HAIs were individually matched to 4,426 patients without HAIs. Main outcomes were excess risks for one-year all-cause mortality and one-year new-onset chronic ventilator dependence or dialysis-dependent end-stage renal disease. Excess one-year mortality was 27.2% in CRAB patients, compared with their matched uninfected inpatients, as well as 15.4% in CSAB patients (also compared with their matched uninfected inpatients), resulting in an attributable mortality of 11.8% (P <0.001) associated with carbapenem resistance. The excess risk associated with carbapenem resistance for new-onset chronic ventilator dependence was 5.2% (P <0.001). Carbapenem resistance was also associated with an extra cost of $2,511 per case of A. baumannii HAIs (P <0.001). Carbapenem resistance is associated with a significant disease burden in terms of excess mortality, long-term ventilator dependence, and medical cost. Further studies on effects of antimicrobial stewardship programs in decreasing this burden are warranted.

Digital monitoring for data-driven antimicrobial stewardship: a process perspective from resource-constrained contexts in India

Antimicrobial Resistance (AMR) is one of society’s most urgent global issues, requiring urgent multidisciplinary-based research and practice approaches to engage with these policies. Several global and national policy statements have been released in the last two decades, particularly emphasising the strengthening of the digital surveillance system. However, implementing these initiatives remains patchy, particularly in the context of public health systems in Low- and Middle-Income Countries. This paper argues that one of the significant reasons contributing to this sub-optimal uptake of these systems is that the top-down implementation models do not adequately cater to the needs, aspirations, and capacities of the health facility staff, who, ultimately, are the end users of the system. The paper highlights the importance of digital technology in healthcare facilities with resource constraints to promote the responsible use of antibiotics. It discusses the process of developing an evidence base for action in low- and middle-income countries (LMICs) through digitally mediated data-driven policy. This process is conceptualised as a three-phase process, which involves stabilising data entry, generating outcomes, and taking action at the local level. The paper argues the need for bottom-up implementation models, which emphasise the need to understand the practices users engage with in their everyday work and design the digital system to add value and not work to these everyday practices. The paper emphasises the importance of building local capacities to develop effective and sustainable antimicrobial stewardship (AMS) programs through enabling networking around digital solutions, creating value in networked partnerships, initiating conversations around data, and raising awareness of the digital to develop AMS programs.

Clinical Impact of the BIOFIRE Blood Culture Identification 2 Panel in Adult Patients with Bloodstream Infection: A Multicentre Observational Study in the United Arab Emirates.

Rapid pathogen identification is key to the proper management of patients with bloodstream infections (BSIs), especially in the intensive care setting. This multicentre study compared the time to pathogen identification results in 185 patients admitted to intensive care with a confirmed BSI, using conventional methods (n = 99 patients) and upon implementation of the BIOFIRE® Blood Culture Identification 2 (BCID2) Panel, a rapid molecular test allowing for the simultaneous identification of 43 BSI-related nucleic acids targets (n = 86 patients). The median time to result informing optimal antibiotic therapy was significantly shorter following the implementation of the BCID2 Panel (92 vs. 28 h pre vs. post BCID2 implementation; p < 0.0001). BCID2 usage in addition to conventional methods led to the identification of at least one pathogen in 98.8% patients vs. 87.9% using conventional methods alone (p = 0.003) and was associated with a lower 30-day mortality (17.3% vs. 31.6%, respectively; p = 0.019). This study at three intensive care units in the United Arab Emirates therefore demonstrates that, in addition to conventional microbiological methods and an effective antimicrobial stewardship program, the BCID2 Panel could improve the clinical outcome of patients admitted to the intensive care unit with a confirmed BSI.

Antibiotic susceptibility profiles of Gram-negative bacterial uropathogens in a tertiary hospital, southwest Nigeria

Background: Increasing rates of antibiotic resistance have made it necessary to regularly monitor antibiotic susceptibility patterns of gram negative bacterial uropathogens in order to optimize antibiotic therapy for urinary tract infections. The aim of this study was to analyze the antibiotic susceptibility patterns of Gram-negative bacterial uropathogens in Babcock University Teaching Hospital, Ilishan-Remo, southwest Nigeria.&#x0D; Methodology: This study was a retrospective review of the Medical Microbiology Laboratory records of the hospital to analyze the in vitro antibiotic susceptibility patterns of Gram-negative urinary bacterial isolates between May 2016 and April 2022. The bacteria were isolated and identified from routine urine samples using standard bacteriological methods. In vitro antibiotic susceptibility test (AST) to amoxicillin-clavulanate, piperacillin-tazobactam, ceftriaxone, ceftazidime, nitrofurantoin, ciprofloxacin and meropenem was routinely performed by the modified Kirby-Bauer disk diffusion test and susceptibility break points determined using the Clinical and Laboratory Standards Institute (CLSI) guidelines.&#x0D; Results: A total number of 3,549 urine samples were processed during the period of review, and 808 (22.8%) samples yielded positive bacterial cultures. Of the 808 isolates, 604 (74.8%) were Gram-negative bacteria. The most frequently isolated Gram-negative bacteria were Escherichia coli (41.9 %) and Klebsiella spp (27.5%) while Pseudomonas spp and Proteus spp accounted for 4.3% and 1.0% of all isolates respectively. Meropenem had the highest in vitro antibacterial activity (74.3% to 90.3% of isolates were sensitive) for all isolates. Overall, E. coli, Klebsiella spp., and Proteus spp. showed high resistance rates to amoxicillin-clavulanate (65.3% to 97.1%).&#x0D; Conclusion: Effective antimicrobial stewardship programs must be in place in order to ensure the appropriate use of antibiotics for treating urinary tract infections.

Four years after the implementation of antimicrobial stewardship program in Jordan: evaluation of program's core elements.

To combat antimicrobial resistance, the World Health Organization (WHO) urged healthcare organizations in Low- and Middle-Income Countries (LMICs) to implement the core elements of the antimicrobial stewardship (AMS) programs. In response, Jordan took action and developed a national antimicrobial resistance action plan (NAP) in 2017 and commenced the AMS program in all healthcare facilities. It is paramount to evaluate the efforts to implement the AMS programs and understand the challenges of implementing a sustainable and effective program, in Low-Middle Income Country (LMIC) contexts. Therefore, the aim of this study was to appraise the compliance of public hospitals in Jordan to the WHO core elements of effective AMS programs after 4 years of commencement. A cross-sectional study in public hospitals in Jordan, using the WHO AMS program core elements for LMICs was carried out. The questionnaire comprised 30 questions that covered the program's six core elements: leadership commitment, accountability and responsibility, AMS actions, education and training, monitoring, and evaluation, and reporting and feedback. A five-point Likert scale was employed for each question. A total of 27 public hospitals participated, with a response rate of 84.4%. Adherence to core elements ranged from (53%) in the leadership commitment domain to (72%) for AMS procedure application (actions). Based on the mean score, there was no significant difference between hospitals according to location, size, and specialty. The most neglected core elements that emerged as top priority areas were the provision of financial support, collaboration, access, as well as monitoring and evaluation. The current results revealed significant shortcomings in the AMS program in public hospitals despite 4 years of implementation and policy support. Most of the core elements of the AMS program were below average, which requires hospital leadership commitment, and multifaceted collaborative actions from the concerned stakeholders in Jordan.

Effectiveness of antimicrobial stewardship programmes on antibiotic consumption - a systematic review and meta-analysis

Effectiveness of antimicrobial stewardship programmes on antibiotic consumption - a systematic review and meta-analysis

Prescription of Rifampicin for Staphylococcus aureus Infections Increased the Incidence of Corynebacterium striatum with Decreased Susceptibility to Rifampicin in a Hungarian Clinical Center.

Several reports have suggested a role for Corynebacterium striatum as an opportunistic pathogen. The authors have conducted a retrospective study at the Clinical Center of the University of Szeged, Hungary, between 2012 and 2021 that revealed significantly increased rifampicin resistance in this species. This work aimed to investigate the reasons behind this phenomenon. The data were collected corresponding to the period between 1 January 2012 and 31 December 2021 at the Department of Medical Microbiology, University of Szeged. To characterize the resistance trends, the antibiotic resistance index was calculated for each antibiotic in use. Fourteen strains with different resistance patterns were further analyzed with Fourier-transform infrared spectroscopy using the IR Biotyper®. The decline in C. striatum sensitivity to rifampicin seen during the COVID-19 pandemic may have been attributable to the use of Rifadin® to treat concomitant Staphylococcus aureus infections. The fact that the IR Biotyper® typing method revealed that the rifampicin-resistant C. striatum strains were closely related supports this hypothesis. The IR Biotyper® infrared spectroscopy proved to be a modern and fast method to support effective antimicrobial stewardship programs.

Impact of Antimicrobial Stewardship Program Intervention Acceptance on Hospital Length of Stay.

Background: Inappropriate antibiotic use is a major public health concern. Excessive exposure to antibiotics results in the proliferation of multidrug-resistant bacteria, increase in potentially avoidable adverse drug reactions, healthcare utilization, and cost. Currently, systematic reviews and controlled trials assessing the effects of antimicrobial stewardship programs (ASP) on hospital length of stay (LOS), mortality, and cost-savings are conflicting. Some studies reported a significant cost-savings driven by shorter hospital LOS while the others found no effect and, in some cases, prolonged LOS. Shortening the time to appropriate therapy and reducing unnecessary days of therapy have been shown to reduce hospital LOS. Objective: The purpose of this study was to evaluate the effects of prescriber acceptance to ASP interventions on hospital LOS. Methods: Between January 2018 and December 2019, 764 charts were retrospectively reviewed for patients who received antimicrobial treatment and in whom an ASP intervention was performed. Patients were allocated into 2 groups: those whose ASP interventions were accepted and those whose were rejected. Provider responses were then documented within 24 hours of being communicated. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates and inpatient antimicrobial duration of therapy (DOT). Results: There were 384 patients with an accepted ASP intervention and 380 with a denied intervention. Baseline characteristics were similar between both groups, except for a difference in the types of intervention performed (P < 0.001). The median hospital LOS for patients in the accepted intervention group was 6.5 days compared to 7 days in the rejected intervention group (P = 0.009). Antimicrobial DOT was also shorter in the accepted intervention group (5 vs 7 days; P < 0.001). There was no difference in 30-day readmission rates (P = 0.98). Conclusion: Prescriber acceptance to ASP interventions decreases hospital LOS and antimicrobial DOT without affecting 30-day readmission rates.

Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments.

Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.

Establishing an effective antimicrobial stewardship program at four secondary-care hospitals in India using a hub-and-spoke model.

The high burden of antimicrobial resistance in India necessitates the urgent implementation of antimicrobial stewardship programs (ASPs) in all healthcare settings in India. Most ASPs are based at tertiary-care centers, with sparse data available regarding the effectiveness of an ASP in a low-resource primary/secondary-care setting. We adopted a hub-and-spoke model to implement ASPs in 4 low-resource, secondary-care healthcare settings. The study included 3 phases measuring antimicrobial consumption data. In the baseline phase, we measured days on antimicrobial therapy (DOTs) with no feedback provided. This was followed by the implementation of a customized intervention package. In the postintervention phase, prospective review and feedback were offered by a trained physician or ASP pharmacist, and days of therapy (DOT) were measured. In the baseline phase, 1,459 patients from all 4 sites were enrolled; 1,233 patients were enrolled in the postintervention phase. Both groups had comparable baseline characteristics. The key outcome, DOT per 1,000 patient days, was 1,952.63 in the baseline phase and significantly lower in the post-intervention period, at 1,483.06 (P = .001). Usage of quinolone, macrolide, cephalosporin, clindamycin, and nitroimidazole significantly decreased in the postintervention phase. Also, the rate of antibiotic de-escalation was significantly higher in the postintervention phase than the baseline phase (44% vs 12.5%; P < .0001), which suggests a definite trend toward judicious use of antibiotics. In the postintervention phase, 79.9% of antibiotic use was justified. Overall, the recommendations given by the ASP team were fully followed in 946 cases (77.7%), partially followed in 59 cases (4.8%), and not followed in 137 cases (35.7%). No adverse events were noted. Our hub-and-spoke model of ASP was successful in implementing ASPs in secondary-care hospitals in India, which are urgently needed.