Principles Of Antibiotic Stewardship Research Articles

Risk Factors and Algorithms for the Empirical Treatment of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia.

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) continue to be major concerns for morbidity and mortality, especially in patients treated in the intensive care unit. With the rise in multidrug-resistant organisms, HAP and VAP treatment is challenged by the need for early appropriate treatment, with broad-spectrum agents, while still being aware of the principles of antibiotic stewardship. The two major society guidelines proposed a series of risk factors in their most recent guidelines to help identify patients who can most benefit from narrow- or broad-spectrum initial empiric antibiotic therapy. The guidelines reveal differences in the proposed risk factors and treatment approaches, as well as major similarities.

COVID-19 observations from hospitalized patients in the Northern Emirates: A practice only preached

Background: The COVID-19 pandemic has established itself as the defining global health crisis of this time. The study describes the clinical profile of hospitalized, non-intensive care unit (ICU) patients with COVID-19 in the UAE during its second wave, through January–March 2021. It also highlights the use of antibiotic stewardship principles in patients admitted with COVID-19. Methods: An observational, retrospective study was conducted at a tertiary care hospital based in the Northern Emirates of UAE. A consecutive sample of 110 acutely hospitalized patients with COVID-19 participated in the study. Pregnant women, patients who were admitted to the ICU, and those receiving antibiotics prior to admission were excluded. Data were collected from the written and electronic health records of included patients and subsequently analyzed using IBM SPSS (v25). Results: Population was 58.2% male with a mean age of 51.2 years; 69.1% had at least one comorbidity and 61.8% had severe COVID-19 disease. Mean white blood cell count was 6.03 ± 2.70 × 109 cells/L with a mean C-reactive protein of 83.3 ± 14.6 mg/L. About 4.2% of the tested (20.9%) blood cultures were positive. Empiric antibiotic use was limited to 9.1% of the population. Conclusion: The UAE population admitted in the second wave of the COVID-19 pandemic was mostly male, older with higher prevalence of comorbidities. Given the limited knowledge of the disease, the calculated clinical measures were taken to bring antibiotic use to an extraordinarily low level, not previously seen during the COVID-19 pandemic.

Antibiotic stewardship in direct-to-consumer telemedicine: translating interventions into the virtual realm.

Direct-to-consumer (DTC) telemedicine is an increasingly popular modality for delivery of medical care via a virtual platform. As most DTC telemedicine visits focus on infection-related complaints, there is growing concern about the magnitude of antibiotic use associated with this setting. However, there is limited scholarship regarding adapting and implementing antibiotic stewardship principles in this setting as most efforts have been focused on hospitals with more recent work in long-term care facilities and primary care settings. We discuss utilizing the core elements for outpatient antibiotic stewardship as a framework for DTC antibiotic stewardship efforts moving forward.

Reduction of surgical site infections in pediatric patients with complicated appendicitis: Utilization of antibiotic stewardship principles and quality improvement methodology

BackgroundThe rate of surgical site infection (SSI) after appendectomy for complicated appendicitis (CA) was high at our children's hospital. We hypothesized that practice standardization, including obtaining intra-operative cultures of abdominal fluid in patients with CA, would improve outcomes and reduce healthcare utilization after appendectomy. MethodsA quality improvement team designed and implemented a clinical practice guideline for CA that included obtaining intra-operative culture of purulent fluid, administering piperacillin/tazobactam for at least 72 h post-operatively, and transitioning to oral antibiotics based on intraoperative culture data. We compared outcomes before and after guideline implementation. ResultsFrom July 2018-October 2019, 63 children underwent appendectomy for CA compared to 41 children from January-December 2020. Compliance with our process measures are as follows: Intra-operative culture was obtained in 98% of patients post-implementation; 95% received at least 72 h of piperacillin-tazobactam; and culture results were checked on all patients. Culture results altered the choice of discharge antibiotics in 12 (29%) of patients. All-cause morbidity (SSI, emergency department visit, readmission to hospital, percutaneous drain, unplanned return to operating room) decreased significantly from 35% to 15% (p=0.02). Surgical site infections became less frequent, occurring on average every 27 days pre-implementation and every 60 days after care pathway implementation (p=0.03). ConclusionsUtilization of a clinical practice guideline was associated with reduced morbidity after appendectomy for CA. Intra-operative fluid culture during appendectomy for CA appears to facilitate the selection of appropriate post-operative antibiotics and, thus, minimize SSIs and overall morbidity.

Influence of microbiological culture results on antibiotic choices for veterans with hospital-acquired pneumonia and ventilator-associated pneumonia.

We examined the impact of microbiological results from respiratory samples on choice of antibiotic therapy in patients treated for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP). Four-year retrospective study. Veterans' Health Administration (VHA). VHA patients hospitalized with HAP or VAP and with respiratory cultures between October 1, 2014, and September 30, 2018. We compared patients with positive and negative respiratory culture results, assessing changes in antibiotic class and Antibiotic Spectrum Index (ASI) from the day of sample collection (day 0) through day 7. Between October 1, 2014, and September 30, 2018, we identified 5,086 patients with HAP/VAP: 2,952 with positive culture results and 2,134 with negative culture results. All-cause 30-day mortality was 21% for both groups. The mean time from respiratory sample receipt in the laboratory to final respiratory culture result was longer for those with positive (2.9 ± 1.3 days) compared to negative results (2.5 ± 1.3 days; P < .001). The most common pathogens were Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin and β-lactam/β-lactamase inhibitors were the most commonly prescribed agents. The decrease in the median ASI from 13 to 8 between days 0 and 6 was similar among patients with positive and negative respiratory cultures. Patients with negative cultures were more likely to be off antibiotics from day 3 onward. The results of respiratory cultures had only a small influence on antibiotics used during the treatment of HAP/VAP. The decrease in ASI for both groups suggests the integration of antibiotic stewardship principles, including de-escalation, into the care of patients with HAP/VAP.

Miniaturized percutaneous Nephrolithotomy without antibiotic prophylaxis: a single institution experience.

To assess the feasibility of sparing routine antibiotic prophylaxis in patients without preoperative urinary tract infection (UTI) undergoing a miniaturized percutaneous nephrolithotomy (mPCNL). A retrospective, monocentric study was conducted to evaluate the outcome of a modified perioperative antibiotic management strategy according to the principles of antibiotic stewardship (ABS). From December 2015 patients undergoing mPCNL for kidney stone with preoperative unremarkable urine culture no longer received an antibiotic prophylaxis (NoPAP). The NoPAP group was compared to mPCNL patients who received standard antibiotic prophylaxis (PAP) in the two years before. Analysis focused on postoperative complications. Logistic regression analysis was performed to identify potential risk factors. Postoperative fever occurred in 8% of the NoPAP and 9% of the PAP patients (p = 0.764). Clavien 1-3 complications did not differ between groups with 33% in the NoPAP and 41% in the PAP (p = 0.511). No Clavien 4-5 complications were seen. A (partial) staghorn stone (HR 5.587; p = 0.019) and an infectious stone component (HR 6.313; p = 0.003) were identified as significant risk factors for postoperative fever. By sparing routine antibiotic prophylaxis the overall antibiotic usage was reduced from 100% (PAP) to 9% (NoPAP). Patients with negative preoperative UC, a none-staghorn stone and no history of recurrent UTI or infectious stones may not need routine antibiotic prophylaxis prior to mPCNL. A prospective validation is warranted.

The negative aftermath of prostate biopsy: prophylaxis, complications and antimicrobial stewardship: results of the global prevalence study of infections in urology 2010\u20132019

PurposeTo evaluate and report the complications, and to analyse antimicrobial stewardship aspects following prostate biopsies (P-Bx) based on the data from a 9-year global study.MethodsThe primary outcome was to compare complications after P-Bx between patients of two cohorts: 2010–2014 and 2016–2019. Primary outcomes included symptoms of lower and severe/systemic urinary tract infection (LUTIS and SUTIS, respectively), and positive urine culture. Readmission to hospital after P-Bx, need for additional antimicrobial therapy, consumption of different antimicrobial agents for prophylaxis and therapy were evaluated. Students t test and chi-square test were used for comparative analyses.ResultsOutcome data were available for 1615 men. Fluoroquinolones-based prophylaxis rate increased from 72.0% in 2010–2014 to 78.6% in 2015–2019. Overall rates of complications increased from 6 to 11.7% including an increase in symptomatic complications from 4.7 to 10.2%, mainly due to an increase in LUTIS. Rates of patients seeking additional medical help in primary care after P-Bx increased from 7.4 to 14.4%; cases requiring post P-Bx antibiotic treatment increased from 6.1 to 9.7%, most of which received fluoroquinolones. Transperineal P-Bx was significantly associated with LUTIS. Following transrectal P-Bx, 2.8% developed febrile infections and 4.0% required hospitalisation. Two men (0.12%) died after transrectal P-Bx due to sepsis.ConclusionsThe rates of complications after P-Bx tended to increase in time, as well as rates of patients seeking additional medical help in the post-P-Bx period. To reduce the risk of infectious complications and to comply with the principles of antibiotic stewardship, clinicians should switch to the transperineal biopsy route.

A Critique of the American Urological Association Penile Prosthesis Antibiotic Prophylaxis Guidelines

Guideline statements are necessary to provide a standardized, evidence-based approach to decrease the risk of perioperative infections while maintaining the principles of antibiotic stewardship. Both the American Urological Association (AUA) and the European Association of Urology (EAU) have published recommendations for antibiotic prophylaxis for urologic surgeries. However, the specific recommendations addressing prophylaxis for inflatable penile prosthesis (IPP) placement are inconsistent and in need of revision given our contemporary understanding of IPP infections.

COVID-19 and antibiotic resistance: Parallel pandemics and different intercessions.

Coronavirus virus disease 2019 (COVID-19) is one of the challenges to the global public health. With COVID-19 impacts across all sectors, the most glaring one is its impact on antibiotic resistance, another silence pandemic. Antibiotic resistance is at a crossroads of becoming a major killer and the emergence of COVID-19 pandemic aggravate the threat, due to excessive and extensive use of antibiotics in the treatment package of COVID-19 despite being a viral pneumonia and for prophylaxis to prevent bacterial co-infection. Low bacterial co-infections were associated with COVID-19, but large antibiotics were employed, this challenged the principles of antibiotic stewardship, thus, further complicate the antibiotic stewardship guidelines. This review revolves to highlight the effect of COVID-19 pandemic and its impacts on bacterial co-infections as well as how it fuels the already existing silent pandemic; antibiotic resistance which is waiting to unleash its effect on public health and socioeconomic sectors. While there is increase focus on COVID-19 pandemic, the review urged that focus should not be taken off on antibiotic resistance.

Screening and eradication of Helicobacter pylori for gastric cancer prevention: the Taipei global consensus

ObjectiveA global consensus meeting was held to review current evidence and knowledge gaps and propose collaborative studies on population-wide screening and eradication of Helicobacter pylori for prevention of gastric cancer...

A Statewide Assessment of Antifungal Stewardship Activities in Acute-Care Hospitals in Connecticut

Background: Morbidity and mortality associated with invasive fungal infections and concerns of emerging antifungal resistance have highlighted the importance of optimizing antifungal therapy among hospitalized patients. Little is known about antifungal stewardship (AFS) practices among acute-care hospitals. We sought to assess AFS activities within Connecticut and to identify opportunities for improvement. Methods: An electronic survey assessing AFS practices was distributed to infectious disease physicians or pharmacy antibiotic stewardship program leaders in Connecticut hospitals. Survey questions evaluated AFS activities based on antibiotic stewardship principles, including several CDC Core Elements. Questions assessed antifungal restriction, prospective audit and feedback practices, antifungal utilization measurements, and the perceived utility of a local or statewide antifungal antibiogram. Results: Responses were received from 15 respondents, which represented 20 of 31 hospitals (65%); these hospitals made up the majority of the acute-care hospitals in Connecticut. Furthermore, 18 of these hospitals (58%) include antifungals in their stewardship programs. Also, 16 hospitals (52%) conduct routine review of antifungal ordering and provide feedback to providers for some antifungals, most commonly for amphotericin B, voriconazole, micafungin, isavuconazole, and flucytosine. All hospitals include guidance on intravenous (IV) to oral (PO) conversions, when appropriate. Only 14 of hospitals (45%) require practitioners to document indication(s) for systemic antifungal use. Most hospitals (17, 55%) provide recommendations for de-escalation of therapy in candidemia, though only 4 (13%) have institutional guidelines for candidemia treatment, and only 11 hospital mandates an infectious diseases consultation for candidemia. Assessing outcomes pertaining to antifungal utilization is uncommon; only 8 hospitals (26%) monitor days of therapy and 5 (16%) monitor antifungal expenditures. Antifungal susceptibility testing on Candida bloodstream isolates is performed routinely at 6 of the hospitals (19%). Most respondents (19, 95%) support developing an antibiogram for Candida bloodstream isolates at the statewide level. Conclusions: Although AFS interventions occur in Connecticut hospitals, there are opportunities for enhancement, such as providing institutional guidelines for candidemia treatment and mandating infectious diseases consultation for candidemia. The Connecticut Department of Public Health implemented statewide Candida bloodstream isolate surveillance in 2019, which includes antifungal susceptibility testing. The creation of a statewide antibiogram for Candida bloodstream infections is underway to support empiric antifungal therapy.Funding: NoneDisclosures: None

Effectiveness of a Clinical Pathway for Pediatric Complex Appendicitis based on Antibiotic Stewardship Principles

PURPOSE: We evaluated outcomes and resource utilization after implementing a novel complex appendicitis (CA) pathway limiting postoperative antibiotic duration based on clinical parameters only. METHODS: Children < 18 years with an intraoperative diagnosis of CA (gangrenous, perforated, or abscess) were treated with intravenous antibiotics postoperatively until clinical criteria were met, without utilizing complete blood counts or oral antibiotics at …

Effectiveness of a Clinical Pathway for Pediatric Complex Appendicitis based on Antibiotic Stewardship Principles

Effectiveness of a Clinical Pathway for Pediatric Complex Appendicitis based on Antibiotic Stewardship Principles

COVID-19: don't neglect antimicrobial stewardship principles!

COVID-19: don't neglect antimicrobial stewardship principles!

Effectiveness of a clinical pathway for pediatric complex appendicitis based on antibiotic stewardship principles

PurposeOutcomes and resource utilization were evaluated after implementing a novel complex appendicitis (CA) pathway limiting postoperative antibiotics based on clinical parameters. MethodsChildren with intraoperative CA (gangrenous, perforated, or abscess) were treated with intravenous antibiotics postoperatively until clinical criteria were met, without utilizing CBC or oral antibiotics at discharge. An interrupted time series (pre-intervention, transition, post-intervention) was used to assess outcomes. Hospital length of stay (LOS) was analyzed using segmented regression. Intra-abdominal abscess and readmission rates were analyzed using non-inferiority and multivariate logistic regression. ResultsFive hundred ten children were included with a median age of 10 [IQR7–12] years. There were no differences in postoperative LOS (slope − 0.008; p = 0.855), intra-abdominal abscess rate (5% vs. 8%; p = 0.135), or readmission rate (12% vs. 8%; p = 0.113) across time periods which remained true when adjusting for age, gender, and intraabdominal disease severity. Post-intervention outcomes were not inferior to pre-intervention, abscess rate (p = 0.002), or readmission rate (p < 0.001). Intraoperative findings of perforation (OR9.0; 95% CI1–71; p = 0.044) and perforation with abscess (OR18.2; 95% CI2–36; p = 0.005) were associated with a greater likelihood of postoperative abscess compared to gangrenous appendicitis. ConclusionA CA protocol based on clinical parameters is safe and effective, resulting in similar intra-abdominal abscess and readmission rates compared to more resource-intense regimens. Level of EvidenceIII Type of ResearchInterrupted Time Series

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA—The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

1086. Antimicrobial Stewardship: From Bedside to Man’s Best Friend

BackgroundAntimicrobial stewardship plays an integral role in ensuring appropriate antimicrobial use in the inpatient hospital setting and is now required by The Joint Commission. Although it is well established that antimicrobial misuse and overuse has societal and ecological implications, the same regulations do not yet apply to our veterinary and agricultural counterparts.MethodsAt The Ohio State University Wexner Medical Center (OSUWMC), the Antimicrobial Stewardship Program (ASP) was created in 2007. A partnership was formed with The Ohio State University Veterinary Medical Center (OSUVMC) in 2017 and was leveraged through a pre-existing campus-wide One Health initiative. The goal was to develop a comprehensive Veterinary Hospital ASP. “The Core Elements of Hospital Antibiotic Stewardship Programs” (Centers for Disease Control and Prevention) and “The Core Principles of Antibiotic Stewardship in Veterinary Medicine” (American Veterinary Medical Association) were also referenced for guidance.ResultsSpecific initiatives within the OSUVMC ASP were modeled after similar interventions in the OSUWMC including development of antibiotic use guidelines by animal type for commonly encountered infections, antimicrobial utilization tracking, antibiogram creation, and both active and passive surveillance of targeted resistant pathogens. A mobile-friendly website was created to allow providers easy access to these ASP tools. Overall antimicrobial prescriptions decreased 22.4% following the first year of program implementation. Planning is currently underway for an ASP outreach program to local veterinary practices to increase awareness of ASP and improve antimicrobial prescribing. A parallel outreach program with rural Ohio hospitals is underway at OSUWMC.ConclusionA comprehensive veterinary hospital ASP was successfully implemented in collaboration with OSUWMC counterparts using successful human interventions applied in the animal setting. Optimizing antimicrobial use and resistance at both sites will likely prevent resistance transmission between these geographically proximate hospitals. Sharing the details of our approach may benefit other institutions looking to expand their stewardship reach.Disclosures All authors: No reported disclosures.

Carbapenemase-producing organisms in solid organ transplantation.

Carbapenem-resistant enterobacteriaceae (CRE) are a critical healthcare threat. Infections caused by CRE disproportionately affect transplant patients. Retrospective case studies suggest that up to 10% of transplant recipients develop a CRE infection. The current literature is reviewed with a particular focus on transplant-specific implications. There are specific risks inherent to transplant recipients that result in an elevated risk for CRE carriage and subsequent infection. Additionally, the manifestations of these infections are dependent on the specific transplant type. The optimal treatment of CRE infections in transplant recipients has not been defined. A reduction in the regional community CRE burden can lead to a secondary reduction in their occurrence within vulnerable transplant populations. Therefore, core principles of antibiotic stewardship and infection control within all levels of the healthcare system remains the most effective strategy for addressing the current health crisis. Simultaneously, an integrated approach to risk stratification and an approach to treatment is postulated for management of CRE infection within the solid-organ transplant population.

Principles and practice of antibiotic stewardship in the management of diabetic foot infections.

Systemic antibiotic therapy in persons with a diabetic foot infection (DFI) is frequent, increasing the risk of promoting resistance to common pathogens. Applying principles of antibiotic stewardship may help avoid this problem. We performed a systematic review of the literature, especially seeking recently published studies, for data on the role and value of antibiotic stewardship (especially reducing the spectrum and duration of antibiotic therapy) in community and hospital populations of persons with a DFI. We found very few publications specifically concerning antibiotic stewardship in persons with a DFI. The case-mix of these patients is substantial and infection plays only one part among several chronic problems. As with other types of infections, attempting to prevent infections and avoiding or reducing the spectrum and duration of antibiotic therapy are perhaps the best ways to reduce antibiotic prescribing in the DFI population. The field is complex and necessitates knowledge over the current scientific literature and clinical experience. On a larger scale, clinical pathways, guidelines, and recommendations are additionally supportive.

Infections in Older Adults: A Case-Based Discussion Series Emphasizing Antibiotic Stewardship.

Compared with younger populations, adults 65 years and older are more likely to suffer infection-related morbidity and mortality, experience antibiotic-related adverse events, and acquire multidrug-resistant organisms. We developed a series of case-based discussions that stressed antibiotic stewardship while addressing management of common infections in older adults. Five 1-hour case-based discussions address recognition, diagnosis, and management of infections common in older adults, including those living in long-term care settings: urinary tract infections, upper respiratory tract infections, lower respiratory tract infections, skin and soft tissue infections, and Clostridium difficile infection. The education was implemented at the skilled nursing centers at 15 Veterans Affairs medical centers. Participants from an array of disciplines completed an educational evaluation for each session as well as a pre- and postcourse knowledge assessment. The number of respondents to the educational evaluation administered following each session ranged from 68 to 108. Learners agreed that each session met its learning objectives (4.80-4.89 on a 5-point Likert scale, 5 = strongly agree) and that they were likely to make changes (2.50-2.89 on a 3-point scale, 3 = highly likely to make changes). The average score on the five-question knowledge assessment increased from 3.6 (72%) to 3.9 (78%, p = .06). By stressing recognition of atypical signs and symptoms of infection in older adults, diagnostic tests, and antibiotic stewardship, this series of five case-based discussions enhanced clinical training of learners from several disciplines.