Antimicrobial Stewardship Principles Research Articles

Barriers and facilitators to implementation of a national antimicrobial stewardship toolkit for inpatient settings

Abstract Introduction Antimicrobial stewardship (AMS) is vital for combating antimicrobial resistance (AMR). The updated 2023 "Start Smart Then Focus" (SSTF) national antimicrobial stewardship (AMS) toolkit1, designed for inpatient settings, supports optimising prescribing of antimicrobials. Aim This project was designed to identify the barriers and facilitators to implementing the national toolkit to improve patient outcomes and reduce AMR. Method An online training workshop was conducted for healthcare professionals across England, focusing on the SSTF toolkit. Before the workshop, participants completed a survey that included consent and gathered information on their roles, familiarity with AMS principles, current practices, and perceived barriers and facilitators to AMS implementation. This information in this survey was used to form basis for the workshop and it was helpful in developing content appropriate for the target audience, which will be delivered during the session. The workshop included discussions on knowledge mobilisation, behavioural science using the COM-B model, and SSTF implementation case studies. Participants engaged in breakout sessions to identify implementation challenges at their organisations. Post-workshop surveys collected feedback on learning outcomes. Collaboration with NHS England AMS leads and UKHSA behavioural scientists was integral. The NHS Health Research Authority tool confirmed the project did not require ethical approval as the surveys were service evaluation. Data were analysed using descriptive statistics for quantitative responses and thematic analysis for qualitative feedback, tailoring workshop content to address specific needs. Results The workshop attracted 57 out of 71 (80%) registered healthcare professionals, including pharmacists (n=45), doctors(n=3), and nurses(n=4). Post-workshop surveys received a 28%(n=16) response rate. Feedback was positive, with 14 out of 16 (88%) of participants expressing high satisfaction. Highlights included SSTF development, e-prescribing implementation, and sessions on barriers and facilitators.Key barriers identified were lack of time, competing priorities, data complexity, insufficient organisational support, and limited resources3. Facilitators included engaging microbiology consultants and the ePMA team, raising awareness through AMS ward rounds, and embedding the SSTF toolkit into guidelines and education. Participants suggested further support from UKHSA and NHSE, including more teaching sessions, workshops, educational materials, and e-learning resources. Practical tools like posters, lanyard cards, infographics, and virtual sessions were recommended to reinforce implementation. The survey responses were analysed using descriptive statistics for quantitative data, such as satisfaction ratings, and thematic analysis for qualitative feedback. This analysis evaluated the workshop's impact on participants' understanding and readiness to implement the toolkit and provided insights for enhancing future training activities. Discussion/Conclusion The workshop identified key facilitators and barriers to SSTF implementation. While the toolkit offers a comprehensive framework for AMS, overcoming barriers requires a multifaceted approach involving education, stakeholder engagement, and continuous support. Clearer role definitions and improved support structures are essential. Limitations include limited participant representation and reliance on self-reported data, which may introduce bias. The study lacks long-term follow-up data to assess sustained impact, and feedback might be influenced by personal experiences or organisational culture, affecting generalisability. Future studies could expand participant diversity, incorporate longitudinal assessments, and explore additional AMS aspects.

The Short-Term Impact of Educational Programs on Knowledge and Attitudes Regarding Antimicrobial Stewardship among Veterinary Students in Serbia.

Effective antimicrobial stewardship (AMS) is crucial for combating the rise of antimicrobial resistance (AMR), particularly in veterinary medicine. Educational programs targeting veterinary students can play a significant role in shaping their knowledge and attitudes toward antimicrobial use and stewardship. This study aimed to evaluate the impact of educational programs on the knowledge and attitudes regarding AMS among veterinary students in Serbia. A structured educational program on AMS was implemented for veterinary students at the Faculty of Agriculture, University of Novi Sad. Pre- and post-symposium assessments were conducted to measure changes in students' knowledge and attitudes. The study employed a mixed-methods approach, including surveys and focus groups, to gather quantitative and qualitative data. The study resulted in significant short-term improvements in students' knowledge of AMS principles and their attitudes toward responsible antimicrobial use. Participants demonstrated a better understanding of the mechanisms of resistance and the importance of adhering to stewardship guidelines. Qualitative feedback indicated increased awareness of the consequences of inappropriate antimicrobial use and a stronger commitment to applying stewardship practices in their future careers. The educational programs effectively enhanced immediate veterinary students' knowledge and attitudes regarding AMS. These findings underscore the importance of integrating targeted educational programs into veterinary curricula to promote responsible antimicrobial use and combat resistance in veterinary practice.

Antimicrobial Drug Utilization and Resistance Trends in Septicemia Patients: A Comprehensive Study at a Tertiary Care Hospital

Background: Septicemia is still among the leading causes of morbidity and mortality worldwide, especially among patients in the intensive care unit. The right use of antimicrobial agents is central to the successful management of septicemia, but increasing incidences of antimicrobial resistance are a big challenge. Objective: This study aimed to quantify the antimicrobial usage, resistant organisms, and clinical performance in septicemia patients in a tertiary healthcare facility in Bangladesh. Methods: A prospective observational study was done in the Department of Medicine, Community Based Medical College Hospital, over a period of 16 months. One hundred and ten participants with septicemia and admitted to the ICU were recruited. Demographic data, antimicrobial consumption, microbiological results, and clinical outcomes were gathered and examined. Results: Most of the patients were male (54.5%) and within the age group of 31–40 years. Cephalosporins were the most common first-line antimicrobials (13.3%), while macrolides (12.3%) and carbapenems (11.7%) were at the second and third rank, respectively. There were frequent alterations in antimicrobial therapy; in 28 percent of cases, ceftriaxone was replaced by levofloxacin. Patients with resistant infections had the advantage of a longer hospital and ICU stay of at least 1 week (p<0.01). 16% in patients with resistant infections. Conclusion: The topics discussed in this study include the issues arising from septicemia management due to antimicrobial resistance, the requirement of broad-spectrum empiric therapy, often changing antimicrobial regimens, and overall poor outcomes for such resistant infections. Overall, the present results highlight the need for strict adherence to principles of antimicrobial stewardship, local resistance pattern monitoring, and the creation of novel therapeutic interventions. Additional multi-centered trials to determine strategies against septicemia and AMR in limited resource .........

Oral versus intravenous empirical antibiotics in children and adolescents with uncomplicated bone and joint infections: a nationwide, randomised, controlled, non-inferiority trial in Denmark

Bone and joint infections (BJIs) are treated with intravenous antibiotics, which are burdensome and costly. No randomised controlled studies have compared if initial oral antibiotics are as effective as intravenous therapy. We aimed to investigate the efficacy and safety of initial oral antibiotics compared with initial intravenous antibiotics followed by oral antibiotics in children and adolescents with uncomplicated BJIs. From Sept 15, 2020, to June 30, 2023, this nationwide, randomised, non-inferiority trial included patients aged 3 months to 17 years with BJIs who presented to one of the 18 paediatric hospital departments in Denmark. Exclusion criteria were severe infection (ie, septic shock, the need for acute surgery, or substantial soft tissue involvement), prosthetic material, comorbidity, previous BJIs, or antibiotic therapy for longer than 24 h before inclusion. Patients were randomly assigned (1:1), stratified by C-reactive protein concentration (<35 mg/L vs ≥35 mg/L), to initially receive either high-dose oral antibiotics or intravenous ceftriaxone (100 mg/kg per day in one dose). High-dose oral antibiotics were coformulated amoxicillin (100 mg/kg per day) and clavulanic acid (12·5 mg/kg per day) in three doses for patients younger than 5 years or dicloxacillin (200 mg/kg per day) in four doses for patients aged 5 years or older. After a minimum of 3 days, and upon clinical improvement and decrease in C-reactive protein, patients in both groups received oral antibiotics in standard doses. The primary outcome was sequelae after 6 months in patients with BJIs, defined as any atypical mobility or function of the affected bone or joint, assessed blindly, in all randomised patients who were not terminated early due to an alternative diagnosis (ie, not BJI) and who attended the primary outcome assessment. A risk difference in sequelae after 6 months of less than 5% implied non-inferiority of the oral treatment. Safety outcomes were serious complications, the need for surgery after initiation of antibiotics, and treatment-related adverse events in the as-randomised population. This trial was registered with ClinicalTrials.gov, NCT04563325. 248 children and adolescents with suspected BJIs were randomly assigned to initial oral antibiotics (n=123) or initial intravenous antibiotics (n=125). After exclusion of patients without BJIs (n=54) or consent withdrawal (n=2), 101 patients randomised to oral treatment and 91 patients randomised to intravenous treatment were included. Ten patients did not attend the primary outcome evaluation. Sequelae after 6 months occurred in none of 98 patients with BJIs in the oral group and none of 84 patients with BJIs in the intravenous group (risk difference 0, one-sided 97·5% CI 0·0 to 3·8, pnon-inferiority=0·012). Surgery after randomisation was done in 12 (9·8%) of 123 patients in the oral group compared with seven (5·6%) of 125 patients in the intravenous group (risk difference 4·2%, 95% CI -2·7 to 11·5). We observed no serious complications. Rates of adverse events were similar across both treatment groups. In children and adolescents with uncomplicated BJIs, initial oral antibiotic treatment was non-inferior to initial intravenous antibiotics followed by oral therapy. The results are promising for oral treatment of uncomplicated BJIs, precluding the need for intravenous catheters and aligning with the principles of antimicrobial stewardship. Innovation Fund Denmark and Rigshospitalets Forskningsfond.

Making a case for outpatient parenteral antimicrobial therapy (OPAT).

In the wake of the COVID-19 pandemic, and its negative impact on both acute and elective care and decline in available inpatient resources, there is an imperative to maximize safe and effective alternatives to inpatient hospital care. Properly governed outpatient parenteral antimicrobial therapy (OPAT) services embed the principles of antimicrobial stewardship (AMS) (including use of early oral therapy) and support admission avoidance and early discharge for a growing range of patient groups with complex infections through well-organized multidisciplinary team working. Expansion of OPAT aligns with the UK's national strategy to deliver care closer to home and cost-effectively maximize use of inpatient resources. OPAT serves as an exemplar to other ambulatory services and presents opportunities for developing and assuring AMS strategies within the rapidly developing hospital-at-home and virtual ward environments.

Exploring Prescription Practices: Insights from an Antimicrobial Stewardship Program at a Tertiary Healthcare Facility, Rwanda.

Antimicrobial resistance (AMR) is a major public health threat linked to increased morbidity and mortality. It has the potential to return us to the pre-antibiotic era. Antimicrobial stewardship (AMS) programs are recognized as a key intervention to improve antimicrobial use and combat AMR. However, implementation of AMS remains limited in Africa, particularly in Rwanda. This study aimed to assess prescription practices, identify areas for improvement, and promote adherence to AMS principles. Conducted at King Faisal Hospital in Rwanda, this qualitative study used semi-structured interviews with eight participants until saturation was reached. The interviews were recorded, transcribed, and thematically analyzed, revealing four emerging themes. The first theme was on AMS activities that were working well based on availability of microbiology laboratory results and prescription guidelines as factors influencing antibiotic prescription adjustments. The second theme was related to challenges during the implementation of the AMS program, including the prescription of broad-spectrum antibiotics, limited local data on AMR patterns, and stock-outs of essential antibiotics. The third theme was on the importance of adhering to AMR management guidelines at KFH. The last emerged on recommendations from participants centered on regular training for healthcare workers, widespread dissemination of AMR findings across departments, and the enforcement of antibiotic restriction policies. These actions can improve prescription behaviors, upholding the highest standards of patient care, and strengthening the nascent AMS program.

Investigating pharmacy students clinical reasoning of antimicrobial stewardship cases using a qualitative, think-aloud methodology

Abstract Introduction Future healthcare workers’ education must include antimicrobial stewardship (AMS) clinical decision-making to achieve optimal clinical outcomes and to treat and prevent infection in a manner that minimises the effects of antimicrobial resistance (AMR) and is safe for patients. Clinical reasoning is an important cognitive process that is essential to evaluate and manage a patient’s medical problem.[1] This study aimed to evaluate the cognitive processes and clinical reasoning skills of pharmacy students when they review AMS cases, as well as identify any existing knowledge gaps in this area that need to be addressed. Methods This qualitative study used a case study approach, in which a sample (n=13) of Master of Pharmacy (MPharm) students in an Irish University were recruited to interpret three patient infection cases. Convenience sampling of MPharm students by email invitation was conducted and students took part voluntarily. Semi-structured interviews were conducted, recorded and transcribed verbatim. A think-aloud procedure with verbal protocol analysis was adopted to determine students’ decision-making processes and clinical reasoning.[2] Thematic analysis was used to analyse interview data. Results Interviews were conducted with 13 students (5 male, 8 female), all aged 22-27 years old. Overall, students interpreted and reasoned through the cases following a structured approach. Some students adopted different approaches to clinical decision-making and did not always follow all the steps outlined in the clinical reasoning cycle. Within the clinical decision-making process, common themes were identified, as outlined in Table 1. Some knowledge gaps were reported by students, including antibiotic prophylaxis, microorganisms, AMS measures, guideline use, soft tissue infection management, and IV-to-oral switch. Conclusion This study provides interesting findings on students’ interpretation and review of infection management and AMS principles which could inform the curriculum development of pharmacy education in AMR and AMS. Educators should consider introducing opportunities to develop clinical reasoning skills to support learning on AMS concepts, particularly in challenging areas such as microbiology, and interpretation and application of guidelines. A limitation of the study is that it was conducted with pharmacy students from one university programme. A strength of the study is the think-aloud methodology which provides in-depth detail on students clinical reasoning thought processes and skills.

Treatment of infections caused by multidrug-resistant Gram-negative bacilli: A practical approach by the Italian (SIMIT) and French (SPILF) Societies of Infectious Diseases

The emergence of multidrug-resistant Gram-negative bacilli and the development of new antibiotics have complicated the selection of optimal regimens. International guidelines are valuable tools, but are limited by the scarcity of high-quality randomized trials in many situations. A panel of experts from the French and Italian Societies of Infectious Diseases aimed to address unresolved issues in clinical practice based on their experience, an updated literature review and open discussions. The panel reached consensus for the following 'first choices': (i) cefepime for ventilator-acquired pneumonia due to AmpC β-lactamase-producing Enterobacterales; (ii) the β-lactam/β-lactamase inhibitor combination most active in vitro, or cefiderocol combined with fosfomycin, and aerosolized colistin or aminoglycosides, for severe pneumonia due to Pseudomonas aeruginosa resistant to ceftolozane-tazobactam; (iii) high-dose piperacillin-tazobactam (including loading dose and continuous infusion) for complicated urinary tract infections (cUTIs) caused by extended-spectrum β-lactamase-producing Enterobacterales with piperacillin-tazobactam minimum inhibitory concentration (MIC) ≤8 mg/L; (iv) high-dose cefepime for cUTIs due to AmpC β-lactamase-producing Enterobacterales other than Enterobacter spp. if cefepime MIC ≤2 mg/L; (v) ceftolozane-tazobactam or ceftazidime-avibactam plus metronidazole for intra-abdominal infections (IAIs) due to third-generation cephalosporin-resistant Enterobacterales; (vi) ceftazidime-avibactam plus aztreonam plus metronidazole for IAIs due to metallo-β-lactamase-producing Enterobacterales; (vii) ampicillin-sulbactam plus colistin for bloodstream infections (BSIs) caused by carbapenem-resistant Acinetobacter baumannii; (viii) meropenem-vaborbactam for BSIs caused by Klebsiella pneumoniae carbapenemase-producing Enterobacterales; and (ix) ceftazidime-avibactam plus fosfomycin for neurological infections caused by carbapenem-resistant P. aeruginosa. These expert choices were based on the necessary balance between antimicrobial stewardship principles and the need to provide optimal treatment for individual patients in each situation.

Understanding antibiotic knowledge, attitudes, and practices: a cross-sectional study in physicians from a Colombian region, 2023.

Antibiotic resistance has been identified as a global health threat. Knowledge, attitudes, and inappropriate prescription practices of antibiotics by physicians play a crucial role in this problem. In Colombia, research addressing this issue is scarce. A cross-sectional study involving 258 physicians was conducted. A scale with questions on sociodemographic aspects, level of education, satisfaction with antibiotic education received, and knowledge, attitudes, and practices was administered. The scale was designed for each item to be analyzed individually or as a total score ranging from 0 to 100 (0 being the lowest and 100 the highest). 31.5% of physicians rated the education received on antibiotics as fair to poor. The knowledge score was 80.1 (IQR 70.5-87.5); however, 25.2% agreed to some extent that amoxicillin is useful in treating most respiratory infections, and 15% agreed that antibiotics are effective in treating upper respiratory infections. Attitudes scored 80.2 (IQR 75.0-86.5), with 99% stating that bacterial resistance is a public health problem in Colombia, but only 56.9% considering it a problem affecting their daily practice. Practices scored 75.5 (IQR 68.8-81.2), and 71.7% affirmed that if they refuse to prescribe antibiotics to a patient who does not need them, the patient can easily obtain them from another physician. General practitioners were found to have lower scores in all three indices evaluated. The study reveals enduring misconceptions and concerning practices in antibiotic prescription, particularly among general practitioners. Enhancing knowledge necessitates the implementation of continuous medical education programs that focus on updated antibiotic guidelines, and resistance patterns. Fostering positive attitudes requires a culture of trust and collaboration among healthcare professionals. Practical enhancements can be realized through the establishment of evidence-based prescribing guidelines and the integration of regular feedback mechanisms. Moreover, advocating for the inclusion of antimicrobial stewardship principles in medical curricula is crucial, emphasizing the significance of responsible antibiotic use early in medical education.

Explainable and Interpretable Machine Learning for Antimicrobial Stewardship: Opportunities and Challenges

There is growing interest in exploiting the advances in artificial intelligence (AI) and machine learning (ML) for improving and \\monitoring antimicrobial prescriptions in line with antimicrobial stewardship principles. Against this background, the concepts of interpretability and explainability are becoming increasingly essential to understand how ML algorithms could predict antimicrobial resistance or recommend specific therapeutic agents, in order to avoid unintended biases related to the “black box” nature of complex models. In this commentary, we review and discuss some hot topics on the use of ML algorithms for antimicrobial stewardship interventions, highlighting opportunities and challenges with peculiar attention to interpretability and explainability of employed models. As in other fields of medicine, the exponential growth of AI/ML shows the potential for improving the efficacy of antimicrobial stewardship interventions, at least in part by reducing time-consuming tasks for overwhelmed healthcare personnel. Improving our knowledge about how complex ML models work could further help to achieve crucial advances in promoting the appropriate use of antimicrobials, as well as in preventing antimicrobial resistance selection and dissemination.

Antimicrobial stewardship markers and healthcare-associated pneumonia threshold criteria in UK hospitals: analysis of the MicroGuideTm application.

To address antimicrobial resistance, antimicrobial stewardship (AMS) principles must be implemented and adhered to. Clinical decision aids such as the MicroGuideTM app are an important part of these efforts. We sought to evaluate the consistency of core AMS information and the diversity of classification thresholds for healthcare-associated pneumonia (HAP) in the MicroGuide app. Guidelines in the MicroGuide app were extracted and analysed for content related to AMS and HAP. Guidelines were characterized according to HAP naming classification; community-acquired pneumonia (CAP) classifications were analysed to serve as a comparator group. In total, 115 trusts (119 hospitals) were included. Nearly all hospitals had developed MicroGuide sections on AMS (n = 112/119, 94%) and sepsis management (n = 117/119, 98%). Other AMS sections were outpatient parenteral antimicrobial therapy (47%), antifungal stewardship (70%), critical care (23%) and IV to oral switch therapy (83%). Only 9% of hospitals included guidance on the maximum six key AMS sections identified. HAP definitions varied widely across hospitals with some classifying by time to onset and some classifying by severity or complexity. The largest proportion of HAP guidelines based classification on severity/complexity (n = 69/119, 58%). By contrast, definitions in CAP guidelines were uniform. The high heterogeneity in HAP classification identified suggests inconsistency of practice in identifying thresholds for HAP in the UK. This complicates HAP management and AMS practices. To address HAP in alignment with AMS principles, a comprehensive strategy that prioritizes uniform clinical definitions and thresholds should be developed.

An Assessment of the Current Level of Implementation of the Core Elements of Antimicrobial Stewardship Programs in Public Hospitals in Ghana.

Introduction: Antimicrobial resistance (AMR) is becoming a threat to global public health. Antimicrobial stewardship (AMS) program (ASP) is one of the 5 strategic areas in the Ghana National Action Plan to fight this menace. Assessment of the core elements of ASP in a hospital setting has been identified as a pragmatic way of identifying the barriers and facilitators for its effective implementation. Method: The World Health Organization's toolkit for assessment of the 7 core elements of ASP in hospitals in low and middle income countries was used for this situational analysis of public hospitals in 2 regions of Ghana. The core elements included leadership commitment, accountability and responsibility, pharmacy expertize, AMS actions and interventions, education and training, and periodic monitoring and surveillance. Data collected using a checklist were imported into STATA version 14 for descriptive and bivariate analyses. Results: 15 public hospitals were assessed with the toolkit. Most of them were primary health care facilities (n = 12, 80.0%), had bed capacities between 100 and 199 beds, less than 50 medical doctors (n = 12, 80.0%), less than 5 pharmacists (n = 10, 66.7%), and between 100 and 199 nurses. Performances in 4 out of the 7 core elements were most deficient and they included leadership commitment, pharmacy expertize, AMS actions (interventions) implemented, monitoring and surveillance of antibiotic use, and bacteria resistance rates. Pharmacist-led ASPs were also found to be associated with their formal training on AMS. Key barriers identified included lack of skilled human resources, lack of available time for AMS-related duties and poor laboratory infrastructure. Conclusion: There was sub-optimal performance for almost all the core elements of ASP in the public hospitals in Ghana hampered mostly by lack of skilled human and financial resources. Pharmacists must be empowered through formal training and certificate programs in infectious disease management and AMS principles and strategies to enhance their contribution toward ASPs in hospitals. The results from this study should encourage nationwide assessment of ASPs across hospital settings in Ghana to better evaluate the level of their implementation and address potential barriers to guide AMS policies and ASP strategy development toward the fight against AMR.

Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series

The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8–19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.

Intermittent hemodialysis: a review of the top antimicrobial stewardship practices to be employed.

The vulnerability of patients on hemodialysis (HD) to infections is evident by their increased susceptibility to infections in general and to resistant organisms in particular. Unnecessary, inappropriate, or suboptimal antimicrobial prescribing is common in dialysis units. This underscores the need for dedicated antimicrobial stewardship (AMS) interventions that can be implemented both in the inpatient and outpatient settings. In this review, we provide a comprehensive approach for clinicians with the most updated coordinated AMS principles in HD setting in six areas: prevention, diagnosis, treatment, education and empowerment, monitoring, and research.

Knowledge and perception of antimicrobial resistance and antimicrobial stewardship among healthcare students in Nigeria.

Assessment of knowledge and perception of healthcare students regarding antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) would facilitate more effective education of these future prescribers. To assess knowledge and perception of AMR and AMS among healthcare students in Nigerian universities. This was a questionnaire-based, cross-sectional survey of medical, nursing and pharmacy undergraduate students from November 2019 to January 2020, using both paper and electronic modes of self-administration. A total of 335 students participated in the survey. Mean age of respondents was 23±3 years; 114 (34.4%) were in their 5th year of study. Most (78.9%) of the respondents agreed that widespread use of antimicrobials promotes AMR. Only 70 (21.1%) were aware that poor hand hygiene promotes AMR; 45.9% (42.7%, 37.3% and 57.7% for medicine, nursing and pharmacy respectively, p = 0.007) agreed that AMR is promoted by substandard quality of antimicrobials. Majority (94.3%) perceived AMR as a worldwide problem. Over half (60.8%) were not familiar with the term 'antimicrobial stewardship'. Eleven (3.3%) and 122 (36.9%) rated their AMS knowledge as 'very good' and 'poor' respectively. Nigerian healthcare students had suboptimal knowledge of AMR and AMS. Current undergraduate healthcare curriculum should be reviewed to incorporate AMS principles.

The impact of the BIOFIRE® Blood Culture Identification 2 Panel on antimicrobial treatment of children with suspected systemic inflammatory response syndrome and sepsis.

This study aimed to assess the therapeutic effects of implementing the BioFire® Blood Culture Identification 2 (BCID2) Panel (bioMérieux, Marcy l'Etoile, France) in the clinical practice of children with sepsis.This retrospective cross-sectional study included children from 15days of age to 18years old with sepsis and of whom the BCID2 Panel was studied from the positive blood culture. If the antimicrobial treatment was changed according to the results of BCID2 Panel, it was recorded and re-grouped as targeted antimicrobial therapy, de-escalation of the antimicrobial treatment and shifting to another antimicrobial drug if any antimicrobial resistance was detected. Seven-days and thirty-days mortality rate was recorded.Thirty-two patients with 36 septic episodes with positive BCID2 Panel results were included. The median age was 10months 15days (ranging from 15days to 16.5years). The mean difference between having positive results by the BCID2 Panel and conventional culture methods was 82.2 ± 45.4h (ranging from 12.3 to 207h). Effect of the BCID2 Panel on the antimicrobial treatment was detected in 69.4% of the episodes (n = 25). Glycopeptides were ceased at 6 patients, piperacillin/tazobactam was ceased at 6 patients, and cefotaxime was ceased at one patient and de-escalation was achieved in 13 episodes which formed the 36.1% of the initial antimicrobial treatment. Conclusion: The BCID2 Panel had an important impact on the patients care and optimization according to the principles of antimicrobial stewardship. The BCID2 Panel may be one of the key items for rapid and accurate diagnosis in children with sepsis. Blood culture is still the mainstay for especially detection of antimicrobial drug resistance, while BCID2 tests had several advantages such as speed and diagnostic accuracy as good as blood culture. What is Known: • The BioFire®Blood Culture Identification 2 (BCID2) Panel (bioMérieux, Marcy l'Etoile, France) is a well-validated assay that allows for the simultaneous identification of 43 nucleic acid targets associated with bloodstream infections within about 1h. What is New: • BCID2 Panel had a direct impact on the patient's treatment decision at the 69.4% of the sepsis episodes. • The clinicians received the microbiological results 82.2h earlier with BCID2 panel compared to blood culture methods with antimicrobial resistanceandde-escalation of the antimicrobial drugs was achieved at 13 episodes which formed the 36.1% of the initial treatment.

Pathways to sustainable antimicrobial use in cats.

Antimicrobial stewardship encompasses all the individual and collective actions that medical professionals take to preserve the efficacy of antimicrobials. It is a one-health problem, affecting animals and humans. The current state of antimicrobial use in cats, particularly (1) the overuse and improper use of cefovecin, which belongs to the third-generation cephalosporin class that is critically important to human health, and (2) use of antimicrobials when they are not needed, poses unsustainable risks of antimicrobial resistance. This paper describes the principles of antimicrobial stewardship and stewardship challenges faced by feline veterinarians, including (1) poor adherence to or awareness of antimicrobial use guidelines, (2) lack of access to affordable diagnostic tests and antibiograms, (3) lack of access to materials and tools for clients that may facilitate more sustainable antimicrobial use and help cat owners understand resistance risks, (4) underestimating the ability of cat owners to administer oral antimicrobials, and (5) limited time and resources to support stewardship efforts. Based on research described in this paper; an original research article by Cazer et al, JAVMA, December 2023; and a Currents in One Health article by Cobo-Angel et al, AJVR, December 2023, several solutions are proposed to advance antimicrobial stewardship in feline medicine. Many of these proposals were expressly requested by veterinarians interviewed in Cazer et al, JAVMA, December 2023. Education and training of veterinarians and cat owners is an essential step toward sustainable antimicrobial use, but it must be complemented with innovations in diagnostic testing, antimicrobial drug development, structural changes, and technological supports.

A descriptive study of vancomycin use at Red Cross War Memorial Children's Hospital, Cape Town.

Antimicrobial stewardship principles guide the clinical use of antimicrobials, including vancomycin, but paediatric vancomycin prescribing practices have not been evaluated in South Africa. To document the use, prescribing practices and monitoring of intravenous vancomycin and the spectrum of bacteria isolated on microbiological culture in children treated with intravenous vancomycin during a 12-month period at Red Cross War Memorial Children's Hospital (RCWMCH). A retrospective audit of intravenous vancomycin use in children admitted to RCWMCH during 2019 was performed. All 158 vancomycin prescription episodes for 143 children were included. Overall usage of intravenous vancomycin was 63 days of therapy per 1000 patient days (interquartile range [IQR]: 38-72). The median starting dose was 15 mg/kg per dose (IQR: 14-15) and median daily dose was 45 mg/kg per day (IQR: 43-60). Vancomycin was prescribed as empiric (127/158, 80%) and directed (31/158, 20%) treatment. The median duration of treatment for the directed group (7 days) was longer than the empiric group (4 days) (p = 0.001). Vancomycin serum trough concentrations were performed in 65/98 (66%) episodes where vancomycin treatment exceeded 3 days, with only 16/65 (25%) of these samples obtained before the fourth dose. Prolonged antibiotic treatment of 14 days or more was not associated with Gram-positive bacteria on culture (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 0.17-4.2). Dosing errors, prolonged empiric treatment and inappropriate vancomycin monitoring were problems associated with vancomycin prescriptions. The study identified multiple opportunities for improved vancomycin prescribing and monitoring. Further research and implementation of improved prescribing practices could contribute to the preservation of vancomycin as an effective antibiotic.

Antibiotic prescribing guideline recommendations in COVID-19: a systematic survey

COVID-19 and antimicrobial resistance (AMR) are two intersecting public health crises. Antimicrobial overuse in patients with COVID-19 threatens to worsen AMR. Guidelines are fundamental in encouraging antimicrobial stewardship. We sought to assess the quality of antibiotic prescribing guidelines and recommendations in the context of COVID-19, and whether they incorporate principles of antimicrobial stewardship. We performed a systematic survey which included a search using the concepts "antibiotic/antimicrobial" up to November 15, 2022 of the eCOVID-19 living map of recommendations (RecMap) which aggregates guidelines across a range of international sources and all languages. Guidelines providing explicit recommendations regarding antibacterial use in COVID-19 were eligible for inclusion. Guideline and recommendation quality were assessed using the AGREE II and AGREE-REX instruments, respectively. We extracted guideline characteristics including panel representation and the presence or absence of explicit statements related to antimicrobial stewardship (i.e., judicious antibiotic use, antimicrobial resistance or adverse effects as a consequence of antibiotic use). We used logistic regression to evaluate the relationship between guideline characteristics including quality and incorporation of antimicrobial stewardship principles. Protocol registration (OSF): https://osf.io/4pgtc. Twenty-eight guidelines with 63 antibiotic prescribing recommendations were included. Recommendations focused on antibiotic initiation (n=52, 83%) and less commonly antibiotic selection (n=13, 21%), and duration of therapy (n=15, 24%). Guideline and recommendation quality varied widely. Twenty (71%) guidelines incorporated at least one concept relating to antimicrobial stewardship. Including infectious diseases expertise on the guideline panel (OR 9.44, 97.5% CI: 1.09-81.59) and AGREE-REX score (OR 3.26, 97.5% CI: 1.14-9.31 per 10% increase in overall score) were associated with a higher odds of guidelines addressing antimicrobial stewardship. There is an opportunity to improve antibiotic prescribing guidelines in terms of both quality and incorporation of antimicrobial stewardship principles. These findings can help guideline developers better address antibiotic stewardship in future recommendations beyond COVID-19. This project was funded by Michael G. DeGroote Cochrane Canada and McMaster GRADE centres.

Use of Ceftriaxone and Benzylpenicillin in Outpatient Parenteral Antimicrobial Therapy: Spectrum vs Cost.

The application of antimicrobial stewardship (AMS) principles may entail increased cost to allow for narrower-spectrum therapy. Prescribing benzylpenicillin (BP) and ceftriaxone (CRO) for outpatient parenteral antimicrobial therapy (OPAT) demonstrates the complex challenge of this principle. The aim of this study is to analyze the use of BP and CRO in our OPAT program, including indications and relative cost. We analyzed all adult patients in our OPAT program who received intravenous BP or CRO over 1 year. We identified a "crossover group" of patients who could have received either agent. Economic comparison was based on acquisition cost of the therapy (drug, infuser, and preparation costs). Of 105 eligible patients, 54 (51%) and 51 (49%) received BP and CRO, respectively. Forty (38%) patients were suitable for either agent; of these, the majority (n = 31, 78%) were treated with BP. Economic analysis demonstrated that the average daily cost of BP therapy was $93.76/d (AUD) vs $1.23/d for CRO. Thus, across our OPAT programs, we had an additional average cost of $92.53/patient/d to use BP instead of CRO. Program-wide the annual additional cost of using BP and thus applying this AMS strategy was $68 386.12. BP is often selected over CRO by clinicians, where possible, as recommended by the Australian guidelines; however, BP is associated with higher daily acquisition costs. More broadly, a number of narrower-spectrum agents may involve significantly higher costs than comparators; as such, the $92.53/d to prevent CRO exposure can be considered when applying other antimicrobial-substitution AMS interventions in an acute health care setting.