Stewardship Role Research Articles

Role of biomarkers in antimicrobial stewardship: physicians' perspectives.

Biomarkers are playing an increasingly important role in antimicrobial stewardship. Their applications have included use in algorithms that evaluate suspected bacterial infections or provide guidance on when to start or stop antibiotic therapy, or when therapy should be repeated over a short period (6-12 h). Diseases in which biomarkers are used as complementary tools to determine the initiation of antibiotics include sepsis, lower respiratory tract infection (LRTI), COVID-19, acute heart failure, infectious endocarditis, acute coronary syndrome, and acute pancreatitis. In addition, cut-off values of biomarkers have been used to inform the decision to discontinue antibiotics for diseases such as sepsis, LRTI, and febrile neutropenia. The biomarkers used in antimicrobial stewardship include procalcitonin (PCT), C-reactive protein (CRP), presepsin, and interleukin (IL)-1β/IL-8. The cut-off values vary depending on the disease and study, with a range of 0.25-1.0 ng/mL for PCT and 8-50 mg/L for CRP. Biomarkers can complement clinical diagnosis, but further studies of microbiological biomarkers are needed to ensure appropriate antibiotic selection.

Antibiotic prescribing practices in community and clinical settings during the COVID-19 pandemic in Nairobi, Kenya.

The COVID-19 pandemic has significantly impacted healthcare systems, including antibiotic use practices. We present data on patterns of antibiotic dispensing and use in community and hospital settings respectively in Nairobi, Kenya during the pandemic. We conducted interviews with 243 pharmacies in Nairobi using a standardised questionnaire from November to December 2021. The data collected included demographic characteristics, antibiotic customers, types of antibiotics sold, and antibiotic prescribing practices. Additionally, we retrospectively reviewed health records for 992 and 738 patients admitted in COVID-19 and general wards at two large inpatient hospitals between April 2020 and May 2021, and January 2019 to October 2021, respectively. Demographic, utilisation of laboratory services, treatment, clinical, and outcome data were collected using a modified Global WHO Point Prevalence Surveys (Global-PPS) tool. Almost all pharmacies (91.4%) served customers suspected of having COVID-19 with a mean weekly number of 15.6 customers. All pharmacies dispensed antibiotics, mainly azithromycin and beta lactams to suspected COVID-19 infected customers. 83.4% of hospitalised COVID-19 patients received at least one antibiotic at some point during their hospitalisation, which was significantly higher than the 53.8% in general ward patients (p<0.001). Similarly, the average number of antibiotics administered to COVID-19 patients was higher than that of patients in the general ward (1.74 vs 0.9). Azithromycin and ceftriaxone were the most commonly used antibiotics in COVID-19 patients compared to ceftriaxone and metronidazole in the general wards. Only 2% of antibiotic prescriptions for COVID-19 patients were supported by microbiological investigations, which was consistent with the proportion of 6.8% among the general ward population. Antibiotics were commonly prescribed to customers and patients suspected of having COVID-19 either in community pharmacies or in hospital, without a prescription or laboratory diagnosis. These findings emphasize the crucial role of antibiotic stewardship, particularly in community pharmacies, in the context of COVID-19.

Do Service Providers Play a Market Stewardship Role in Social Care Quasi-Markets, and Should They?

Market stewardship of social care quasi-markets has been an important area of inquiry. While most focus has been on central government stewardship, local level actors can also play a role. Using a case study of the Australian National Disability Insurance scheme, this article focuses on both how service providers can be market stewards and whether they should be. Findings suggest that while some aspects of market stewardship are appropriate for service providers to perform, others may be better done by different actors. We propose a preliminary framework for distributed stewardship to help join up the work of local level actors with central agencies.

Antibiotic Stewardship in Surgical Departments.

Antimicrobial resistance (AMR) has emerged as one of the leading public health threats of the 21st century. New evidence underscores its significance in patients' morbidity and mortality, length of stay, as well as healthcare costs. Globally, the factors that contribute to antimicrobial resistance include social and economic determinants, healthcare governance, and environmental interactions with impact on humans, plants, and animals. Antimicrobial stewardship (AS) programs have historically overlooked surgical teams as they considered them more difficult to engage. This review aims to summarize the evolution and significance of AS in surgical wards, including the surgical intensive care unit (SICU) and the role of diagnostic stewardship (DS). The contribution of AS team members is presented. The new diagnostic modalities and the new technologies including artificial intelligence (AI) are also reviewed.

Stop in Time: How to Reduce Unnecessary Antibiotics in Newborns with Late-Onset Sepsis in Neonatal Intensive Care.

The fear of missing sepsis episodes in neonates frequently leads to indiscriminate use of antibiotics, and prescription program optimization is suggested for reducing this inappropriate usage. While different authors have studied how to reduce antibiotic overprescription in the case of early onset sepsis episodes, with different approaches being available, less is known about late-onset sepsis episodes. Biomarkers (such as C-reactive protein, procalcitonin, interleukin-6 and 8, and presepsin) can play a crucial role in the prompt diagnosis of late-onset sepsis, but their role in antimicrobial stewardship should be further studied, given that different factors can influence their levels and newborns can be subjected to prolonged therapy if their levels are expected to return to zero. To date, procalcitonin has the best evidence of performance in this sense, as extrapolated from research on early onset cases, but more studies and protocols for biomarker-guided antibiotic stewardship are needed. Blood cultures (BCs) are considered the gold standard for the diagnosis of sepsis: positive BC rates in neonatal sepsis workups have been reported as low, implying that the majority of treated neonates may receive unneeded drugs. New identification methods can increase the accuracy of BCs and guide antibiotic de-escalation. To date, after 36-48 h, if BCs are negative and the baby is clinically stable, antibiotics should be stopped. In this narrative review, we provide a summary of current knowledge on the optimum approach to reduce antibiotic pressure in late-onset sepsis in neonates.

Community Development Initiatives and Sustainable Tourism in Rural Thailand: A Case Study of Chiang Mai

Chiang Mai, renowned for its cultural heritage and natural beauty, faces the dual challenge and opportunity of sustainable tourism development. This paper explores the intricate dynamics of sustainable tourism in Chiang Mai, focusing on community-led initiatives, economic benefits, cultural preservation efforts, challenges, and opportunities. Through case studies and analysis, we examine the role of community participation, environmental stewardship, and cultural authenticity in shaping the future of tourism in the region. Despite facing challenges such as overcrowding, environmental degradation, and social disparities, Chiang Mai holds vast potential for innovative, inclusive, and environmentally responsible tourism practices. By embracing sustainable tourism principles, fostering community empowerment, and leveraging collaborative partnerships, Chiang Mai can chart a path towards a more resilient, equitable, and culturally vibrant tourism destination.

Fire severity drives understory community dynamics and the recovery of culturally significant plants

AbstractAnthropogenic influences are altering fire regimes worldwide, resulting in an increase in the size and severity of wildfires. Simultaneously, throughout western North America, there is increasing recognition of the important role of Indigenous fire stewardship in shaping historical fire regimes and fire‐adapted ecosystems. However, there is limited understanding of how ecosystems are affected by or recover from contemporary “megafires,” particularly in terms of understory plant communities that are critical to both biodiversity and Indigenous cultures. To address this gap, our collaborative study, in partnership with Secwépemc First Nations, examined understory community recovery following a large, mixed‐severity wildfire that burned in the dry and mesic conifer forests of British Columbia, Canada, with a focus on plants of high cultural significance to Secwépemc communities. To measure the effect of a continuous gradient of fire severity across forest types, we conducted field assessments of fire severity and sampled understory plants 4 years postfire. We found that native species richness and richness of species of high cultural significance were lowest in areas that burned at high severity, with distinct compositional differences between unburned areas and those that burned at high severity. These findings were consistent across forest types characterized by distinct historical fire regimes. In contrast, richness of exotic species increased with increasing fire severity in the dominant montane interior Douglas‐fir forests, with exotic species closely associated with areas that burned at high severity. Our study indicates that recent megafires may be pushing ecosystems outside their historical range of variability, with negative implications for ecosystem recovery and cultural use across these fire‐affected landscapes. We also found consistently higher plant diversity, and both native and cultural species richness, in subalpine forests. Collectively, our results provide strong evidence of the ecological and cultural significance of low‐ to moderate‐severity fire and subalpine forests, and the longstanding and ongoing role of Indigenous peoples in shaping these landscapes. As wildfires continue to impact ecosystems and human communities, this study offers novel insights into the recovery of important ecological and cultural values, while highlighting the need to support ethical research collaborations with Indigenous communities and Indigenous‐led revitalization of fire and plant stewardship.

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis.

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

PAPEL DOS INTERMEDIÁRIOS DE INVESTIMENTO INSTITUCIONAL NO CONTROLE CORPORATIVO: UMA ANÁLISE CRÍTICA

Purpose: The study aims to critically analyse the role of institutional investment intermediaries in the corporate control of their investee companies in Anglo-Saxon jurisdictions. Theoretical framework: Critical analysis of the role of institutional investment intermediaries derived out of the theoretical basis of classical theory of separation of ownership from management, agency theory, agency cost, stewardship theory and the modern corporate governance. Method: This is theoretical research using the analogy of the different accepted theories of corporate law on corporate management and control into the underlying utility of emerging institutional investment intermediaries in corporate control. Result and Conclusion: The result of the study shows major inferences that the suitable engagement in corporate control by institutional investment intermediaries is the stewardship relationship with its investee companies. However, their stewardship role can be converted to agency role to protect their private interests, which can also be resulted in the threat of corporate control monopolization as well as horizontal corporate control. Research implications: The research indicates the need for prevention of stewardship relationship transposing to agency relationship for preventing corporate control monopolization as well as horizontal corporate control. Originality/value: The current legal framework so far didn’t expect the possibility for transposition of stewardship relationship to agency relationship and its adverse impacts. Hence, corporate law and its allied laws shall take precautionary deterrence measures to avoid such transposition.

Optimizing the Treatment of Invasive Candidiasis-A Case for Combination Therapy.

Invasive candidiasis is a rising global health threat with increasing incidence, persistently high mortality, and diminishing treatment options. Antifungal resistance has rapidly emerged and spread, with multidrug-resistant species deemed an urgent and serious threat. While acknowledging the key role of antifungal stewardship and infection control in curbing spread, we examine the role of antifungal monotherapy in driving resistance and the potential for combination therapy to prevent stress adaptation and emergence of drug resistance. In addition to its role in mitigating resistance, combination treatment may improve drug penetration, expedite fungal clearance, and allow lower, less toxic doses of individual drugs to be used. A growing body of laboratory-based evidence suggests that antifungal combinations can yield synergistic activity against Candida spp., including against frequently multidrug-resistant Candida auris. It is imperative to test these combinations in clinical trials, incorporating resistance end points as a marker of success.

Evaluation after implementation of chemical bowel preparation for surgical site infections in elective colorectal cancer surgery and role of antimicrobial stewardship pharmacist: Retrospective cohort study

BackgroundWe evaluated the predictive factors for surgical site infections (SSIs) in elective colorectal cancer surgery and the role of antimicrobial stewardship (AS) pharmacists in modifying the clinical pathway.Main bodyBetween February 2017 and January 2022, 414 elective colorectal cancer surgeries were performed. The results of multivariate analysis by SSI incidence were adjusted odds ratio (aOR): 0.45; 95% confidence interval (CI): 0.22–0.96 (P = 0.039) for sex (female), aOR: 0.27; 95% CI: 0.13–0.58 (P < 0.001) for laparoscopy, aOR: 0.42; 95% CI: 0.19–0.91 (P = 0.029) for chemical bowel preparation. The median (interquartile range) postoperative length of stay was 12 (10.0–18.5) vs. 10 (9.0–13.0) days before and after the clinical pathway was modified (P < 0.001).ConclusionThe role of AS pharmacists was primarily to conduct a literature search to explore whether SSIs could be ameliorated by pharmacotherapy, coordinate the addition of chemical bowel preparation, and epidemiologically confirm their effectiveness.

“Just as curry is needed to eat rice, antibiotics are needed to cure fever”—a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India

ObjectivesTo understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West...

Implementasi Penerapan Good Corporate Governance Pada PT. Bank Muamalat KCP Stabat

This research explores the implementation of Good Corporate Governance (GCG) at Bank Muamalat KCP Stabat. The findings show that the bank has succeeded in establishing a strong corporate governance structure, with the active involvement of the supervisory board and audit committee, which reflects a commitment to transparency and accountability. Bank management is considered as a reliable agent, in accordance with the principles of Agency Theory, creating positive tendencies in policies that support the interests of shareholders. In the dimensions of Stewardship Theory, banks actively integrate the interests of customers, employees and society into their GCG policies, showing the importance of a corporate culture that supports management's stewardship role. The success of GCG implementation is realized in achieving compliance with regulations and standards, with transparent financial reports. Bank Muamalat KCP Stabat, through its GCG practices, has a positive impact on shareholders and other stakeholders.

Alternatives to β-Lactams as Agents for the Management of Dentoalveolar Abscess.

Dentoalveolar abscess are localized infections within the tooth or the surrounding alveolar bone, often resulting from untreated dental caries or dental trauma causing alveolar bone resorption or even loss. Serious consequences arising from the spread of a dental abscess can often lead to significant morbidity and mortality. The acute dentoalveolar abscess is a polymicrobial infection comprising strict anaerobes, such as anaerobic cocci i.e., Prevotella fusobacterium species, and facultative anaerobes i.e., Streptococci viridians and Streptococcus anginosus. Moreover, inappropriately managed dental infections can progress to severe submandibular space infections with associated serious complications, such as sepsis and airway obstruction. An audit of the Hull Royal Infirmary between 1999 and 2004 showed an increase in the number of patients presenting to oral and maxillofacial surgery services with dental sepsis. Thus, the scientific community is forced to focus on treatment strategies for the management of dentoalveolar abscess (DAA) and other related dental problems. The current treatment includes antibiotic therapy, including β-lactams and non-β- lactams drugs, but it leads to the development of resistant microorganisms due to improper and wide usage. Furthermore, the currently used β-lactam therapeutics is non-specific and easily hydrolyzed by the β-lactamase enzymes. Thus, the research focused on the non-β-lactams that can be the potential pharmacophore and helpful in the management of DAA, as the appropriate use and choice of antibiotics in dentistry plays an important role in antibiotic stewardship. The newer target for the choice is NLRP inflammasome, which is the major chemical mediator involved in dental problems. This review focused on pathogenesis and current therapeutics for the treatment of dentoalveolar abscesses.

Deciphering the genomic character of the multidrug-resistant &lt;i&gt;Staphylococcus aureus&lt;/i&gt; from Dhaka, Bangladesh

&lt;p&gt;&lt;italic&gt;Staphylococcus aureus&lt;/italic&gt; is one of the leading agents of nosocomial and community-acquired infections. In this study, we explored the genomic characterization of eight methicillin-resistant clinical isolates of &lt;italic&gt;S. aureus&lt;/italic&gt; from Dhaka, Bangladesh. Notably, all strains were resistant to penicillin, cephalosporins, and monobactams, with partial susceptibility to meropenem and complete susceptibility to amikacin, vancomycin, and tigecycline antibiotics. The strains were found to have an average genome size of 2.73 Mbp and an average of 32.64% GC content. Multi-locus sequence typing analysis characterized the most predominant sequence type as ST361, which belongs to the clonal complex CC361. All isolates harbored the &lt;italic&gt;mecA&lt;/italic&gt; gene, often linked to SCC&lt;italic&gt;mec&lt;/italic&gt;_type IV variants. Multidrug resistance was attributed to efflux pumps NorA, NorC, SdrM, and LmrS alongside genes encoding beta-lactamase BlaZ and factors like ErmC and MepA. Additionally, virulence factors including &lt;italic&gt;adsA&lt;/italic&gt;, &lt;italic&gt;sdrC&lt;/italic&gt;, &lt;italic&gt;cap8D&lt;/italic&gt;, &lt;italic&gt;harA&lt;/italic&gt;, &lt;italic&gt;esaA&lt;/italic&gt;, essC, &lt;italic&gt;isdB&lt;/italic&gt;, &lt;italic&gt;geh&lt;/italic&gt;, and &lt;italic&gt;lip&lt;/italic&gt; were commonly identified. Furthermore, genes associated with heme uptake and clumping were present, highlighting their roles in &lt;italic&gt;S. aureus&lt;/italic&gt; colonization and pathogenesis. Nine secondary metabolite biosynthetic gene clusters were found, of which six were common in all the strains. Numerous toxin-antitoxin systems were predicted, with ParE and ParB-like nuclease domains found to be the most prevalent toxin and antitoxin, respectively. Pan-genome analysis revealed 2007 core genes and 229 unique genes in the studied strains. Finally, the phylogenomic analysis showed that most Bangladeshi strains were grouped into two unique clades. This study provides a genomic and comparative insight into the multidrug resistance and pathogenicity of &lt;italic&gt;S. aureus&lt;/italic&gt; strains, which will play a crucial role in the future antibiotic stewardship of Bangladesh.&lt;/p&gt;

Outpatient parenteral antimicrobial therapy in pediatrics: the role of antimicrobial stewardship

Abstract This study characterized outpatient parenteral antimicrobial therapy (OPAT) orders and associated antimicrobial stewardship program (ASP) pharmacist recommendations made in a freestanding children’s hospital. Recommendations occurred in over 50% of orders, indicating an opportunity for the review of OPAT by ASP pharmacists.

Treatment of onychomycosis in an era of antifungal resistance: Role for antifungal stewardship and topical antifungal agents.

A growing body of literature has marked the emergence and spread of antifungal resistance among species of Trichophyton, the most prevalent cause of toenail and fingernail onychomycosis in the United States and Europe. We review published data on rates of oral antifungal resistance among Trichophyton species; causes of antifungal resistance and methods to counteract it; and invitro data on the role of topical antifungals in the treatment of onychomycosis. Antifungal resistance among species of Trichophyton against terbinafine and itraconazole-the two most common oral treatments for onychomycosis and other superficial fungal infections caused by dermatophytes-has been detected around the globe. Fungal adaptations, patient characteristics (e.g., immunocompromised status; drug-drug interactions), and empirical diagnostic and treatment patterns may contribute to reduced antifungal efficacy and the development of antifungal resistance. Antifungal stewardship efforts aim to ensure proper antifungal use to limit antifungal resistance and improve clinical outcomes. In the treatment of onychomycosis, critical aspects of antifungal stewardship include proper identification of the fungal infection prior to initiation of treatment and improvements in physician and patient education. Topical ciclopirox, efinaconazole and tavaborole, delivered either alone or in combination with oral antifungals, have demonstrated efficacy invitro against susceptible and/or resistant isolates of Trichophyton species, with low potential for development of antifungal resistance. Additional real-world long-term data are needed to monitor global rates of antifungal resistance and assess the efficacy of oral and topical antifungals, alone or in combination, in counteracting antifungal resistance in the treatment of onychomycosis.

Towards harmonized laboratory methodologies in veterinary clinical bacteriology: outcomes of a European survey.

Veterinary clinical microbiology laboratories play a key role in antimicrobial stewardship, surveillance of antimicrobial resistance and prevention of healthcare associated-infections. However, there is a shortage of international harmonized guidelines covering all steps of veterinary bacterial culture from sample receipt to reporting. In order to gain insights, the European Network for Optimization of Veterinary Antimicrobial Treatment (ENOVAT) designed an online survey focused on the practices and interpretive criteria used for bacterial culture and identification (C&ID), and antimicrobial susceptibility testing (AST) of animal bacterial pathogens. A total of 241 microbiology laboratories in 34 European countries completed the survey, representing a mixture of academic (37.6%), governmental (27.4%), and private (26.5%) laboratories. The C&ID turnaround varied from 1 to 2 days (77.8%) to 3-5 days (20%), and 6- 8 days (1.6%), with similar timeframes for AST. Individual biochemical tests and analytical profile index (API) biochemical test kits or similar were the most frequent tools used for bacterial identification (77% and 56.2%, respectively), followed by PCR (46.6%) and MALDI-TOF MS (43.3%). For AST, Kirby-Bauer disk diffusion (DD) and minimum inhibitory concentration (MIC) determination were conducted by 43.8% and 32.6% of laboratories, respectively, with a combination of EUCAST and CLSI clinical breakpoints (CBPs) preferred for interpretation of the DD (41.2%) and MIC (47.6%) results. In the absence of specific CBPs, laboratories used human CBPs (53.3%) or veterinary CBPs representing another body site, organism or animal species (51.5%). Importantly, most laboratories (47.9%) only report the qualitative interpretation of the result (S, R, and I). As regards testing for AMR mechanisms, 48.5% and 46.7% of laboratories routinely screened isolates for methicillin resistance and ESBL production, respectively. Notably, selective reporting of AST results (i.e. excluding highest priority critically important antimicrobials from AST reports) was adopted by 39.5% of laboratories despite a similar proportion not taking any approach (37.6%) to guide clinicians towards narrower-spectrum or first-line antibiotics. In conclusion, we identified a broad variety of methodologies and interpretative criteria used for C&ID and AST in European veterinary microbiological diagnostic laboratories. The observed gaps in veterinary microbiology practices emphasize a need to improve and harmonize professional training, innovation, bacterial culture methods and interpretation, AMR surveillance and reporting strategies.

Registered nurses’ antimicrobial stewardship roles: a qualitative descriptive exploratory study

Registered nurses’ antimicrobial stewardship roles: a qualitative descriptive exploratory study

Rooting natural climate solutions in Wahkohtowin through Indigenous guardianship: insights from a youth-led initiative in Northern Ontario, Canada

In recent years, increasing attention has been directed to “natural climate solutions” to mitigate climate change through the protection, restoration, and improved management of carbon-storing ecosystems. In practice, Indigenous Peoples have been implementing natural climate solutions for millennia through land stewardship. As Indigenous nations and communities in Canada reassert stewardship roles through Indigenous Guardians programs, the question arises: what possibilities emerge when natural climate solutions are driven by Guardians, guided by multifaceted community priorities and Indigenous knowledge? This paper responds to this question, drawing upon collaborative research with Wahkohtowin Development, a social enterprise based in Treaty 9 territory (Ontario, Canada), made up of Chapleau Cree First Nation, Missanabie Cree First Nation, and Brunswick House First Nation. We engaged youth Guardians in workshops that generated insights on the role of youth, cross-cultural collaboration, and holistic conceptualizations of climate action rooted in Indigenous ontologies (such as the Cree philosophy of wahkohtowin, embodying kinship and interconnectedness). Our analysis reveals that Indigenous Guardians are well positioned to advance natural climate solutions and to do so in an integrative manner that addresses intersecting challenges—with benefits for communities, ecosystems, climate action, and reconciliation.