Stewardship Interventions Research Articles

Approaches to developing and implementing a molecular diagnostics stewardship program for infectious diseases: an ASM Laboratory Practices Subcommittee report.

Diagnostic stewardship (DxS) for infectious disease testing requires a multi-disciplinary approach to optimize test selection, performance, interpretation and patient treatment. Nucleic acid amplification-based tests for the diagnosis of infectious diseases, or "molecular microbiology tests," have rapidly expanded over the past two decades. With the increased availability and complexity of these tests, there is also an increased need for collaborative approaches to optimize test use to promote positive impacts on patient care, while mitigating potential negative impact or resource waste. In this review, we provide recommendations on building collaborative DxS teams, including microbiologists and the diverse stakeholders that use and interpret molecular microbiology tests. We then detail approaches to identify high-priority molecular microbiology tests that may need utilization assessment, select appropriate diagnostic stewardship interventions, and monitor the impact of implemented interventions. This strategic process may be employed by laboratories to realize optimal testing for selected tests at their institution.

Implementation of a tailored multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for urinary tract infections in frail older adults (ImpresU) in four European countries: a process evaluation alongside a pragmatic cluster randomized controlled trial

BackgroundWe previously performed a pragmatic cluster randomized controlled trial (RCT) in general practices and older adult care organizations in Poland, the Netherlands, Norway, and Sweden. We found that a multifaceted antibiotic stewardship intervention (ASI) substantially reduced antibiotic use for suspected urinary tract infections (UTIs) in frail older adults compared with usual care. We aimed to evaluate the implementation process of the ASI to provide recommendations for clinical practice.MethodsWe conducted a process evaluation alongside the cluster RCT. The ASI consisted of a decision-tool and a toolbox, which were implemented using a participatory-action-research (PAR) approach with sessions for education and evaluation. We documented the implementation process of the intervention and administered a questionnaire to health care professionals (HCPs) from participating organizations in the intervention and usual care clusters. We evaluated the multiple components of the intervention and its implementation following a structured framework.ResultsThe questionnaire was completed by 254 HCPs from the 38 participating clusters. All components were largely delivered according to plan and evaluated as useful. The decision-tool and toolbox materials were reported to facilitate decision-making on UTIs. Regarding the PAR approach, educational sessions focusing on the distinction between UTIs and asymptomatic bacteriuria were held in all 19 intervention clusters. In 17 out of these 19 clusters, evaluation sessions took place, which were reported to help remind HCPs to implement the ASI. During both sessions, HCPs valued the reflection that took place and the resulting awareness of their behavior. It allowed them to explore implementation barriers and to tailor their local implementation process to overcome these. For example, HCPs organized extra educational sessions or revised local policies to incorporate the use of the decision-tool. Various HCPs took key roles in implementation. Staff changes and the COVID-19 pandemic were important contextual barriers.ConclusionsWe found each component of the multifaceted ASI and its implementation to have added value in the process to improve antibiotic prescribing for suspected UTIs in a heterogeneous older adult care setting. We recommend using a multifaceted, multidisciplinary approach that enables HCPs to reflect on their current practice and accordingly tailor local implementation.Trial registrationClinicalTrials.gov NCT03970356. Registered on May 31, 2019.

Lack of Diagnostic Value from Fungal and Mycobacterial Cultures in Cases of Suspected Prosthetic Joint Infection

Abstract Introduction/Objective Infections of prosthetic joints cause significant morbidity and often result in removal of the infected joint. In many cases, an infectious etiology can be difficult to definitively identify. As a result, providers suspecting prosthetic joint infections (PJI) often place large order sets of microbiology tests, including fungal and mycobacterial cultures. Fungal and mycobacterial cultures are labor-intensive for the laboratory taking up to 28 days and 42 days, respectively, to complete. As a potential area for a diagnostic stewardship intervention, we wanted to evaluate how often a fungal or mycobacterial culture produced actionable information in cases of suspected PJI. Methods/Case Report Data reports were retrieved from both the Electronic Health Record (EHR) and the Laboratory Information System (LIS) from May 2022 to May 2023. As sources submitted by the provider often do not specify that the joint is prosthetic, data from LIS was evaluated to identify microbiology culture test sets ordered on joint sources, while data from EHR was examined to isolate patients with implanted joints. Using Microsoft Excel, data from both systems was compared in order to match microbiology culture test sets to the known implanted joints. LIS data from implanted joint sources was assessed to record negative (no growth) and positive (growth) cultures, and to register all organisms isolated. Results (if a Case Study enter NA) Of 794 order sets for cultures collected from prosthetic joint sources, 430 included requests for fungal culture and 79 included requests for mycobacterial culture. Of these 79 requests for mycobacterial culture, 0 organisms were isolated (0%). Of these 430 requests for fungal culture, 7 grew yeast (1.6%) and 7 out of 7 (100%) of these yeasts were also isolated on general (aerobic bacterial) culture. No molds were isolated. Conclusion Discontinuing the routine practice of ordering fungal and mycobacterial culture for prosthetic joint sources would have no negative impact on patient care but would reduce unnecessary work in the microbiology laboratory and potentially avoid additional costs to the patient. Education to the orthopedic provider group as well as best practice alerts in the EHR will be pursued, based on the findings from this study, in order to reduce unnecessary culture orders.

A Systematic Review of Dental Antibiotic Stewardship Interventions.

Antimicrobial resistance is a significant threat to global health. Antimicrobial stewardship is reducing inappropriate antimicrobial prescribing to counter it. Dentists prescribe ~10% of all antibiotics worldwide, yet up to 90% of antibiotic prescriptions by dentists are inappropriate. The aim of this systematic review was to update a 2017 review evaluating the effects of antibiotic stewardship interventions in dental settings, using the international consensus on core outcomes for dental antibiotic stewardship. Systematic database searches were undertaken in April 2023, of the: Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE via OVID, EMBASE via OVID, Dentistry and Oral Sciences Source, the US National Institutes of Health Trials Register, the World Health Organisation International Clinical Trials Registry Platform and the ISRCTN registry databases. Randomised controlled trials (or non-randomised studies with clearly reported mechanism of group formation and inclusion criteria) of interventions to optimise and/or reduce dental antibiotic prescribing were eligible for inclusion. Two authors independently screened for eligible studies. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, certainty of evidence assessed using GRADE. Meta-analysis was planned whether the results of studies reported similar outcomes, otherwise narrative synthesis was undertaken. Three eligible studies randomising 2148 participants were included. The interventions were combinations of education, audit and feedback and written behaviour change messages, guideline summary, practice visits and patient leaflets. None of the control groups received an intervention. All three included studies measured the quantity of antibiotics prescribed and two measured the appropriateness of prescribing. None measured patient-reported or adverse outcomes. Two included studies were assessed as 'high risk' and one with 'low risk' of bias. There was high-certainty evidence that audit and personalised feedback with individualised behaviour change messages can be effective. Evidence for in-person education was low-certainty. Guideline dissemination alone was ineffective at improving antibiotic prescribing. Due to different outcomes reported, meta-analysis was inappropriate. Although various dental antibiotic stewardship interventions have been reported in the literature, none provided high-certainty evidence of effectiveness and only three have been evaluated using a randomised design. To strengthen the body of evidence, well-powered, robust, randomised controlled trials are required, with adequate follow-up, reporting the internationally-agreed core outcomes and including a parallel process evaluation is recommended. PROSPERO (CRD42023411476).

Implementation of a Nurse-Initiated Antibiotic Time-Out (NATO) in Childhood Cancer Patients in Central America

Abstract Background Children with cancer are at high risk for infection and frequently require antimicrobials. Antimicrobial stewardship (AMS) interventions can mitigate toxicity and development of antibiotic resistance yet the pharmacy and infectious diseases specialists who usually perform AMS are often absent in global settings. We report our experience testing a novel intervention to shift the antibiotic timeout to nurses in six pediatric oncology units in Central America. Methods The Nurse-initiated Antibiotic Timeout (NATO) is a scripted conversation between nurses and physicians to reevaluate antibiotic appropriateness after 48 to 72 hours of empiric use for febrile neutropenia. First, we performed a baseline assessment of AMS capacity using the WHO Practical Toolkit for AMS Programmes checklist. Based on these results, sites tailored a generic implementation plan emphasizing educational and documentation tools and iterative PDSA (Plan-Do, Study-Act) cycles to improve implementation and effectiveness outcomes. Results All sites collected antimicrobial use data for a minimum of two months. Four sites then piloted NATO, producing change ideas, including changes to documentation tools, antimicrobial decision categories, communication processes, and times. From August 2022 – October 2023, NATO was performed in 53.4% of febrile neutropenia episodes in the three sites reporting data. Sites had substantial NATO performance rate variation from month to month. Sites reported changes in antimicrobial therapy in 47% of episodes after a 6-month period (Figure 1). Conclusion The difference in performance rate of NATO underscores the importance of real-time reporting to adjust AMS implementation strategies. The change ideas developed by each site differed, however, core tools emerged, which will support AMS in other global settings. Next steps include comparing antimicrobial use pre- and post-intervention and determining a sustainability and scalability plan. Figure 1. Incidence of change in antibiotic therapy over time.

Sustainment of perioperative antimicrobial prophylaxis guidelines in children following discontinuation of an educational intervention to support stewardship.

Adherence to perioperative antimicrobial guidelines among Greek children was markedly decreased years after the discontinuation of an antimicrobial stewardship (AS) intervention. An educational intervention is effective to improve the perioperative antimicrobial use, but the continuous implementation of AS is important for its long-term sustainability.

Optimal Pediatric Outpatient Antibiotic Prescribing

In the US, 50% of all pediatric outpatient antibiotics prescribed are unnecessary or inappropriate. Less is known about the appropriateness of pediatric outpatient antibiotic prescribing. To identify the overall percentage of outpatient antibiotic prescriptions that are optimal according to guideline recommendations for first-line antibiotic choice and duration. This cross-sectional study obtained data on any clinical encounter for a patient younger than 20 years with at least 1 outpatient oral antibiotic, intramuscular ceftriaxone, or penicillin prescription filled in the state of Tennessee from January 1 to December 31, 2022, from IQVIA's Longitudinal Prescription Claims and Medical Claims databases. Each clinical encounter was assigned a single diagnosis corresponding to the lowest applicable tier in a 3-tier antibiotic tier system. Antibiotics prescribed for tier 1 (nearly always required) or tier 2 (sometimes required) diagnoses were compared with published national guidelines. Antibiotics prescribed for tier 3 (rarely ever required) diagnoses were considered to be suboptimal for both choice and duration. Primary outcome was the percentage of optimal antibiotic prescriptions consistent with guideline recommendations for first-line antibiotic choice and duration. Secondary outcomes were the associations of optimal prescribing by diagnosis, suboptimal antibiotic choice, and patient- and clinician-level factors (ie, age and Social Vulnerability Index) with optimal antibiotic choice, which were measured by odds ratios (ORs) and 95% CIs calculated using a multivariable logistic regression model. A total of 506 633 antibiotics were prescribed in 488 818 clinical encounters (for 247 843 females [50.7%]; mean [SD] age, 8.36 [5.5] years). Of these antibiotics, 21 055 (4.2%) were for tier 1 diagnoses, 288 044 (56.9%) for tier 2 diagnoses, and 197 660 (39.0%) for tier 3 diagnoses. Additionally, 194 906 antibiotics (38.5%) were optimal for antibiotic choice, 259 786 (51.3%) for duration, and 159 050 (31.4%) for both choice and duration. Acute otitis media (AOM) and pharyngitis were the most common indications, with 85 635 of 127 312 (67.3%) clinical encounters for AOM and 42 969 of 76 865 (55.9%) clinical encounters for pharyngitis being optimal for antibiotic choice. Only 257 of 4472 (5.7%) antibiotics prescribed for community-acquired pneumonia had a 5-day duration. Optimal antibiotic choice was more likely in patients who were younger (OR, 0.98; 95% CI, 0.98-0.98) and were less socially vulnerable (OR, 0.84; 95% CI, 0.82-0.86). This cross-sectional study found that less than one-third of antibiotics prescribed to pediatric outpatients in Tennessee were optimal for choice and duration. Four stewardship interventions may be targeted: (1) reduce the number of prescriptions for tier 3 diagnoses, (2) increase optimal prescribing for AOM and pharyngitis, (3) provide clinician education on shorter antibiotic treatment courses for community-acquired pneumonia, and (4) promote optimal antibiotic prescribing in resource-limited settings.

Appropriateness of antibiotic prescribing among patients treated for dental diseases in Mekelle city, Northern Ethiopia: a cross sectional study

BackgroundLocal operative treatments are generally preferred for most dental diseases, with antibiotics only recommended as an adjunct in specific cases. Misuse and overuse of antibiotics has been shown to significantly contribute to the development of resistant bacteria. However, the antibiotic prescribing practices of dentists in Ethiopia have not been thoroughly studied. This study aimed to assess the appropriateness of antibiotic prescribing for patients with dental diseases at dental clinics in Mekelle City, Northern Ethiopia.MethodsA cross sectional study was conducted in April and May 2020 among patients visiting dental clinics in Mekelle City. Data were collected through patient medical record reviews and dentist interviews. The appropriateness of antibiotic prescription was evaluated based on guidelines from the American Dental Association and the European Society of Endodontology. Data were analyzed using SPSS Statistics, version 29. Binary logistic regression analysis was performed, and the results were presented as odds ratios with 95% confidence intervals. A p value less than 0.05 was considered statistically significant.ResultsTwo hundred and thirty-one patients with dental diseases participated in the study. The mean age was 30.6 years with a standard deviation of 16.1. Most participants had dental pulp related disease. 89% of patients were prescribed antibiotics, with amoxicillin being the most common. Inappropriate antibiotic prescribing was identified in 175 (75.8%) of the study participants. The most common inappropriate prescribing was unnecessary antibiotic prescribing for dental conditions without systemic signs, assessed in 141 (80.1%) participants. Patients diagnosed with pulp related disease without systemic signs and those who had tooth extractions were significantly associated with inappropriate antibiotic prescription (p value < 0.001).ConclusionsThe study findings show that antibiotics are over-prescribed for dental conditions in this resource constrained setting, especially in patients who have had tooth extractions. Dentists need training on appropriate antibiotic use and antimicrobial stewardship interventions should be implemented in dental setting to reduce unnecessary antibiotic prescriptions and prevent antibiotic resistance development.

Validation of Administrative Data and Timing of Point Prevalence Surveys for Antibiotic Monitoring

Point prevalence surveys (PPSs) are used globally to collect data on antibiotic prescriptions. However, the optimal frequency for data collection to ensure comprehensive understanding of antibiotic use and to target and monitor stewardship interventions remains unknown. To identify the optimal frequency for collecting data on antibiotic use among the pediatric population through PPSs leveraging administrative data. This prognostic study used a cross-sectional validation approach and was conducted in pediatric outpatient and inpatient settings in the Veneto region of Italy. Antibiotics were classified according to the World Health Organization Access, Watch and Reserve criteria. Prescribing rates of access antibiotics were analyzed for pediatric inpatients with records dated between October 1, 2014, and December 31, 2022, and outpatients with records dated between January 1, 2010, and December 31, 2022. The study included children younger than 15 years with an antibiotic prescription who were admitted to the pediatric acute care unit or evaluated by a primary care pediatrician. Data analysis was performed from October 2023 to January 2024. An algorithm was developed to identify optimal time frames for conducting PPSs. This approach sought to minimize the discrepancy between quarterly and yearly PPS results, aiming to accurately estimate annual antibiotic prescribing rates in both inpatient and outpatient settings (primary outcome). External validity of the optimal PPS time frames derived from outpatient data when applied to the inpatient setting was also investigated. Validation involved assessing the effectiveness of administrative data in identifying strategic PPS periods for capturing inpatient antibiotic use patterns (secondary outcome). This analysis included 106 309 children: 3124 were inpatients (1773 males [56.8%]) and 103 185 were outpatients (53 651 males [52.0%]). A total of 5099 and 474 867 antibiotic prescriptions from inpatients and outpatients were analyzed, respectively. Outpatients tended to be older than inpatients, with a median age of 3.2 (IQR, 1.3-6.3) years vs 2.6 (IQR, 0.6-6.6) years, respectively, and with a lower burden of clinical comorbidities (≥1 comorbidity: 6618 [6.4%] vs 1141 [36.5%], respectively). The algorithm successfully identified distinct time frames within the calendar year from inpatient and outpatient records optimized for PPS data collection. Rates obtained from the quarterly PPS during these identified periods exhibited greater agreement with annual antibiotic prescribing rates (inpatient: r = 0.17, P < .001; and outpatient: r = 0.42, P < .001) than those derived from the yearly PPS (inpatient: r = 0.04, P = .58; and outpatient: r = 0.05, P = .34), with a Δ reduction of up to 89.8% (where Δ represents the percentage point change in antibiotic prescribing rates). Furthermore, the optimal PPS time frames gleaned from the outpatient data demonstrated robust applicability to the inpatient setting, yielding comparable results in both scenarios. This study evaluated the potential of administrative data in determining the optimal timing of PPS implementation. The quarterly PPS balanced precision and sustainability, especially when implemented during strategically selected periods across different seasons. Further studies are needed to validate the algorithm used in this study, especially in post-COVID-19 pandemic years and different settings.

How do experts determine where to intervene on test ordering? An interview study

Abstract Objectives Lab testing is a high-volume activity that is often overused, leading to wasted resources and inappropriate care. Improving test ordering practices in tertiary care involves deciding where to focus scarce intervention resources, but clear guidance on how to optimize these resources is lacking. We aimed to explore context-sensitive factors and processes that inform individual decisions about laboratory stewardship interventions by speaking to key interest holders in this area. Methods We conducted semi-structured interviews with test-ordering intervention development experts and authors of test-ordering guidance documents to explore five broad topics: 1) processes used to prioritize tests for intervention; 2) factors considered when deciding which tests to target; 3) measurement of these factors; 4) interventions selected; 5) suggestions for a framework to support these decisions. Transcripts were double coded using directed-content and thematic analysis. Results We interviewed 14 intervention development experts. Experts noted they frequently consider test volume, test value, and patient care when deciding on a test to target. Experts indicated that quantifying many relevant factors was challenging. Processes to support these decisions often involved examining local data, obtaining buy-in, and relying on an existing guideline. Suggestions for building a framework emphasized the importance of collaboration, consideration of context and resources, and starting with “easy wins” to gain support and experience. Conclusions Our study provides insight into the factors and processes experts consider when deciding which tests to target for intervention and can inform the development of a framework to guide the selection of tests for intervention and guideline development.

Validation of short culture method for rapid bacterial identification of blood cultures via matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

Development of rapid bacterial identification from blood cultures has been an area of intense study in diagnostic microbiology. Shortened turnaround time coupled with antimicrobial stewardship interventions have been shown to improve patient outcomes and decrease healthcare-associated costs. We report the validation of a short incubation method for Gram-positive and Gram-negative bacterial identification utilizing MALDI-TOF MS without additional instrumentation, processing or cost compared with current practice. Prospective, observational, single-centre study in a quaternary care academic hospital encompassing 376 blood cultures subjected to bacterial identification after short incubation periods of 3-4 and 6-8 h. There was 97.5% species-level identification agreement with tests undertaken after 3-4 h incubation with 83.6% isolates identified, and 99.7% species-level identification agreement after 6-8 h incubation with 96.7% isolates identified. The short incubation method provides a rapid MALDI-TOF MS bacterial identification method, reducing turnaround time by 10-18 h compared with standard practice without additional cost, processing or instrumentation.

Evaluation of Antibiotic Use for Dental-Related Infections in Dental Clinics Associated With an Academic Safety Net Institution.

This retrospective study found lower antibiotic prescribing rates by outpatient dentists than previous literature, but with deviations from guideline recommendations in antibiotic indications and durations of treatment for oral pain and swelling. These findings will guide future stewardship interventions to promote guideline-directed therapy plans.

“Antimicrobial utilization in a paediatric intensive care unit in India: A step towards strengthening antimicrobial stewardship practices"

Antimicrobials are frequently used in critically ill children admitted to the Paediatric Intensive Care Unit (PICU). The antimicrobial use data from Indian PICUs is limited using standard metrics such as Days of therapy (DOT). This study aimed to determine the baseline trend of antimicrobial use in PICU of a tertiary care teaching hospital of Raipur district of Chhattisgarh, India using standard metrics with the goal of developing facility-wide antibiotic policy and strengthening the antimicrobial stewardship activities. This active surveillance was conducted over a period of 18 months, from November 1, 2019, to March 21, 2021, in patients aged one month to 14 years who were admitted for ≥ 48 hours to the PICU at a tertiary care teaching hospital of Raipur District. Data on patient characteristics, antimicrobial indications, antimicrobial prescription information, and clinical outcomes were collected using pre-designed data abstraction forms. The descriptive statistic was used to represent the results. The antimicrobial consumption was analyzed according to the WHO AWaRe Class (Access, Watch, and Reserve groups) of antibiotics. The antimicrobial consumption was expressed as DOT/1000 patient-days (PD). A total of 216 patients were surveyed during the study period. The average number of antimicrobials prescribed per hospitalisation was 2.60 (range: 1–12), with 97.22% administered via parenteral route. Overall, DOT/1000-PD was 1318. The consumption of Watch Group antimicrobials was highest with 949 DOT/1000-PD, followed by Access (215) and Reserve Group (154), respectively. Ceftriaxone (208 DOT/1000 PD) was the most commonly prescribed antimicrobial agent, followed by Vancomycin (201), Meropenem (175), Piperacillin-Tazobactam (122) and Colistin (91). The patients who were escalated (28.24%) from empirical antimicrobial therapy had longer median PICU stay (8 days) compared those who were de-escalated (23.6%). Targeted therapy was given in 10.2% patients. The overall mortality rate was 14.35% and was higher (29.3%) in patients in whom empirical therapy was escalated compared to those who were de-escalated or continued. The study established a benchmark for antimicrobials use in the PICU and highlighted priority areas for antimicrobial stewardship intervention to enhance de-escalation rates, enhance targeted therapy, and reduce the overuse of antimicrobials especially belonging to the reserve group.

Antibiotics at End of Life: Where Are We Now and Where Are We Going? A Narrative Review.

Antibiotics are frequently prescribed at the end of life, though the benefits and harms are not well understood. We abstracted relevant findings from articles published in English in the past 25years to answer questions generated by discussion among the authors and with stakeholders in Palliative Care and Infectious Diseases. Prescribing practices vary based on individual situation and geographic location. Patients with cancer and those hospitalized receive more antibiotics than those enrolled in outpatient hospice. Urinary tract infections and pulmonary infections are the most common conditions treated with antibiotics at the end of life -most often with penicillin derivatives and vancomycin in the hospital, fluoroquinolones in outpatient, and cephalosporins in both settings. When asked, patients most often prefer limiting antibiotics to symptom management at the end of life. Physicians' over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis increases antibiotic prescription rates. Antibiotics can improve symptoms when used for specific diseases at the cost of drug reactions, resistant organisms, and delayed discharge. Antibiotic use has variable results on survival duration. Antimicrobial stewardship exists in hospital and long-term care facilities, but not outpatient hospice groups. Stewardship interventions could increase proper use of antibiotics, but more information is needed to apply these interventions to hospice groups. Antibiotics at the end of life are impactful and efforts to educate patients and providers will be invaluable in optimizing care.

Impact of a tracheal aspirate culture diagnostic test stewardship intervention in a tertiary care PICU.

To assess the impact of a diagnostic test stewardship intervention focused on tracheal aspirate cultures. Quality improvement intervention. Tertiary care pediatric intensive care unit (PICU). Mechanically ventilated children admitted between 9/2018 and 8/2022. We developed and implemented a consensus guideline for obtaining tracheal aspirate cultures through a series of Plan-Do-Study-Act cycles. Change in culture rates and broad-spectrum antibiotic days of therapy (DOT) per 100 ventilator days were analyzed using statistical process control charts. A secondary analysis comparing the preintervention baseline (9/2018-8/2020) to the postintervention period (9/2020-8/2021) was performed using Poisson regression. The monthly tracheal aspirate culture rate prior to the COVID-19 pandemic (9/2018-3/2020) was 4.6 per 100 ventilator days. A centerline shift to 3.1 cultures per 100 ventilator days occurred in 4/2020, followed by a second shift to 2.0 cultures per 100 ventilator days in 12/2020 after guideline implementation. In our secondary analysis, the monthly tracheal aspirate culture rate decreased from 4.3 cultures preintervention (9/2018-8/2020) to 2.3 cultures per 100 ventilator days postintervention (9/2020-8/2021) (IRR 0.52, 95% CI 0.47-0.59, P < 0.01). Decreases in tracheal aspirate culture use were driven by decreases in inappropriate cultures. Treatment of ventilator-associated infections decreased from 1.0 to 0.7 antibiotic courses per 100 ventilator days (P = 0.03). There was no increase in mortality, length of stay, readmissions, or ventilator-associated pneumonia postintervention. A diagnostic test stewardship intervention was both safe and effective in reducing the rate of tracheal aspirate cultures and treatment of ventilator-associated infections in a tertiary PICU.

The imperative of teamwork in antimicrobial stewardship (AMS) interventions: insights from an ethnographic study with practitioners in Spain.

Teamwork-the activity of working together in a group towards a similar goal-is a defining feature of the practice of clinical medicine carried out in hospitals and other healthcare facilities. This Viewpoint suggests that teamwork is a defining feature of antimicrobial stewardship (AMS) programmes, and identifies six elements that characterise AMS team dynamics. These insights arise from an original ethnographic study of AMS carried out in Spain, where these programmes are known as Programas para la Optimización de Antimicrobianos. The study used qualitative research methods including ethnographic observations in public hospitals and scientific and educational fora, in-depth interviews and archival research. It calls for a reflection on the part of the global community of AMS practitioners on the role of team dynamics in building sustainable AMS interventions and the inclusion of teamwork skills in training curricula aimed at future practitioners.

Lack of Knowledge of Antibiotic Risks Contributes to Primary Care Patients' Expectations of Antibiotics for Common Symptoms.

Patient expectations of receiving antibiotics for common symptoms can trigger unnecessary use. We conducted a survey (n = 564) between January 2020 to June 2021 in public and private primary care clinics in Texas to study the prevalence and predictors of patients' antibiotic expectations for common symptoms/illnesses. We surveyed Black patients (33%) and Hispanic/Latine patients (47%), and over 93% expected to receive an antibiotic for at least 1 of the 5 pre-defined symptoms/illnesses. Public clinic patients were nearly twice as likely to expect antibiotics for sore throat, diarrhea, and cold/flu than private clinic patients. Lack of knowledge of potential risks of antibiotic use was associated with increased antibiotic expectations for diarrhea (odds ratio [OR] = 1.6; 95% CI, 1.1-2.4) and cold/flu symptoms (OR = 2.9; 95% CI, 2.0-4.4). Lower education and inadequate health literacy were predictors of antibiotic expectations for diarrhea. Future antibiotic stewardship interventions should tailor patient education materials to include information on antibiotic risks and guidance on appropriate antibiotic indications.

Unravelling the complex mechanisms of multidrug resistance in bovine mastitis pathogens: Insights into antimicrobial resistance genes, biofilm dynamics, and efflux systems

Mastitis remains a paramount economic threat to dairy livestock, with antibiotic resistance severely compromising treatment efficacy. This study provides an in-depth investigation into the multidrug resistance (MDR) mechanisms in bacterial isolates from bovine mastitis, emphasizing the roles of antimicrobial resistance genes (ARGs), biofilm formation, and active efflux systems. A total of 162 Staphylococci, eight Escherichia coli, and seven Klebsiella spp. isolates were obtained from 215 milk samples of clinical and subclinical mastitis cases. Antibiotic susceptibility testing identified Twenty Staphylococci (12.35 %), six E. coli (75 %) and seven Klebsiella (100 %) identified as MDR displaying significant resistance to β-lactams and tetracyclines The Multiple Antibiotic Resistance (MAR) index of these isolates ranged from 0.375 to 1.0, highlighting extensive resistance. Notably, 29 of the 33 MDR isolates produced biofilms on Congo red agar, while all exhibited biofilm formation in the Microtitre Plate assay. Critical ARGs (blaZ, blaTEM, blaCTX-M, tetM, tetA, tetB, tetC, strA/B, aadA) and efflux pump genes (acrB, acrE, acrF, emrB, norB) regulating active efflux were identified. This pioneering study elucidates the synergistic contribution of ARGs, biofilm production, and efflux pump activity to MDR in bovine mastitis pathogens. To our knowledge, this comprehensive study is the first of its kind, offering novel insights into the complex resistance mechanisms. The findings underscore the imperative need for advanced antibiotic stewardship and strategic interventions in dairy farming to curb the rise of antibiotic-resistant infections, thereby protecting both animal and public health.

Preneutropenic Fever in Patients With Hematological Malignancies: A Novel Target for Antimicrobial Stewardship.

Many patients with hematological malignancy develop fever after chemotherapy/conditioning but before chemotherapy-induced neutropenia (preneutropenic fever [PNF]). The proportion of PNF with an infectious etiology is not well established. We conducted a single-center, prospective observational substudy of PNF (neutrophils >0.5 cells/μL, ≥38.0°C) in adults receiving acute myeloid leukemia (AML) chemotherapy, or allogeneic hematopoietic cell transplant (allo-HCT) conditioning enrolled in a neutropenic fever randomized controlled trial between 1 January and 31 October 2018. Eligible patients had anticipated neutropenia ≥10 days and exclusions included concurrent infection and/or neutropenia prior to chemotherapy or conditioning. PNF rates and infections encountered were described. Associations between noninfectious etiologies and fever were explored. Antimicrobial therapy prescription across preneutropenic and neutropenic periods was examined. Of 62 consecutive patients included (43 allo-HCT, 19 AML), 27 had PNF (44%) and 5 (19%) had an infective cause. Among allo-HCT, PNF occurred in 14 of 17 (82%) who received thymoglobulin; only 1 of 14 (7%) had infection. During AML chemotherapy, 18 of 19 received cytarabine, of which 8 of 18 (44%) had PNF and 3 of 8 (38%) had infection. Most patients with PNF had antimicrobial therapy continued into the neutropenic period (19/27 [70%]). Those with PNF were more likely to be escalated to broader antimicrobial therapy at onset/during neutropenic fever (5/24 [21%] vs 2/30 [7%]). Rates of PNF were high, and documented infection low, leading to prolonged and escalating antimicrobial therapy. In the absence of infection, early cessation of empiric therapy after PNF is recommended as an important stewardship intervention.

Antibacterial activity of natural flavones against bovine mastitis pathogens: in vitro, SAR analysis, and computational study

Bovine mastitis is a worldwide disease affecting dairy cattle and causes major economic losses in the dairy industry. Recently, the emergence of microbial resistance to the current antibiotics complicates the treatment protocol which necessitates antibiotic stewardship and further research to find new active compounds. Recently, phytobiotics have gained interest in being used as an alternative to antibiotics in the poultry industry as an antibiotic stewardship intervention. This study evaluated the in vitro antibacterial activity of 16 flavonoids against bovine mastitis pathogens. Two flavones: 2-(4-methoxyphenyl)chromen-4-one (1) and 2-(3-hydroxyphenyl)chromen-4-one (4) showed inhibition of the growth of Klebsiella oxytoca with MIC values range (25–50 µg mL− 1) followed by a structure-activity relationship (SAR) study indicating that the presence of a hydroxyl group at C-3` or methoxy at C-4` increases the activity against Klebsiella oxytoca while the presence of hydroxyl group at C-7 decreases the activity. Furthermore, a structure-based drug development approach was applied using several in silico tools to understand the interactions of active flavones at the active site of the DNA gyrase protein. Compound (4) showed a higher docking score than quercetin (standard) which is known to have antibacterial activity by inhibiting the DNA gyrase. In addition, the structure-based pharmacophores of compound (4) and quercetin showed similar pharmacophoric features and interactions with DNA gyrase. Based on our findings, compounds (1) and (4) are promising for further study as potential anti-microbial phytochemicals that can have a role in controlling bovine mastitis as well as to investigate their mechanism of action further.