Stewardship Practices Research Articles

Bloodstream infections after solid organ transplantation: clinical epidemiology and antimicrobial resistance (2016-21).

Solid organ transplant (SOT) recipients are at risk of bloodstream infections (BSIs) with MDR organisms (MDROs). To describe the epidemiology of BSI in the year after several types of SOT, as well as the prevalence of MDRO infections in this population. We conducted a single-centre, retrospective study of kidney, liver, heart, and multi-organ transplantation patients. We examined BSIs ≤1 year from SOT and classified MDRO phenotypes for Staphylococcus aureus, enterococci, Enterobacterales, Pseudomonas aeruginosa and Candida spp. We compared BSI characteristics between SOT types and determined risk factors for 90 day mortality. We included 2293 patients [1251 (54.6%) kidney, 663 (28.9%) liver, 219 (9.6%) heart and 160 (7.0%) multi-organ transplant]. Overall, 8.5% of patients developed a BSI. BSIs were most common after multi-organ (23.1%) and liver (11.3%) transplantation (P < 0.001). Among 196 patients with BSI, 323 unique isolates were recovered, 147 (45.5%) of which were MDROs. MDROs were most common after liver transplant (53.4%). The most frequent MDROs were VRE (69.8% of enterococci) and ESBL-producing and carbapenem-resistant Enterobacterales (29.2% and 27.2% of Enterobacterales, respectively). Mortality after BSI was 9.7%; VRE was independently associated with mortality (adjusted OR 6.0, 95% CI 1.7-21.3). BSI incidence after SOT was 8.5%, with a high proportion of MDROs (45.5%), especially after liver transplantation. These data, in conjunction with local antimicrobial resistance patterns and prescribing practices, may help guide empirical antimicrobial selection and stewardship practices after SOT.

Vegetal Agency in Street Tree Stewardship Practices: People-Plant Involutions Within Urban Green Infrastructure in New York City

In cities nature is taking on a new role as infrastructure, providing essential services in terms of temperature regulation and water management, as well as the provision of habitat for biodiversity conservation. With this turn to green infrastructure have come new challenges to maintenance. Plants are lively things and if they are to perform their infrastructural roles they must be routinely tended to in particular ways. In the context of neoliberal governance, much of this labor falls to volunteer humans. Framed as stewardship, this volunteerism for plant-city thriving is posited as a way to meet maintenance needs while promoting human health and well-being and creating support for nature-based solutions through a sense of ownership and responsibility. While it is thus possible to read stewardship as an enrollment of people and plants into the reproduction of neoliberal urban political ecologies, in this paper I argue that such an analysis overlooks the involution of plants and people that occurs during acts of stewardship. Drawing on ethnographic research with street tree stewards in New York City I explore how vegetal agency draws people into affective, embodied relations. During acts of stewardship, trees act on people and reconfigure their relations in ways that potentially exceed the strictures of stewardship. Rather than allowing stewardship discourses and critiques thereof to be our sole frame for understanding these people-plant relations, we should also consider them from the perspective of vegetal agency and what human-tree involutions do within, around, and to human practices of stewardship.

Antibiotic and antifungal use in paediatric departments at three academic hospitals in South Africa

ObjectivesSouth Africa implemented a National Strategic Framework to optimise antimicrobial stewardship in 2014; however, there is limited data on how this has affected prescribing, especially to children treated in academic centres. MethodsWe conducted a point prevalence survey using the World Health Organization (WHO) methodology to evaluate antibiotic and antifungal prescribing practices in paediatric departments at three academic hospitals in South Africa. ResultsWe recorded 1946 antimicrobial prescriptions in 1191 children, with 55.2% and 39.2% of the antibiotics classified as WHO AWaRe Access and Watch drugs, respectively. There were significant differences in prescription of Reserve antibiotics and antifungals between institutions. Receipt of WHO Watch and Reserve antibiotics was independently associated with infancy (<12 months) and adolescents (13-17 years) (adjusted relative risk [aRR]: 2.09-9.95); prolonged hospitalisation (aRR: 3.29-30.08); rapidly or ultimately fatal illness (aRR: 1.94 to 5.52); and blood transfusion (aRR: 3.28-5.70). Antifungal prescribing was associated with treatment of hospital-associated infection (aRR: 2.90), medical prophylaxis (aRR: 3.30), and treatment in intensive care units (aRR: 2.15-2.27). ConclusionsGuidance on optimisation of infection prevention and control practice and strengthening of antimicrobial stewardship would impact positively on the care of sick children in our setting.

Church Finances for Missional Leaders: Best Practices for Faithful Stewardship

Church leaders have a corporate social responsibility (CSR) to their communities and congregations. In this context, CSR is used as a business model to hold church leaders accountable to themselves, stakeholders, and the public. In Church Finances for Missional Leaders: Best Practice for Faithful Stewardship, Bonnie Marden analyzes how churches can steward growth in their congregants and church finances. The author expresses how the practices of church stewardship and financial stewardship must come together and form a continuous joint relationship for the success of the church.

Knowledge and Perceptions of Antimicrobial Stewardship Concepts Among Final Year Veterinary Students in South Africa.

Antimicrobial resistance (AMR) has become a major global public health crisis due to inappropriate use in humans, animals, and crops. Studies to assess the knowledge and perceptions of antimicrobial stewardship (AMS) practices among medical and health care professionals have been conducted, yet this is the first among veterinary students in South Africa. A descriptive study surveyed 147 final year veterinary students at the Faculty of Veterinary Science, University of Pretoria. Of these, 102 completed the questionnaire (69% response rate). Most stated they knew what AMS was, while a minority heard of it for the first time. A small number understood poor hand washing could contribute to AMR. Almost a quarter of students stated their AMS knowledge was poor, and most noted a need for more training. The BVSc curriculum should include more material on AMS and AMR to bridge training gaps.

Views and experiences of volunteers for the Commonwealth Partnerships for Antimicrobial Stewardship Extension Programme

Abstract Introduction Antimicrobial resistance (AMR) is a global public health issue, which can be addressed through improved antimicrobial stewardship (AMS) knowledge and practice. The CwPAMS programme, launched in 2019, is funded by the UK aid Fleming Fund and managed by Commonwealth Pharmacists Association (CPA) and Tropical Health and Education Trust (THET).1,2,3 It expanded in 2021 to support 14 health partnerships to enhance AMS capacity by leveraging UK expertise between the UK and 8 Commonwealth countries: Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, Zambia. CwPAMS was supported by UK and LMIC volunteers. Aim The aim of this study was to explore views and experiences of volunteers who took part in the CwPAMS Extension Programme. Methods A cross-sectional survey was developed using Survey Monkey by CPA internal AMS experts and programme managers. The questions explored the key benefits to health organisations and professionals, including the development of AMS skills and competencies, barriers to AMS, and personal/professional development opportunities. Open-ended questions were included to gather further insights into volunteers' views and experiences of volunteering and participating in CwPAMS. The survey was emailed to the 14 health partnerships who took part in the CwPAMS programme between October 2021-May 2022 to be disseminated to all volunteers. Data were collected between 14 April-1 June 2022, transferred to Microsoft Excel and analysed thematically, with frequency counting where appropriate. As it was an internal CPA programme evaluation, no ethical approval was required. Results A total of 83 survey responses were received. The majority respondents were female (60%) and were pharmacists (54%). Volunteers recognised the programme’s positive impact on a personal/professional and organisational level, by fostering knowledge exchange and enhancing AMS practices. Amongst volunteers, 87% noted that their organisation had benefited through their participation in CwPAMS, with 72% stating they had increased AMS capacity in their team. Volunteers highlighted several areas where they applied their newly acquired skills and experiences from their participation in CwPAMS. The most frequently mentioned impactful areas were: 1) Leadership and project management: Volunteers reported improved competencies in establishing local expertise in AMS and infection management, strengthening stakeholder and partnership engagement and improved confidence in project leadership, monitoring, and evaluation. 2) Use of new tools (digital/virtual) for training and AMS use 3) Mentoring, teaching and sharing their knowledge and experiences to support others in their professional development. In addition, volunteers reported they had the opportunity to network and form international partnerships, fostering multidisciplinary collaborations. They also experienced personal development by acquiring leadership, communication, problem-solving, grant application writing, and project management skills. Discussion/Conclusion CwPAMS offers volunteers within health partnerships a distinct opportunity for personal and professional growth, while simultaneously improving AMS related healthcare practices in their organisations. We will continue to expand upon the achievements of the programme by enhancing volunteer experiences, such as the Africa Leadership Fellowship-AMS offering as part of CwPAMS 2, to upskill and enable pharmacists in LMICs to develop leadership roles. Additionally, we aim to strengthen the evaluation of CwPAMS to showcase its impact to the UK and LMICs, respectively.

1250. Association Between Antimicrobial Stewardship Resources and Practices Reported by California Hospitals in the National Healthcare Safety Network Annual Survey and California Department of Public Health Antimicrobial Stewardship Program Honor Roll Designation

Abstract Background California hospitals report information on antimicrobial stewardship (AS) Core Elements, resources, and practices through the National Healthcare Safety Network Annual Survey. The California Department of Public Health has an AS Program (ASP) Honor Roll to recognize and promote hospital AS. We explored associations between AS-related responses in the Annual Survey with Honor Roll designation, which ranks increasingly comprehensive ASP as Bronze, Silver, or Gold. Methods We linked 2020–2021 Annual Survey data to Honor Roll designations for acute care and critical access hospitals by year. We included 59 AS-related survey questions based on completeness and consistency between survey years. We compared survey responses by designations with chi-square and Fisher’s exact tests. We used a multivariable proportional odds regression model to evaluate the association of survey responses with the likelihood of ordinal designations. We used a stepwise approach and compared goodness-of-fit statistics at each iteration of model variable selection. Results Of 179 Honor Roll hospital designations with linked survey data, 21% were Gold, 41% Silver, and 38% Bronze in 2020, and 21% were Gold, 53% Silver, and 26% Bronze in 2021. The final ordinal model included 29 survey covariates related to leadership oversight, ASP lead, AS practices, and education. Hospitals significantly associated with higher designation included those that: performed prospective audit and feedback (PAF) of vancomycin (OR:4.09, 95%CI 1.27-13.83) and azoles (OR:3.37, 95%CI 1.07-11.31); and required prior authorization of newer beta-lactam/-lactamase inhibitors (OR:3.31, 95%CI 1.18-9.49) and echinocandins (OR:2.78, 95%CI 1.02-7.77), holding constant all other variables. Odds for higher designations were reduced if facilities performed PAF of echinocandins (OR:0.17, 95%CI 0.05-0.53). Conclusion Higher Honor Roll designation is a marker for a more effective ASP; thus, AS practices, especially prospective audit and feedback, in conjunction with resources related to ASP lead(s) and leadership oversight, should be prioritized by ASPs. Further exploration of practices, such as prior authorization of select antimicrobials, would be warranted as there were varying associations with designations. Disclosures All Authors: No reported disclosures

1244. Antimicrobial Stewardship Knowledge, Attitudes, and Practices (KAP) Among Nurses

Abstract Background Nurses are underutilized members of the antimicrobial stewardship (AS) team. Understanding knowledge, attitudes, and practices (KAP) is essential to designing effective AS initiatives. While KAP surveys have been performed among a variety of provider types, less is known about KAP among nurses. We describe KAP pertaining to AS among nurses at a large, academic hospital. Methods An electronic, 24-question KAP survey was designed by the AS team with relevant nursing and infection prevention champions. Nine knowledge-based questions about antimicrobials focused on 4 domains: beta-lactams first in sepsis, intravenous to oral transition, urinary tract infections, and penicillin allergies. Voluntary responses were collected via Qualtrics from January 9, 2023-March 31, 2023. Surveys were distributed by email link, with reminders to enhance survey response. Incentives included a chance to win a meal voucher. Results 85 complete survey responses were received. The majority of respondents worked on dayshift (69%) in a staff nurse role (66%). Discrepancies were seen in perceptions of issues of stewardship nationally and locally. While nurses felt antimicrobial resistance and harm caused by antimicrobials are high nationally (92 and 69%, respectively), this was not as commonly felt to be true on a local level (35% and 26%). The majority (87%) agreed or strongly agreed that nurses’ responsibility includes promoting appropriate antimicrobial use. When assessing knowledge of AS domains, reported confidence in performance was discordant with actual performance and differed by domain (Figure 1). Respondents were largely unfamiliar with common AS reference resources (73-74%) and were more likely to consult an ID pharmacist (81%), ID physician (78%) or infection prevention team member (78%) with questions. Conclusion Nurses recognized AS as an important part of their professional responsibilities, but perceived AS opportunities to be a national rather than local need. Differing patterns in knowledge vs. confidence among topic domains provides key information to then design relevant, sustainable, nurse-driven antimicrobial stewardship initiatives. Disclosures Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties

1706. Risk factors for infections caused by extended spectrum beta lactamase (ESBL) producing and Carbapenem-resistant Enterobacterales (CRE) in pediatric critical care settings: A case control study

Abstract Background Infections due to Gram negative resistant bacterial pathogens are a major concern in intensive care units. The purpose of this study is to determine the risk factors for developing ESBL-producing and CRE infections in pediatric patients in critical care settings (PICU and NICU). Methods A retrospective case control study of infections due to ESBL-producing and CRE during a 5-year period (2016-2021) at Children’s Hospital of Michigan, Detroit. All patients had positive cultures during their PICU/NICU stay. Control cases were matched for age, infection site and year of infection but their cultures grew Enterobacterales that were non-ESBL or carbapenemase producers. Results A total of 58 patients with ESBL/Carbapenemase-producing Enterobacterales (cases) and 59 control patients were included. Majority of organisms were E. coli and Klebsiella species recovered from respiratory tract. There was no difference in both groups in regards to age, gender, race or length of hospital stay (p &amp;gt;0.3). There was no difference in prior hospital admission, PICU or NICU stay during the previous 6 months, indwelling devices, comorbid conditions, or surgery in the last 6 months (p &amp;gt;0.3). However, the presence of gastrostomy tube was more frequent in the cases group (29.3%) than the control group (15.3%) (p=0.078). Risk factors by univariate analysis included history of antibiotic use in last 6 months (93% in cases vs 73% in controls; p=0.006), cephalosporins use &amp;gt; 14 days (67% vs 31.2%; p=0.006),Trimethoprim/Sulfamethoxazole treatment duration &amp;gt; 14 days (11.1% vs 0%; p=0.012), carbapenem treatment duration &amp;gt; 14 days (14% vs 1.9%; p=0.027), and vancomycin use &amp;gt; 14 days (43.6% vs 21.6%; p=0.053). However, multivariate logistic regression analysis showed that antibiotic usage in the last 6 months was the single best predictor for cases with odds ratio of 5.02-fold (95% CI 1.56-16.13) (p=0.007). Conclusion Prior broad spectrum antibiotic usage was significantly associated with acquisition of ESBL and carbapenemase producing Enterobacterales. The study further underscores the need for optimizing antimicrobial stewardship practices to limit unnecessary and prolonged use of antibiotics to prevent the emergence of resistant pathogens. Disclosures All Authors: No reported disclosures

582. Comparing Broad-range PCR Testing and The Biofire® FilmArray® Pneumonia (PN) Panel in the Diagnosis of Bacterial Pneumonia

Abstract Background Given the low sensitivity of conventional microbial isolation methods for identifying respiratory pathogens in bacterial pneumonia, target-specific syndromic multiplex real-time PCR panels have been used in conjunction with culture methods to improve diagnostic yield. Additionally, broad-range polymerase chain reaction (BR-PCR) targeting bacterial 16s rRNA conserved region has shown higher sensitivity with certain specimen types, so we sought to evaluate the clinical performance of BR-PCR performed on bronchoalveolar lavage (BAL) specimens in comparison to The Biofire® FilmArray® Pneumonia (PN) Panel (BioFire Diagnostics, Salt Lake City, UT, USA). Methods A retrospective chart review was performed on all BAL specimens that had both a PN panel test and BR-PCR performed from January 2020 to May 2022 at all Indiana University affiliated hospitals. The PN panel test was performed in-house as per laboratory protocol, while BR-PCR was performed in a reference laboratory. Outcomes assessed included turn-around times (TAT), sensitivity and specificity of BR-PCR and clinical impact, if any. Results A total of 68 BAL specimens from 53 patients were identified (83% of patients were immunocompromised). Percent positivity for the PN panel was 19% and that of BR-PCR was 18%. With the PN panel used as the gold standard, the sensitivity and specificity of BR-PCR was 85% and 98%, respectively. Only one respiratory organism was detected by BR-PCR but not by the PN panel, and it was not considered pathogenic or to have a significant clinical impact. The median TAT for the PN panel was 2.1 hours (1.8, 3.2) versus 7.8 days (6.9, 10.4) for BR-PCR. Conclusion In our cohort of patients, BR-PCR testing was not superior to the Biofire® FilmArray® Pneumonia (PN) Panel when used to detect certain bacterial etiologies of pneumonia. Additionally, faster TAT for the panel test has the potential to enhance antimicrobial stewardship practices by enabling better antibiotic utilization. Adjunctive BR-PCR testing may be useful for clinical care when conventional testing is negative and patients are at risk for a variety of potential pathogens, including fungi. Disclosures All Authors: No reported disclosures

1369. Effect of COVID-19 on Antibiotic Consumption: An Analysis of the COVID-19 Community Research Partnership

Abstract Background The COVID-19 Community Research Partnership (CCRP) is a multisite healthcare system-based study of the COVID pandemic. Community residents in this study provided consent for electronic health record (EHR) access allowing for analysis of antibiotic prescribing. Methods We conducted a retrospective, self-controlled cohort study to determine antibiotic consumption in the CCRP pre-COVID (Jan 2018 - Dec 2019) and post-COVID (Jan 2020 - Jan 2022). Participants were ≥18 years with an EHR record in the pre-COVID period. The primary outcome was the number of antibiotic prescriptions (AP) per 1000 patient care encounters in each time period. Secondary outcomes included the AP location of care, analysis of antibiotic classes, and COVID attributable antibiotic consumption, defined as an AP written ≤14 days before or after an EHR documented or self-reported positive SARS-CoV-2 test or COVID diagnosis. Results 34,234 participants were included representing 2,775,711 encounters. Median age was 53 years with 70% female and 88% white. 41% lived in a rural or suburban area. There were 26,121 APs among 25,433 participants. Mean rate of AP per 1000 encounters was 12.1 and 7.6 pre vs post-COVID (p&amp;lt; 0.001). A decline in AP occurred at onset of the pandemic persisting through the post-COVID period (Fig 1). The prescribing rate for all antibiotics, except linezolid, decreased during the pandemic (p&amp;lt; 0.001, Fig 2). The largest declines were seen with antibiotics typically prescribed for respiratory illnesses. The decline in antibiotic consumption was driven by outpatient encounters (Fig 3). 6,341 participants were diagnosed with COVID and 333 APs were COVID attributable. These participants were more likely to receive a macrolide (45% vs. 22%, p&amp;lt; 0.001), live in a rural area (31% vs. 20%, p&amp;lt; 0.001), and receive care in an emergency department (12% vs. 6.1%, p&amp;lt; 0.001). Figure 1. Antibiotic Prescriptions During The Study Time Period Figure 2. Analysis Of Antibiotic Classes Figure 3. Location of Antibiotic Prescribing Conclusion The COVID pandemic was associated with a broad decline in antibiotic consumption. These results may be due to declines in other respiratory viruses, anchoring bias for COVID during the pandemic, improved antibiotic stewardship practices, or social isolation. Antibiotics for respiratory illnesses declined the most, suggesting this may be a target for outpatient stewardship efforts. Disclosures All Authors: No reported disclosures

626. Antibiotic Stewardship Practices in hospitalized patients with Dengue in South India

Abstract Background Antibiotics are commonly prescribed for upper respiratory viral infections, including COVID–19 infections worldwide. However, in the developing world, tropical viral infections like dengue, chikungunya, and zika are common causes of hospitalization throughout the year. But antibiotic prescribing behaviors for these infections were not studied well. Here, we are reporting the antibiotic prescribing practices for hospitalized patients with dengue in South India. Methods We conducted a retrospective analysis during the period of October 2022 to April 2023 at multiple tertiary care hospitals, involving serologically confirmed dengue (NS-1 antigen positive) fever patients in South India. Demographic data, laboratory parameters, antibiotic prescribing practices, supportive care treatment like papaya leaf extract tablets, and antibiotics on discharge were recorded using an audit tool. Descriptive statistics were used to analyze the data and the results were tabulated. Results During the study period 298 patients were admitted with confirmed dengue fever, other findings are listed in Table 1 Conclusion Antibiotics were prescribed to 44% of hospitalized dengue patients and 41% of the patients were discharged with antibiotics. Doxycycline and cefixime were commonly prescribed antibiotics for the patients. Most (72%) of the dengue patients were receiving papaya leaf extract as a platelet-stimulating agent despite no evidence. In the future, antimicrobial stewardship practices in the developing world should focus on tropical infections apart from bacterial and fungal infections. Disclosures All Authors: No reported disclosures

1185. Evaluation of Antimicrobial Stewardship Practices at a Veterans Affairs Health Care System Community Living Center

Abstract Background Antimicrobial stewardship programs (ASP) have demonstrated improvement in patient outcomes, reduction of antimicrobial adverse drug events (ADE) and a decrease in antimicrobial resistance in hospitals. Antimicrobials maintain the second highest rate of ADEs in long-term care facilities. Prescribed antimicrobials in nursing homes may be unnecessary or inappropriate in upwards of 75% of cases. There is limited evidence available quantifying the impact of pharmacist-led ASP interventions in long-term care facilities. The purpose of this project is to evaluate the effectiveness of antimicrobial stewardship interventions completed at the Salisbury Veterans Affairs Health Care System Community Living Center (SVAHCS CLC). Methods This is a retrospective quality improvement project. Eligible subjects included Veterans residing in the SVAHCS CLC to which an ASP intervention documented in TheraDoc® was proposed from May 2018 to January 2021. The primary objective is to determine the effectiveness of ASP interventions in the CLC based on acceptance rate. Secondary objectives include to assess safety of select implemented CLC ASP interventions through reported ADEs within 30 days of performed CLC ASP intervention and determine potential cost savings of the implemented ASP interventions. Results A total of 379 interventions were included. Of these interventions, 370 were accepted (98%), 5 were accepted with modification (1%) and 4 were rejected (1%). The most common ASP interventions included lab monitoring, renal adjustment, pharmacokinetic consults and duration changes. The most common indications for many ASP interventions performed were osteomyelitis, influenza and bacteremia. Vancomycin, cefepime and ceftriaxone were the most common antimicrobials involved for which ASP interventions were performed. Of the 131 interventions assessed for safety, one Veteran experienced ADEs within 30 days of the intervention including nephrotoxicity and Clostridioides difficile infection. There was a total potential cost savings of $101,704. Most Common Infections ASP Intervention Acceptance Rate and ADEs within 30 Days of ASP Intervention Conclusion This study demonstrates that pharmacist-led ASP interventions proposed in the SVAHCS CLC were effective with a high rate of acceptance. These interventions resulted in a low rate of ADEs and potential cost savings for the facility. Disclosures All Authors: No reported disclosures

Texas Well User Stewardship Practices Three Years after Hurricane Harvey

Private wells are susceptible to contamination from flooding and are exempt from the federal requirements of the Safe Drinking Water Act. Consequently, well users must manage (e.g., disinfect) and maintain (e.g., regularly test) their own wells to ensure safe drinking water. However, well user practices and perceptions of well water quality in the years following a natural disaster are poorly characterized. An online follow-up survey was administered in October 2020 to private well users who had previously experienced Hurricane Harvey in 2017. The survey was successfully sent to 436 participants, and 69 surveys were returned (15.8% return rate). The survey results indicate that well users who had previously experienced wellhead submersion or a positive bacteria test were more likely to implement well stewardship practices (testing and disinfection) and to report the feeling that their well water was safe. While the majority of well users believed that their water was safe (77.6%), there was a significant decrease in well water being used for drinking, cooking, and for their pets after Hurricane Harvey. Generally, these well users tend to maintain their wells at higher rates than those reported in other communities, but there continues to be a critical need to provide outreach regarding well maintenance practices, especially before natural disaster events occur.

Antibiotic susceptibility patterns of bacteria isolated from patients with community acquired urinary tract infections.

Objective: The emergence of multi-drug resistant uro-pathogenic bacteria has negatively impacted the treatment of urinary tract infections. The objective of this study was to identify the rising rates of resistance of uro-pathogenic bacteria to antimicrobials. Study Design: Retrospective Analysis of Bacteria Isolated from urine cultures of adult outpatients with complicated or long-term urinary tract infections was done. Setting: Out- patient Clinics of Independent University Hospital, An Urban Tertiary Care Teaching Hospital in Faisalabad. Period: July 2021 to July 2022. Material &amp; Methods: Urine samples from patients advised urine cultures after presenting with symptoms of urinary tract infections were included using convenience sampling technique. Results: The most common etiologic agent isolated was E.coli, followed by Klebsiella, Pseudomonas and Staphylococcus saprophyticus. The drugs with the highest susceptibility were ciprofloxacin (56.3%), nitrofurantoin (53.1%), and imipenem (44.8%). Nalidixic acid (40.6%), sulfamethoxazole-trimethoprim (37.5%), and erythromycin (25%) had low efficacy, while penicillin G and co-amoxiclav failed to work on all bacterial isolates in this study. Conclusion: The rising rates of resistance of uro-pathogenic bacteria to multiple drugs indicate the employment of good antibiotic stewardship practices by clinicians in outpatient clinics, to decrease the burden of infections in the communities.

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Opioid Prescribing by Emergency Physicians: Trends Study of Medicare Part D Prescriber Data 2013-2019

BackgroundEmergency physicians play a critical role in mitigating the opioid epidemic in public health. ObjectivesTo analyze the prescribing of emergency physicians for opioids among Medicare beneficiaries enrolled in the Part D program from 2013 to 2019. MethodsWe conducted a retrospective, cross-sectional, descriptive analysis of Medicare Part D prescriber data, focusing on opioid claims between 2013 and 2019. The primary outcome variables evaluated included proportion of opioid claims, trends of the most prescribed opioids, cost of opioid claims, and days’ supply per claim. ResultsA total of 63,586 emergency physicians were identified over the study period. Opioid prescription by emergency physicians decreased from 14.45% to 11.55%, and the cost spent on opioid drugs declined by 50%. The use of drugs such as hydrocodone-acetaminophen and oxycodone-acetaminophen declined substantially, whereas tramadol and acetaminophen-codeine prescription increased. The opioid prescribing rate and days’ supply also decreased. ConclusionsThe decline in traditional opioid agents such as hydrocodone-acetaminophen was partly offset by an increase in opioids like tramadol, which carry additional potential adverse events. Opioid prescribing rate, average days’ supply, and cost of opioid drugs significantly decreased from 2015 to 2019, after a spike in 2015. All regions observed a decrease in emergency physicians, but opioid prescribing rates varied across regions. These trends highlight successful opioid stewardship practices in some areas and the need for further development in others. This information can aid in designing tailored guidelines and policies for emergency physicians to promote effective opioid stewardship practices.

Appraising Nigeria's approach to combating antimicrobial resistance.

Antibiotic consumption has increased dramatically in recent years, and this increase is predominantly fuelled by low- and middle-income countries. This is a worrying report, as antimicrobial resistance (AMR) is primarily driven by antibiotic consumption. To combat AMR, the Nigerian Ministry of Health established the Antimicrobial Resistance Technical Working Group (AMR-TWG), which developed and implemented the National Action Plan on Antimicrobial Resistance. This study aims to identify and appraise the current situation in the fight against AMR in Nigeria. This study contains a qualitative descriptive assessment of the advancements and the present status of efforts to combat AMR in Nigeria following the execution of the 2017-2022 National Action Plan (NAP) for AMR. The data for this study is soured primarily from the official national policy document on AMR and the responses of the Tracking AMR Country Self-assessment Survey (TrACSS). The results from this study reveal that there have been significant efforts aimed at addressing AMR in Nigeria. These efforts have been focused on improving public awareness of AMR, improving One Health surveillance of AMR, improving infection prevention and control, improving antimicrobial stewardship practices in the country, and investing in research on AMR. However, significant gaps still exist in each of these focus areas that can potentially undermine the attempts that have been made hitherto. Nigeria's commitment to the fight against AMR, as exemplified by the 2017-2022 National Action Plan, needs to be sustained and reinforced to safeguard public health and promote responsible antimicrobial use.

Antimicrobial Prophylaxis for Percutaneous Nephrolithotomy: Contemporary Practice Patterns.

Background: Updated in 2019, the American Urological Association's (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these recommendations. We hypothesized that endourologists do not routinely follow the AUA's statement on antibiotic use during PCNL and assessed their prescribing patterns. Methods: A 24-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA's recommendations. Two multiple logistic regression analyses were performed with demographics and antibiotic preference as predictors of following the AUA. Results: A total of 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data were predictive of following the AUA. 90.9% and 83.6% reported they have "never" used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 63.1% prescribe ≤24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤24 hours of perioperative antibiotics, while 20.4% begin antibiotics 7 or more days prior. Conclusions: Nearly half of respondents do not follow the AUA's recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first-line antibiotic choice for PCNL and their roles needs to be further evaluated as first-line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

Antimicrobial resistance of Escherichia coli from dairy farms participating in an antimicrobial stewardship educational program for farm employees

Antimicrobial use in food-producing animals is under increasing scrutiny due to the potential effect on the selection of antimicrobial-resistant bacteria that may be transmitted to humans by direct contact, with the food chain, or the environment. Novel data monitoring commensal Escherichia coli from dairy farms is essential for understanding antimicrobial resistance (AMR) patterns and their association with herd health management practices. The objectives of this study were to: (1) compare the prevalence of antimicrobial resistance in the E. coli isolates from the hospital, fresh, and mid-lactation pens from 18 conventional dairy farms participating in an educational training program in antimicrobial stewardship practices in California and Ohio, and (2) to characterize the prevalence of antimicrobial resistance of commensal E. coli isolated from pooled fecal pat samples before and 3 mo after participating in the educational training program. Pooled fecal pat samples were collected from the hospital pen, the fresh pen (1 to 5 DIM), and the mid-lactation pens (90 to 150 DIM) on conventional dairies in CA (n = 9) and OH (n = 9). Fecal samples were collected as part of a larger study using a quasi-experimental design that assigned farms to the training intervention group (TG; 6 per state) or the control group (CG; 3 per state). For the TG, farm worker(s) identified as having the task of diagnosis and treatment of adult cows on the farm participated in a training program on antimicrobial stewardship practices. Pooled fecal samples (n = 7) were collected at enrollment and 3 mo after completing the intervention on each of the participating farms (n = 18), followed by culture for E. coli isolation and antimicrobial sensitivity testing using the broth microdilution methodology. Logistic regression models were used to evaluate the association between E. coli antimicrobial resistance patterns with the training intervention and farm-level factors. No effect was observed in the prevalence of resistant isolates between the control and intervention farms after the training was delivered. Isolates from the hospital pens were 2.48 (95% CI: 1.06-6.22, P = 0.03) and 5.61 (95% CI: 1.94-16.91, P < 0.001) times, more likely to be resistant to streptomycin and chloramphenicol, respectively, than isolates from the mid-lactation pens. Our findings indicate there was a higher prevalence of AMR in E. coli associated with the hospital pen within the farm, while the training program for 3 mo did not affect the prevalence of AMR in E. coli on the farms participating in the program. Further research efforts should be conducted to identify factors driving AMR at the pen level, as well as approaches that could be used to reduce the risk of disseminating AMR from sick pens to animals being housed and to other pens on the farm.