Antimicrobial Stewardship Training Research Articles

Nationwide survey of pharmacists’ involvement in antimicrobial stewardship programs in Nigerian tertiary hospitals

ObjectivesTo evaluate the activities and barriers to hospital pharmacists’ participation in antimicrobial stewardship programs (ASP) in Nigerian tertiary hospitals. MethodsA cross-sectional nationwide online survey was conducted over a 6-week period between May and June 2019. Invitation was sent to all the Heads of pharmacy department or pharmacists in charge of infectious diseases (ID) or antimicrobial pharmacists in tertiary hospitals in Nigeria. A validated questionnaire that consist of 24-items was used for data collection. ResultsForty-five hospitals were invited and 37 completed the survey (response rate, 82.2%). Five (13.5%) hospitals had a formal antimicrobial stewardship (AMS) team, with each of them having pharmacist representation. Regardless of the existence of an AMS team, hospital pharmacists have implemented AMS strategies, including evaluation of the appropriateness of antimicrobial prescriptions (54.1%) and monitoring of antimicrobial consumption (48.6%). The most common barriers to pharmacists’ involvement in ASP were lack of training in AMS and ID (51.4%), lack of pharmacists with ID specialisation (40.5%) and lack of support from hospital administrators (37.8%). The majority of the pharmacists recommended training in AMS and ID (100%), participation on ward rounds (89.2%) and employment of more pharmacists (73%) as strategies to improve pharmacists’ participation in ASP. ConclusionsHospital pharmacists are actively involved in AMS activities despite the lack of established AMS teams in most tertiary hospitals in Nigeria. However, lack of training and personnel were major barriers to pharmacist’s involvement in ASP.

Impact of a Telehealth-Based Antimicrobial Stewardship Program in a Community Hospital Health System.

Data on antimicrobial stewardship programs (ASPs) facilitated via telehealth in the community hospital setting are limited. A telehealth-based ASP was implemented in 2 community hospitals (285 and 176 beds). Local pharmacists without residency or prior antimicrobial stewardship training were trained to conduct prospective audit and feedback. For approximately 60 minutes 3 times weekly at the 285-bed hospital and 2 times weekly at the 176-bed hospital, infectious diseases (ID) physicians remotely reviewed patients on broad-spectrum antibiotics and those admitted with lower respiratory tract infections and skin and soft tissue infections with local pharmacists. Recommendations for ASP interventions made by ID physicians were relayed to primary teams and tracked by local pharmacists. Antimicrobial utilization was collected in days of therapy (DOT) per 1000 patient-days (PD) for a 12-month baseline and 6-month intervention period, and analyzed with segmented linear regression analysis. Local ID consultations were tracked and antimicrobial cost savings were estimated. During the 6-month intervention period, 1419 recommendations were made, of which 1262 (88.9%) were accepted. Compared to the baseline period, broad-spectrum antibiotic utilization decreased by 24.4% (342.1 vs 258.7 DOT/1000 PD; P < .001) during the intervention period. ID consultations increased by 40.2% (15.4 consultations per 1000 PD vs 21.5 consultations per 1000 PD; P = .001). Estimated annualized savings on antimicrobial expenditures were $142 629.83. An intense ASP model, facilitated in the community hospital setting via telehealth, led to reduced broad-spectrum antimicrobial utilization, increased ID consultations, and reduced antimicrobial expenditures.

Organization and training at national level of antimicrobial stewardship and infection control activities in Europe: an ESCMID cross-sectional survey

Antimicrobial stewardship (AMS) and Infection prevention and control (IPC) are two key complementary strategies that combat development and spread of antimicrobial resistance. The ESGAP (ESCMID Study Group for AMS), EUCIC (European Committee on Infection Control) and TAE (Trainee Association of ESCMID) investigated how AMS and IPC activities and training are organized, if present, at national level in Europe. From February 2018 to May 2018, an internet-based cross-sectional survey was conducted through a 36-item questionnaire, involving up to three selected respondents per country, from 38 European countries in total (including Israel), belonging to the ESGAP/EUCIC/TAE networks. All 38 countries participated with at least one respondent, and a total of 81 respondents. Education and involvement in AMS programmes were mandatory during the postgraduate training of clinical microbiology and infectious diseases specialists in up to one-third of countries. IPC was acknowledged as a specialty in 32% of countries. Only 32% of countries had both guidance and national requirements regarding AMS programmes, in contrast to 61% for IPC. Formal national staffing standards for AMS and IPC hospital-based activities were present in 24% and 63% of countries, respectively. The backgrounds of professionals responsible for AMS and IPC programmes varied tremendously between countries. The organization and training of AMS and IPC in Europe are heterogeneous and national requirements for activities are frequently lacking.

Designing antimicrobial stewardship initiatives to enhance scientific dissemination

AbstractAntimicrobial overuse and resistance pose an immediate threat to human health. Antimicrobial stewardship (AMS) refers to efforts designed to improve antimicrobial use and optimize associated outcomes across health care settings. Pharmacists are integral leaders of AMS teams and are increasingly engaged in AMS research. However, AMS scholarship often lacks scientific rigor and subsequently, representative evidence in AMS guidelines is low quality. Because pharmacists are often on the front lines of AMS in health care systems, they must be cognizant of robust AMS study design to increase both quality and generalizability of their AMS interventions and observations. Sustainability of AMS interventions is equally important. This paper provides a primer for pharmacists engaged in AMS on fundamental AMS scholarship concepts including defining the study objective, study design, study methodology, data analysis, and promoting sustainability of the intervention. Recommendations are made for pharmacists across the spectrum of AMS, from new to well‐established programs. Additional AMS training and AMS scholarship is needed to support both the profession and pharmacists engaged in AMS. A concerted effort by pharmacists to enhance the quality of AMS research may improve AMS scholarship impact and further enhance outcomes throughout the continuum of care.

How far do we still need to go? A survey on knowledge, attitudes, practice related to antimicrobial stewardship regulations among Chinese doctors in 2012 and 2016

ObjectivesTo explore doctors’ knowledge, willingness, concerns and the countermeasures to the most stringent antimicrobial stewardship regulations of China which implemented in August 2012.DesignCross-sectional survey. A pretested 32-point structured questionnaire was...

Antimicrobial stewardship knowledge and perception among physicians and pharmacists at leading tertiary teaching hospitals in Zambia: implications for future policy and practice

Antimicrobial stewardship (AMS) is a key strategy promoting rational antimicrobial use. In Zambia, information on health professionals’ knowledge, attitude, and practice of AMS is limited. This study was undertaken to address this at Zambia’s leading specialized teaching hospitals. Descriptive, cross-sectional study involved 137 physicians and 61 pharmacists. AMS knowledge was relatively low among physicians (51%) and pharmacists (39%). Few physicians (9%) and pharmacists (20%) demonstrated sufficient knowledge of the basic principles of AMS. Physicians’ and pharmacists’ knowledge levels were significantly associated with years of practice, job position or practice rank, and previous AMS training. The majority (95%) perceived AMR as a current problem in their practise. Most physicians (92%) and pharmacists (86%) had not undertaken AMS training before. All indicated the need for context-specific educational interventions to promote AMS in Zambia. Despite positive perceptions, basic knowledge of AMS was relatively low. Context-specific educational interventions and capacity building are needed to address AMS gaps.

Exploring the gaps between education and pharmacy practice on antimicrobial stewardship: a qualitative study among pharmacists in Qatar.

Background: Antimicrobial resistance is a public health issue and is the focus of antimicrobial stewardship (AMS) teams within health care institutions. However, AMS is not comprehensively and fully taught in medical or pharmacy curricula and little is known about the relevance of pharmacist training to meet AMS needs in the Middle East region. We aimed to explore the discord that may exist between infectious diseases education and actual clinical practice with regard to AMS knowledge and training skills in Qatar. Then, we sought to further explore pharmacist perceptions of their AMS roles in hospital environments.Methods: A qualitative study was undertaken at Qatar University using three focus groups consisting of 15 pharmacy alumni who are currently practicing as clinical pharmacists in Qatar. Focus groups were facilitated using a topic guide developed by study investigators. Discussions were audio-recorded and transcribed verbatim. Results were analyzed using framework analysis.Results: Two major themes related to the first objective emerged throughout the discussions and associated recommendations made to improve (i) infectious diseases (ID) module content and delivery and (ii) ID knowledge and skills application. Two themes related to the second objective included (i) impact of pharmacist’s interventions on decision-making and (ii) continuing professional development programming.Conclusion: Our findings guide ongoing efforts to enhance ID content in the curriculum and will close gaps related to AMS training. Pharmacists are core AMS team members where there is an ongoing need to align continuing education for health professionals with realities of practice.

RPS offers free antimicrobial stewardship training to pharmacists in England

RPS offers free antimicrobial stewardship training to pharmacists in England

977. An Innovative 3-Year Medical Student Spiral Curriculum in Antimicrobial Stewardship and Infectious Diseases

BackgroundBy 2050, infections due antimicrobial-resistant organisms are predicted to account for 10 million deaths/year worldwide. Physician antibiotic prescribing patterns are a significant factor in the development of antibiotic resistance organisms. Early, continual, and integrated medical student education may help students develop a framework for responsible antimicrobial use as they develop prescribing patterns.MethodsWe designed a spiral antimicrobial stewardship curriculum (defined as revisiting the same concept but with increasing complexity) for medical students in years 2–4. Data provided by the Graduation Questionnaire (GQ) administered by the US Association of American Colleges were used. We compared student responses during the curriculum rollout in 2013–2015 between students at our institution and other schools. We also surveyed graduating seniors in 2015 about antimicrobial stewardship training.ResultsUsing GQ data for the class of 2013 (preintervention), a similar proportion of UCSF medical students compared with other US medical students rated microbiology clinical preparation as excellent (43.6% vs. 45.1%, P > 0.20). For the 2014 class, we developed interactive case-based sessions at the beginning of years 3 and 4. After this first intervention, a higher proportion of UCSF students rated the microbiology clinical preparation as excellent (51.3%) compared with responses at all schools (39.8%, odds ratio [OR] 1.59, 95% confidence interval [CI] 1.1–2.3, P = 0.013). For the class of 2015, we added content during the medicine clerkship and 1 week before graduation. For the 2015 class, an even higher proportion of UCSF students rated microbiology preparation as excellent (57.6%), compared with all schools (41.2%, OR 2.23, 95% CI 1.54–3.22, P < 0.0001). From our survey, 88% were very or extremely satisfied with antimicrobial stewardship training.ConclusionA spiral curriculum focusing on antimicrobial stewardship and infectious diseases increases student perception of clinical preparation prior to graduation. As the curriculum was incrementally introduced, students’ knowledge increased indicating a dose–response pattern. Based on these positive results, we plan to introduce more content throughout UME, and link to curriculum for GME and practicing clinicians.Disclosures All authors: No reported disclosures.

1845. Implementing Outpatient Antimicrobial Stewardship in a Primary Care Office Through Pharmacist-led Audit and Feedback

BackgroundMore than 30% of antibiotics prescribed in the outpatient setting are unnecessary. This study aimed to determine the impact of pharmacist-led audit and feedback on outpatient antibiotic prescribing for upper respiratory tract infections (URIs) and urinary tract infections (UTIs).MethodsA retrospective, observational study was conducted at an outpatient primary care office to evaluate implementation of a pharmacist-led audit and feedback process. The office includes 0.6 FTE ambulatory care pharmacist (ACP) who completed antimicrobial stewardship training, and is part of a health system supported by a pharmacist and physician co-led antimicrobial stewardship program (ASP). Education, including pocket cards with URI and UTI guidelines was provided by the ASP leads in July 2017 prior to the study period (August 2017–March 2018). The ACP was responsible for weekly audit of all prescribed antibiotics for URI and UTI and provided feedback to prescribers. Appropriateness of therapy was determined via the guidelines presented by the ASP team. Feedback included recommendations regarding watch-and-wait, antimicrobial selection, dose, and duration of therapy. The primary outcome was to compare antibiotic use over time following the implementation of the audit and feedback program.ResultsOver the study period 1,107 prescriptions were audited by the ACP: 825 URI and 282 UTI. Feedback was provided for all cases, positive feedback for 580 (52.4%), negative feedback for 380, (34.3%) and mixed feedback for 147 (13.3%). The most common reasons for feedback were inappropriate agent (26.3%) and too long of duration of therapy (24.3%). Fluoroquinolone prescribing rates for UTIs decreased from 85% at baseline to 40% in Month 1 and to 11.7% of UTI prescriptions over the next 6 months. Nitrofurantoin prescribing increased from 0.4% in Month 1 to 38.6% of UTI prescriptions over the next 6 months to become the most commonly prescribed agent. Β-lactams were the most commonly prescribed antibiotics for URIs (66.7%). The median URI duration of therapy decreased from 10 days at baseline to 7 days across all 7 study months.ConclusionPharmacist-led audit and feedback significantly reduced fluoroquinolone prescribing for UTIs and shortened median duration of therapy for URIs in the outpatient setting.Disclosures All authors: No reported disclosures.

Hospitalists as Integral Stakeholders in Antimicrobial Stewardship

The purpose of this review is to discuss the role of the hospitalist in antimicrobial stewardship programs (ASPs), to offer antimicrobial stewardship strategies that hospitalists can implement, to discuss opportunities for hospitalists to serve as educators on stewardship practices, and to offer resources for hospitalists to gain further training in antimicrobial stewardship. Antimicrobial stewardship is vital to combat antibiotic resistance, and effective stewardship requires a multidisciplinary approach. Antimicrobial stewardship programs have typically included infectious disease specialists and pharmacists and, traditionally, have been limited to larger academic centers. With the 2017 Joint Commission standards requiring ASPs in all hospitals, there is increasing need for involvement of additional bedside stewards. Hospitalists care for a majority of inpatients allowing them to collaborate with traditional ASPs or lead new stewardship efforts. Hospitalists should engage in current antimicrobial stewardship programs and can also serve as leaders in program development in resource-limited settings. Methods of engagement include assisting with recruitment of multidisciplinary personnel, participating in current stewardship committees and protocol development, and leading educational efforts on antimicrobial stewardship strategies. Antimicrobial stewardship metrics such as length of stay, readmission rates, and mortality are parallel to metrics used by hospital medicine groups and unifying efforts will, ideally, result in improved patient outcomes as well as reduction in antibiotic resistance.

Antimicrobial Stewardship Training for Infectious Diseases Fellows: Program Directors Identify a Curriculum Need.

A needs assessment survey of infectious diseases (ID) training program directors identified gaps in educational resources for training and evaluating ID fellows in antimicrobial stewardship. An Infectious Diseases Society of America-sponsored core curriculum was developed to address that need.

Education and management of antimicrobials amongst nurses in Africa-a situation analysis: an Infection Control Africa Network (ICAN)/BSAC online survey.

To assess the current involvement of nurses in the use and management of antimicrobials and their training in antimicrobial stewardship (AMS) across Africa. After a pilot study, an online questionnaire (SurveyMonkey) in both French and English was circulated via the Infection Control Africa Network (ICAN) mailing list to both members and non-members in Africa. The study was conducted from 26 May to 19 August 2016. Data were summarized in proportions and bar charts; proportions were compared using the χ2 test. A multivariate logistic regression model was built to identify independent factors associated with the practice of AMS. While 96% of the 173 respondents were aware of the term 'AMS', 88.5% (146/165) undertook AMS tasks as part of their job; 91.9% (158/172) wanted to be more involved in AMS but 44.9% (71/158) reported there were barriers in doing so. AMS training was delivered to 36.7% (62/169) and 53.6% (90/168), respectively, during their undergraduate and postgraduate education. AMS training for healthcare workers in their institutions was reported by 50.3% (86/171), including training aimed at doctors (56.9%), pharmacists (76.7%), microbiologists (31.4%) and nurses (95.3%). However, 95.4% (164/172) of respondents asked for further education on AMS and the majority preferred AMS training to be part of the infection prevention curriculum (IPC) education. Three-quarters of institutions had an AMS initiative, but only ∼41% reported having seen a national AMS guideline. For Africa, we recommend AMS education at undergraduate level, AMS policies at institution and national levels and incorporating AMS training into the IPC for nurses.

A review of antimicrobial stewardship training in medical education.

ObjectivesWe reviewed the published literature on antimicrobial stewardship training in undergraduate and postgraduate medical education to determine which interventions have been implemented, the extent to which they have been evaluated, and to understand which are most effective. MethodsWe searched Ovid MEDLINE and EMBASE from inception to December 2016. Four thousand three hundred eighty-five (4385) articles were identified and underwent title and abstract review. Only those articles that addressed antimicrobial stewardship interventions for medical trainees were included in the final review. We employed Kirkpatrick’s four levels of evaluation (reaction, learning, behaviour, results) to categorize intervention evaluations. ResultsOur review included 48 articles. The types of intervention varied widely amongst studies worldwide. Didactic teaching was used heavily in all settings, while student-specific feedback was used primarily in the postgraduate setting. The high-level evaluation was sparse, with 22.9% reporting a Kirkpatrick Level 3 evaluation; seventeen reported no evaluation. All but one article reported positive results from the intervention. No articles evaluated the impact of an intervention on undergraduate trainees’ prescribing behaviour after graduation. ConclusionsThis study enhances our understanding of the extent of antimicrobial stewardship in the context of medical education. While our study demonstrates that medical schools are implementing antimicrobial stewardship interventions, rigorous evaluation of programs to determine whether such efforts are effective is lacking. We encourage more robust evaluation to establish effective, evidence-based approaches to training prescribers in light of the global challenge of antimicrobial resistance.

Vancomycin Prescribing Habits – Are We Still Afraid of Mississippi Mud?

Abstract Background Debates over the safety and efficacy of vancomycin have plagued clinical practice for more than half a century. A recent paradigm shift has occurred as the science of PK-PD has encouraged the use of optimized regimens which achieve targeted exposures. However, change is slow and we suspect prescribing habits may not be in line with this consensus approach. Herein, using data from electronic decision support software (EDSS), we describe clinicians’ vancomycin prescribing habits. Methods Data obtained over a 20-month period from an EDSS included: 1) clinician demographics; 2) patient demographics; 3) clinician-selected antimicrobials; and 4) EDSS suggested PK-PD optimized antimicrobial regimens. A vancomycin regimen was considered to be PK-PD optimized if the EDSS provided percent probability of PK-PD target attainment (PTA) was ≥90%. Results Data for 87 clinicians and 104 vancomycin-treated cases were available. Of all clinicians, 62% were clinical pharmacists, 38% were physicians, with close to half of being ID specialists. Of all the clinicians, 55% had ≥10 years of clinical experience. Of the 104 cases, the median (min, max) patient age, weight and creatinine clearance were 43.5 (23, &amp;gt;90) years, 81.6 (47.6, 170.6) kg, and 100.2 (7.3, 188.1) mL/min/1.73 m2, respectively. For 61.5% of selected vancomycin regimens, PTA were ≥90%. The distribution of PTA for the remaining 38.5% of cases is shown in Figure 1. Among these 38.5%, an alternative optimized regimen was presented 97.5% of the time. Further evaluation of clinician demographics among cases with a PK-PD optimized regimen demonstrated that 61% had ≥ 10 years clinical experience while only 44% of those who did not chose a PK-PD-optimized regimen had the same experience. While the majority of clinicians in both the optimized and non-optimized groups were clinical pharmacists, ID physicians represented 55% of all physicians who chose a non-optimized vancomycin regimen. Conclusion Data obtained from an EDSS demonstrated that clinicians who chose a non-optimized vancomycin regimen had less experience than those who chose an optimized regimen. Data suggest that education for optimizing vancomycin dosing using PK-PD is needed as part of antimicrobial stewardship training initiatives. Disclosures S. M. Bhavnani, ICPD Technologies: Shareholder, stock options. C. M. Rubino, ICPD Technologies: Shareholder, stock options. P. G. Ambrose, ICPD Technologies: Shareholder, stock options.

Evidence in support of veterinary involvement in antimicrobial stewardship training programs in the dairy industry

The recent emergence of antimicrobial resistance has triggered initiatives aimed at conveying antimicrobial stewardship in human and veterinary medicine. The importance of effective education and training programs has been highlighted as a key area of expansion for championing judicious use of antimicrobial agents. In order to provide data that would aid in design of interventions encouraging prudent antimicrobial use, Illinois dairy farmers (n=Z0) were surveyed using a probability cluster sampling technique. Survey responses were analyzed and examined for significant trends based upon potential knowledge, attitudinal, and behavioral indices of antimicrobial stewardship. The key areas of training needs that were identified from the survey responses include appropriate antimicrobial selection, the use of protocols, improved on-farm record keeping, and understanding of the factors that constitute extra-label drug use. The results from this preliminary study highlight the need for additional antimicrobial stewardship training in this sector of the livestock industry, and may be used to guide veterinarians in developing producer-focused education and training programs aimed at encouraging best practices surrounding the practical antimicrobial stewardship necessary to foster high-health animal care systems.

Workforce Supply and Training in Antimicrobial Stewardship

To improve the quality and safety of antimicrobial prescribing while minimizing unnecessary cost, antimicrobial stewardship programs (ASPs) require the unique services of a variety of healthcare and ancillary personnel with varied skill sets. At the center of such teams are pharmacists and physicians with specialty training in infectious diseases (ID). The potential implementation of regulations and accreditation standards requiring institutions to have antimicrobial stewardship programs (ASP)s, along with growing evidence to their effectiveness and their increasing presence in different practice settings, are likely to increase the demand for such programs. An assessment of present and potential future antimicrobial stewardship (AS) operations is required to ensure the supply of trained clinicians to meet the growing demand. Presently, the majority of training is achieved either through private study or as part of experiential postgraduate programs. While postgraduate ID-focused programs for pharmacists generally incorporate antimicrobial AS training, such experiences are rarely part of the formalized experience for ID-trained physicians. Although some professional organizations are addressing the perceived lack of individuals with formal postgraduate ID training through certification programs, there are currently no formal regulations or guidelines for such training. It is unlikely the present supply of ID-trained pharmacists will meet the future demands in this area. Therefore, novel strategies (such as access to AS networks, the expanded use of communication and/or information technology, use of alternate personnel, and/or intermittent programs) may increase access to AS-trained clinicians.

Guidelines for Antimicrobial Stewardship Training and Practice

Guidelines for Antimicrobial Stewardship Training and Practice

Participation of clinical pharmacists without specialized infectious diseases training in antimicrobial stewardship

The advances in medical care brought by the development of antimicrobial agents are threatened by the increasing rates of antimicrobial resistance. The Society for Healthcare Epidemiology of America and Infectious Diseases Society of America have delineated two major strategies to prevent the