Reporting behaviors and perceptions toward the National Healthcare Safety Network antimicrobial use (AU) and antimicrobial resistance (AR) modules.

OBJECTIVES: To identify characteristics of US health systems and end users that report antimicrobial use and resistance (AUR) data, to determine how NHSN AUR data are used by hospitals and health systems and end users, and to identify barriers to AUR reporting. DESIGN: An anonymous survey was sent to Society of Infectious Diseases Pharmacists (SIDP) and Society for Healthcare Epidemiology of America (SHEA) Research Network members. METHODS: Data were collected via Survey Monkey from January 21 to February 21, 2020. Respondent and hospital data were analyzed using descriptive statistics. RESULTS: We received responses from 238 individuals across 43 US states. Respondents were primarily pharmacists (84%), from urban areas, (44%), from nonprofit medical centers (81%), and from hospitals with >250 beds (72%). Also, 62% reported data to the AU module and 19% reported data to the AR module. Use of software for local AU or AR tracking was associated with increased reporting to the AU module (19% vs 64%) and the AR module (2% vs 30%) (P < .001 each). Only 36% of those reporting data to the AU module used NHSN AUR data analysis tools regularly and only 9% reported data to the AR module regularly. Technical challenges and time and/or salary support were the most common barriers to AUR participation cited by all respondents. Among those not reporting AUR data, increased local expectations to report and better software solutions were the most commonly identified solutions to increase AUR reporting. CONCLUSIONS: Efforts to increase AUR reporting should focus on software solutions and salary support for data-entry activities. Increasing expectations to report may incentivize local resource allocation to improve AUR reporting rates.

Penicillin Allergy Evaluation Access: A National Survey.

In a study of 121 hospitals from 38 US states, 44% had access to an allergist for inpatient consultations and 39% had access to inpatient penicillin skin testing, indicating that the majority of US hospitals lack sufficient resources to address inpatient penicillin allergies.

Collaborative Antimicrobial Stewardship: Working with Information Technology.

Information technology (IT) is vitally important to making antimicrobial stewardship a scalable endeavor in modern health care systems. Without IT, many antimicrobial interventions in patient care would be missed. Clinical decision support systems and smartphone apps, either stand-alone or integrated into electronic health records, can all be effective tools to help augment the work of antimicrobial stewardship programs and support the management of infectious diseases in any health care setting.

Impact of Procalcitonin Levels Combined with Active Intervention on Antimicrobial Stewardship in a Community Hospital.

BACKGROUND: Procalcitonin (PCT) guidance alone or in conjunction with antibiotic stewardship programs (ASP) has been shown to reduce antibiotic utilization and duration of therapy without adversely affecting patient outcomes. METHODS: In a community hospital, we investigated the impact of PCT with ASP recommendations on length of stay (LOS), length of antimicrobial therapy (LOT) after ASP recommendation, and total LOT over a one-year period. Adult patients with at least one PCT value and concomitant ASP recommendations were included. Patients were grouped by provider ASP compliance and further stratified by normal versus elevated PCT values. No specific PCT algorithm was utilized. RESULTS: A total of 857 patients were retrospectively analyzed. Physicians complied with 73.7% of ASP recommendations. There were no significant differences in LOS based on ASP compliance. Mean LOT after ASP recommendations and mean total LOT were significantly shorter (2.5 vs. 3.9 days, p<0.0001 and 5.1 vs. 6.6 days, p<0.0001, respectively) in the ASP complier group. When stratified by initial PCT levels, ASP compliers for patients with normal PCT levels had the shortest duration of therapy for all groups; among patients with elevated PCT levels, the duration of therapy was significantly shorter in the ASP compliant group (5.79 vs. 7.12 days, p<0.0111). When controlling for baseline differences in initial PCT levels, LOS was found to be marginally shorter in the ASP compliant group (p = 0.076). CONCLUSIONS: PCT-guided ASP physician recommendations, when accepted by providers, led to reduction in antimicrobial LOT in a community hospital. This benefit was extended across patient groups irrespective of initial PCT levels.

Association between meeting core elements for inpatient antimicrobial stewardship and antibiotic utilization.

We used multivariable analyses to assess whether meeting core elements was associated with antibiotic utilization. Compliance with 7 elements versus not doing so was associated with higher use of broad-spectrum agents for community-acquired infections [days of therapy per 1,000 patient days: 155 (39) vs 133 (29), P = .02] and anti-methicillin-resistant S. aureus agents [days of therapy per 1,000 patient days: 145 (37) vs 124 (30), P = .03].

The role of electronic health record and "add-on" clinical decision support systems to enhance antimicrobial stewardship programs.

Increasingly, demands are placed on healthcare systems to meet antimicrobial stewardship standards and reporting requirements. This trend, combined with reduced financial and personnel resources, has created a need to adopt information technology (IT) to help ease these burdens and facilitate action. The incorporation of IT into an antimicrobial stewardship program can help improve stewardship intervention efficiencies and facilitate the tracking and reporting of key metrics, including outcomes. This paper provides a review of the stewardship-related functionality within these IT systems, describes how these platforms can be used to improve antimicrobial use, and identifies how they can support current and potential future antimicrobial stewardship regulatory and accreditation standards. Finally, recommendations to help close the gaps in existing systems are provided and suggestions for future areas of development within these programs are delineated.

Epidemic Clostridioides difficile Ribotype 027 Lineages: Comparisons of Texas Versus Worldwide Strains.

BACKGROUND: The epidemic Clostridioides difficile ribotype 027 strain resulted from the dissemination of 2 separate fluoroquinolone-resistant lineages: FQR1 and FQR2. Both lineages were reported to originate in North America; however, confirmatory large-scale investigations of C difficile ribotype 027 epidemiology using whole genome sequencing has not been undertaken in the United States. METHODS: Whole genome sequencing and single-nucleotide polymorphism (SNP) analysis was performed on 76 clinical ribotype 027 isolates obtained from hospitalized patients in Texas with C difficile infection and compared with 32 previously sequenced worldwide strains. Maximum-likelihood phylogeny based on a set of core genome SNPs was used to construct phylogenetic trees investigating strain macro- and microevolution. Bayesian phylogenetic and phylogeographic analyses were used to incorporate temporal and geographic variables with the SNP strain analysis. RESULTS: Whole genome sequence analysis identified 2841 SNPs including 900 nonsynonymous mutations, 1404 synonymous substitutions, and 537 intergenic changes. Phylogenetic analysis separated the strains into 2 prominent groups, which grossly differed by 28 SNPs: the FQR1 and FQR2 lineages. Five isolates were identified as pre-epidemic strains. Phylogeny demonstrated unique clustering and resistance genes in Texas strains indicating that spatiotemporal bias has defined the microevolution of ribotype 027 genetics. CONCLUSIONS: Clostridioides difficile ribotype 027 lineages emerged earlier than previously reported, coinciding with increased use of fluoroquinolones. Both FQR1 and FQR2 ribotype 027 epidemic lineages are present in Texas, but they have evolved geographically to represent region-specific public health threats.

Pharmacists' Familiarity with and Institutional Utilization of Rapid Diagnostic Technologies for Antimicrobial Stewardship.

Rapid diagnostic technologies (RDTs) significantly reduce organism identification time and can augment antimicrobial stewardship program (ASP) activities. An electronic survey quantified familiarity with and utilization of RDTs by clinical pharmacists participating in ASPs. Familiarity was highest with polymerase chain reaction (PCR). Formal infectious diseases training was the only significant factor influencing RDT familiarity. Infect Control Hosp Epidemiol 2017;38:863-866.

Assessment of Antimicrobial Stewardship Activities in a Large Metropolitan Area.

PURPOSE: To describe antimicrobial stewardship programs (ASPs) of acute and long-term acute care (LTAC) hospitals in Houston, Texas. METHODS: Two-part survey to clinical pharmacists and pharmacy directors. All acute care and LTAC facilities from the Harris County Medical Society database were invited to participate. RESULTS: In part 1 of the telephone survey, 82 facilities within Houston, Harris county, were contacted by telephone of which 51 responded (response rate: 62%). Of respondents, 55% (n = 28) reported having an active ASP and 8% (n = 4) planned implementation within 12 months. Acute care and LTAC hospitals reported ASPs in 57% and 67% of facilities, respectively. Physician champions were involved in 71% (n = 20) of active ASPs; clinical pharmacists were involved in 75% (n = 21) of programs. In part II, 22 (43%) facilities completed the online survey; postprescription review with feedback was used in facilities with an ASP and medical training program (5 of 5) while formulary restriction was in facilities without stewardship or medical training (6 of 8). CONCLUSION: This is the first major survey of ASP in a major metropolitan area. The stewardship effort in the city of Houston is encouraging; we expect the number of stewardship programs in all facilities will continue to rise as focus on antimicrobial resistance grows.

Echinocandin use in hospitalized patients: a multi-institutional study.

BACKGROUND: The echinocandin antifungals are recommended as initial therapy in hospitalized patients with candidemia. Contemporary usage rates and indication for use of echinocandins have not been studied in the United States. The purpose of this study was to evaluate echinocandin usage patterns in community and academic teaching hospitals over time and to evaluate dose, duration of therapy and indications for use. METHODS: This study used hospital pharmacy databases from academic and community hospitals to collect information on adult inpatients given systemic antifungal agents from 2008 to 2012. Patient medical information was also obtained from randomly selected patients given an echinocandin over the same time period. RESULTS: Echinocandin use was determined for 4 academic and 34 community hospitals. A significant increase in echinocandin use was observed in academic and community hospitals during the time period (P < 0.001). Two hundred forty-two randomly selected patients receiving an echinocandin were retrospectively reviewed. Indications for echinocandin use did not change during the time period and included empiric therapy in a high-risk patient without subsequent mycologic confirmation from a normally sterile site (55%), systemic candidiasis (43%) and prophylactic (2%). Fifty-six percent of patients had at least 1 anatomic site of mycologic growth; most commonly urine only (14%), respiratory only (12%) or blood only (7%). In patients with candidemia, the hospital treatment course with an echinocandin averaged 8.4 ± 7.9 days (range, 1-35 days). CONCLUSIONS: This study provides useful benchmark data on antifungal use and indications for use that could be used for antifungal stewardship program comparisons.

Perioperative management of bariatric surgery patients.

PURPOSE: The perioperative management of bariatric surgery patients is described. SUMMARY: Obesity and anatomical changes create unique challenges for clinicians when caring for bariatric surgery patients. Common bariatric surgery procedures performed include Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Pain management in the acute postoperative period depends on careful dosing of opioid agents and the use of adjunctive agents. Prevention and management of infectious complications include appropriate surgical prophylaxis, monitoring and rapid treatment of suspected intra-abdominal infections, and detection and treatment of Helicobacter pylori infection. Venous thromboembolism (VTE) prophylaxis and treatment are complicated by obesity, and the use of pharmacologic agents must be balanced with bleeding risk. Bleeding is a serious complication that should be closely monitored in the immediate postoperative period. Blood products remain first-line therapy for the treatment of bleeding in this population. Acute differences in drug absorption as well as emerging hormonal changes necessitate the immediate postoperative adjustment of chronic medications to ensure both safety and efficacy. Pharmacists are valuable members of interprofessional teams for bariatric surgery patients because they provide expertise on the availability of dosage forms and dosage modification to ensure that patient pharmacotherapy is not interrupted; assist in the management of hypertension, diabetes, and psychotropic medications; and ensure appropriate antimicrobial prophylaxis and VTE prophylaxis and treatment dosages. CONCLUSION: The management of patients in the perioperative period of bariatric surgery requires appropriate selection and dosing of medications for pain management and treatment of infectious complications, VTE, bleeding, and other chronic diseases.

Hospital antimicrobial stewardship in the nonuniversity setting.

Inappropriate antimicrobial use and antimicrobial resistance persist across the healthcare continuum. Antimicrobial stewardship guidelines assist healthcare institutions in establishing antimicrobial stewardship programs but rely on infectious diseases expertise and leadership, which are not available in all settings. Despite this, many institutions have found ways to use available resources to perform stewardship activities, with improvements in antimicrobial use and reductions in resistance and cost. This article highlights success stories in nonuniversity hospital settings and proposes antimicrobial stewardship strategies that may be more feasible in settings with limited infectious diseases expertise, information technology, or financial resources.

Significant publications on infectious diseases pharmacotherapy in 2012.

PURPOSE: The most important articles pertaining to infectious diseases (ID) pharmacotherapy published in 2012, as nominated and ranked by panels of pharmacists and physicians with ID expertise, are summarized. SUMMARY: Members of the Houston Infectious Diseases Network were asked to nominate articles on ID research published in prominent peer-reviewed journals during the period January 1-December 31, 2012, with a major impact in the field of ID pharmacotherapy. A list of 42 nominated articles on general ID-related topics and 8 articles pertaining to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) was compiled. In a survey conducted in January 2013, members of the Society of Infectious Diseases Pharmacists (SIDP) were asked to select from the list 10 general ID articles and 1 HIV/AIDS-related article that they considered to be the most important. Of the 180 SIDP members surveyed, 100 (55%) and 44 (24%) participated in ranking the general ID and HIV/AIDS-related articles, respectively. Summaries of the highest-ranked articles in both categories are presented here. CONCLUSION: With the volume of published ID-related research growing each year, both ID specialists and nonspecialists are challenged to stay current with the literature. Key ID-related publications in 2012 included updated recommendations on management of diabetic foot infections, articles on promising approaches to prevention and early treatment of HIV disease, and reports on developments in research on pharmacotherapies for methicillin-resistant Staphylococcus aureus bacteremia and Klebsiella pneumoniae infections.

Antifungal susceptibility testing: a primer for clinicians.

Antifungal susceptibility testing is not as commonly performed as antibacterial susceptibility testing. The methodology for detecting antifungal resistance is newer and requires different testing supplies that may not be readily available in a clinical laboratory setting. Breakpoints for molds are lacking. Yeast breakpoints are available for most antifungals but are continually updated based on epidemiologic surveillance. Reliable and reproducible antifungal susceptibility testing methods, as well as more research on the role of susceptibility testing in patient care, are necessary in order to provide the clinician with information that can be translated into positive clinical outcomes at the bedside. There are nuances with current testing methods that, if unrecognized, could lead to misinterpretation of results and inappropriate antifungal selection. Clinicians who have an understanding of qualitative and quantitative methods, automated susceptibility testing systems, and other commercial tests can successfully engage this knowledge to improve antifungal use and patient outcomes. This primer describes the common antifungal susceptibility tests used in the clinical microbiology laboratory and reviews literature related to the impact of appropriate drug selection, timing, fungal resistance mechanisms, pharmacokinetics, and pharmacodynamics on clinical outcomes. Both conventional and modern testing methods are discussed.

Antimicrobial susceptibility testing: a primer for clinicians.

Appropriate use of antimicrobials in health care continues to be a challenge. Reliable and reproducible antimicrobial susceptibility testing methods are necessary to provide the clinician with valuable information that can be translated into positive clinical outcomes at the bedside. However, there are nuances with these testing methods that, if unrecognized, could lead to misinterpretation of results and inappropriate antibiotic selection. This primer describes the common antimicrobial susceptibility tests used in the clinical microbiology laboratory and reviews how subtle differences in testing methods and technique can influence reported results. Clinicians who have a thorough understanding of qualitative and quantitative methods, automated susceptibility testing systems, and commonly used screening and confirmatory tests for antibiotic-resistant organisms can strengthen institutional antibiotic stewardship programs and improve patient outcomes.

Significant publications on infectious diseases pharmacotherapy in 2008.

PURPOSE: Significant publications on infectious diseases (ID) pharmacotherapy in 2008 were compiled and summarized. SUMMARY: On December 31, 2008, the Houston Infectious Diseases Network compiled a listing of published articles identified as having a significant impact on ID pharmacotherapy. The publication period was limited to January 1 through December 31, 2008. Articles were selected based on prior presentations at ID and pharmacy meetings or were listed as major articles in prominent ID journals. Priority was given to articles that were published in peer-reviewed journals and to treatment guidelines endorsed by major medical and pharmacy organizations. A bibliography of 56 articles (40 not related to human immunodeficiency virus [HIV] infection and 16 related to HIV infection) was distributed to members of the Society of Infectious Diseases Pharmacists (SIDP) via an Internet survey in early January 2009. Members were asked to select 10 publications not related to HIV infection and 1 HIV-related publication that they believed made the greatest contribution to the antimicrobial-related medical literature in 2008. A total of 115 SIDP members participated in the survey. Summaries of the top articles selected, along with an interpretation of their effect on clinical practice, are included. CONCLUSION: The increasing number of articles in the peer-reviewed medical literature related to the diagnosis and treatment of ID has made it challenging to maintain a contemporary knowledge base of key publications. This summary of significant ID articles published in 2008 can help to alleviate this burden.

Significant publications on infectious diseases pharmacotherapy in 2007.

PURPOSE: Significant publications on infectious diseases (ID) pharmacotherapy in 2007 were compiled and summarized. SUMMARY: On January 2, 2008, the 21 members of the Houston Infectious Disease Network (HIDN) were asked to select an article that was published in a peer-reviewed journal between January 1 and December 31, 2007, and write a summary highlighting why the article was significant to the diagnosis or treatment of ID. Articles were selected based on prior "top 10" presentations at major ID and pharmacy meetings or were listed as major articles in prominent ID journals. Priority was given to peer-reviewed publications and nationally recognized clinical treatment guidelines. Nineteen articles and summaries were submitted by HIDN members. The publication listing was distributed to Society of Infectious Diseases Pharmacists members via an Internet survey in early February 2008. Members were asked to select the 10 most significant articles relating to ID pharmacotherapy from the list of 19 and were allowed to add an additional article that was not already listed. A total of 102 individuals participated in the survey. A listing of the top 10 articles published in 2007 and one honorable mention was compiled, and the significance of each article was summarized. CONCLUSION: The increased number of articles in the peer-reviewed medical literature related to the diagnosis and treatment of ID has made it challenging to maintain a contemporary knowledge base of key publications. This summary of significant ID articles published in 2007 can help to alleviate the burden of knowledge management.