Barriers to the implementation of antimicrobial stewardship programmes in long-term care facilities: a scoping review.

BACKGROUND: Long-term care facilities (LTCFs) present specific challenges for the implementation of antimicrobial stewardship (AMS) programmes. A growing body of literature is dedicated to AMS in LTCFs. OBJECTIVES: We aimed to summarize barriers to the implementation of full AMS programmes, i.e. a set of clinical practices, accompanied by recommended change strategies. METHODS: A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase and Cochrane Central. Studies addressing barriers to the implementation of full AMS programmes in LTCFs were included. Implementation barriers described in qualitative studies were identified and coded, and main themes were identified using a grounded theory approach. RESULTS: The electronic search revealed 3904 citations overall. Of these, 57 met the inclusion criteria. All selected studies were published after 2012, and the number of references per year progressively increased, reaching a peak in 2020. Thematic analysis of 13 qualitative studies identified three main themes: (A) LTCF organizational culture, comprising (A1) interprofessional tensions, (A2) education provided in silos, (A3) lack of motivation and (A4) resistance to change; (B) resources, comprising (B1) workload and staffing levels, (B2) diagnostics, (B3) information technology resources and (B4) funding; and (C) availability of and access to knowledge and skills, including (C1) surveillance data, (C2) infectious disease/AMS expertise and (C3) data analysis skills. CONCLUSIONS: Addressing inappropriate antibiotic prescribing in LTCFs through AMS programmes is an area of growing interest. Hopefully, this review could be helpful for intervention developers and implementers who want to build on the most recent evidence from the literature.

Candida auris: A bibliometric analysis of an emerging global health threat.

BACKGROUND: Candida auris (CA) is an emerging fungus, classified as an urgent global health threat, that resists common antifungal drugs and decontamination procedures; identification requires specific tools; transmissibility and mortality are high in healthcare settings. Infection and colonisation can be long-lasting, leading to problems in isolation procedures and the risk of outbreaks. This study aims to evaluate publication and citation related metrics, identify major keywords and topics, and assess geographic distribution of published articles. METHODS: A list of all publications containing "Candida auris" in all fields was extracted from Web Of Science on date 2023/01/02. Bibliometric analysis was conducted using the bibliometrix and biblioshiny packages on RStudio. RESULTS: Total publications (TP) were 1283 with an annual growth rate of 53.91%. Total citations were 27854, with an average of 21.71 citations per paper. The core sources are 9 out of 322, according to Bradford's law. In only 42 countries where CA was identified, articles on the topic were published (89%). The origin of TP is concentrated in high-income countries (68.22%). Trending topics about CA include epidemiology, identification and resistance. CONCLUSION: Our analysis shows a growing interest in scientific literature on the topic of CA, led by Europe. In some countries where CA has been identified, no papers have been published. Despite the multidrug-resistance of CA, the topic of therapy is not much debated. Our findings highlight the need to increase focus on CA in order to promote health systems' preparedness and to properly address the spread of this worrisome pathogen.

Antimicrobial stewardship experiences in acute-care hospitals of Northern Italy: Assessment of structure, process and outcome indicators, 2017-2019.

BACKGROUND: Antimicrobial stewardship (AMS) programs are effective strategies for optimizing antimicrobial use. We aimed to assess AMS programs implemented in acute-care trusts of the region of Piedmont, Northern Italy. METHODS: AMS programs were investigated via a survey addressing structure, process and outcome indicators. For outcome indicators, annual means for the years 2017-2019 were considered, as well as the percentage change between 2017 and 2019. Outcome indicators were investigated in relation to structure and process scores using Spearman correlation. RESULTS: In total, 25 AMS programs were surveyed. Higher scores were achieved for process over structure indicators. Improvements in alcohol-based handrub usage (+30%), total antimicrobial usage (-4%), and percentages of methicillin-resistant Staphylococcus aureus and carbapenem-resistant Enterobacteriaceae over invasive isolates (respectively -16 and -23%) were found between 2017 and 2019. Significant correlations were found between structure score and percentage change in total antimicrobial usage and carbapenem-resistant Enterobacteriaceae over invasive isolates (Spearman's ρ -0.603, P .006 and ρ -0.433, P .044 respectively). DISCUSSION: This study identified areas for improvement: accountability, microbiological laboratory quality management and feedback to clinicians. Improving the organization of AMS programs in particular should be prioritized. CONCLUSION: Repeated measurements of structure and process indicators will be important to guide continuing quality improvement efforts.

Hand hygiene monitoring: Comparison between app and paper forms for direct observation.

Healthcare-associated infections (HAIs) are a global public health threat. Italy is one of the countries with the highest prevalence of HAI. Hand hygiene (HH) is a pillar of infection prevention and control. Monitoring HH is necessary to improve HH compliance, and direct observation is considered the gold standard. Transcription and analysis of data collected during direct observation of HH compliance with the WHO paper form are time-consuming. We collected, during a 9-day observation period, HH opportunities and compliance both with a smartphone application (SpeedyAudit) and with the WHO paper form. Then, we investigated the difference in the required time for data transcription and analysis between the WHO paper form and the use of the app. The difference in the required time for data transcription and analysis was significant with a mean time of 2 s using the app and about 14-54 min/day using paper form (p = .004) while no significant difference was found in measured compliance rates between the two data collecting methods. HH monitoring with an app is time-saving, and the app we used was easy to use.

Hand Hygiene Practices during the COVID-19 Pandemic in Northern Italy: Assessment of Compliance Rates Measured by Direct Observation and Alcohol-Based Handrub Usage.

Hand hygiene (HH) is among the most effective measures for reducing the transmission of healthcare-associated infections and SARS-CoV-2. We aimed to assess HH practices among healthcare workers (HCWs) of three hub hospitals in Northern Italy during the COVID-19 pandemic, by assessing HH compliance measured by direct observation and alcohol-based handrub usage. An observational study was conducted over a period of three months, between February and April 2021. HH compliance audits were conducted using the WHO My 5 Moments for HH approach. Multivariable logistic regression was used to evaluate independent predictors of HH compliance: ward type, HCW category and HH indication. Spearman correlation was used to investigate the relationship between HH compliance and alcohol-based handrub consumption. In total, 2880 HH opportunities were observed, with an overall compliance of 68%. Significant differences were found in compliance rates across ward types, HCW categories and HH indications. The mean alcohol-based handrub usage among included wards was 41.63 mL/PD. No correlation was identified between compliance rates and alcohol-based handrub consumption (ρ 0.023, p 0.943). This study provided a snapshot of HH practices in a pandemic context, which could be useful as a reference for future studies.

Tailoring Antimicrobial Stewardship (AMS) Interventions to the Cultural Context: An Investigation of AMS Programs Operating in Northern Italian Acute-Care Hospitals.

Antibiotic misuse and overuse are important contributors to the development of antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) programs are coordinated sets of actions aiming to promote appropriate antibiotic use, improving patient outcomes whilst reducing AMR. Two main organizational models for AMS programs have been described: restrictive strategies (RS) vs. enabling strategies (ES). Evaluating and understanding social and cultural influences on antibiotic decision-making are critical for the development of successful and sustainable context-specific AMS programs. Characteristics and surrogate outcomes of AMS programs operating in acute-care hospitals of Piedmont in north-western Italy were investigated. The aim of this study was assessing whether RS vs. ES operating in our context were associated with different outcomes in terms of total antimicrobial usage and percentage of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) over invasive isolates. In total, 24 AMS programs were assessed. ES were more frequently chosen compared to RS, with the latter being implemented only in broader AMS programs involving enabling components (combined strategy, CS). This study found no difference in evaluated outcomes among hospitals implementing ES vs. CS, suggesting both approaches could be equally valid in our context.

Surrogate models provide new insights on metrics based on blood flow for the assessment of left ventricular function.

Recent developments on the grading of cardiac pathologies suggest flow-related metrics for a deeper evaluation of cardiac function. Blood flow evaluation employs space-time resolved cardiovascular imaging tools, possibly integrated with direct numerical simulation (DNS) of intraventricular fluid dynamics in individual patients. If a patient-specific analysis is a promising method to reproduce flow details or to assist virtual therapeutic solutions, it becomes impracticable in nearly-real-time during a routine clinical activity. At the same time, the need to determine the existence of relationships between advanced flow-related quantities of interest (QoIs) and the diagnostic metrics used in the standard clinical practice requires the adoption of techniques able to generalize evidences emerging from a finite number of single cases. In this study, we focus on the left ventricular function and use a class of reduced-order models, relying on the Polynomial Chaos Expansion (PCE) technique to learn the dynamics of selected QoIs based on a set of synthetic cases analyzed with a high-fidelity model (DNS). The selected QoIs describe the left ventricle blood transit and the kinetic energy and vorticity at the peak of diastolic filling. The PCE-based surrogate models provide straightforward approximations of these QoIs in the space of widely used diagnostic metrics embedding relevant information on left ventricle geometry and function. These surrogates are directly employable in the clinical analysis as we demonstrate by assessing their robustness against independent patient-specific cases ranging from healthy to diseased conditions. The surrogate models are used to perform global sensitivity analysis at a negligible computational cost and provide insights on the impact of each diagnostic metric on the QoIs. Results also suggest how common flow transit parameters are principally dictated by ejection fraction.

Safety and diagnostic performance of image-guided lung biopsy in the targeted therapy era.

OBJECTIVE OF THE STUDY: To identify risk factors for the adverse events and determine the diagnostic yield of a large series of image-guided thoracic biopsies performed in a single institution. MATERIALS AND METHODS: We reviewed a consecutive series of 811 patients (546 males; average age: 68 years.) who underwent 824 image-guided biopsies of pulmonary lesions performed between 2009 and 2013. Indications for biopsy were always evaluated by a multidisciplinary board. All complications were registered. The diagnostic accuracy was calculated on the basis of histology after surgery, response to medical therapy, or outcome at imaging follow-up. Safety and accuracy was correlated with patient-related and lesion-related factors. RESULTS: 61 biopsies were performed under US-guidance, 750 under CT-guidance, and 13 under combined guidance. The average lesion size was 36.4 mm (6-150 mm). FNAB was exclusively performed in 247 patients, whereas 577 patients underwent also or only core biopsy (CB). 40 (4.8 %) major complications and 172 (20.8 %) minor complications occurred. US-guidance, absence of perilesional emphysema and minor depth of the target lesion from the skin resulted as favorable predictors against major complications. According to the gold standard criteria, we demonstrated 497 true positives, 72 true negatives, 18 false negatives, 0 false positives. Sensitivity, specificity and diagnostic accuracy were 96.5, 100 and 97 %. No predictors for accuracy were found, but the number of samples largely related to the pathologist on site. CONCLUSIONS: Image-guided lung biopsy is safe and highly accurate for diagnosing thoracic lesions. In the targeted therapy era, CB with larger needles can be safely applied when the need for larger amounts of tumor tissue is presumed.