Long-Term Effects of Phased Implementation of Antimicrobial Stewardship in Academic ICUs: 2007-2015.

OBJECTIVES: Antimicrobial stewardship is advocated to reduce antimicrobial resistance in ICUs by reducing unnecessary antimicrobial consumption. Evidence has been limited to short, single-center studies. We evaluated whether antimicrobial stewardship in ICUs could reduce antimicrobial consumption and costs. DESIGN: We conducted a phased, multisite cohort study of a quality improvement initiative. SETTING: Antimicrobial stewardship was implemented in four academic ICUs in Toronto, Canada beginning in February 2009 and ending in July 2012. PATIENTS: All patients admitted to each ICU from January 1, 2007, to December 31, 2015, were included. INTERVENTIONS: Antimicrobial stewardship was delivered using in-person coaching by pharmacists and physicians three to five times weekly, and supplemented with unit-based performance reports. Total monthly antimicrobial consumption (measured by defined daily doses/100 patient-days) and costs (Canadian dollars/100 patient-days) before and after antimicrobial stewardship implementation were measured. MEASUREMENTS AND MAIN RESULTS: A total of 239,123 patient-days (57,195 patients) were analyzed, with 148,832 patient-days following introduction of antimicrobial stewardship. Antibacterial use decreased from 120.90 to 110.50 defined daily dose/100 patient-days following introduction of antimicrobial stewardship (adjusted intervention effect -12.12 defined daily dose/100 patient-days; 95% CI, -16.75 to -7.49; p < 0.001) and total antifungal use decreased from 30.53 to 27.37 defined daily doses/100 patient-days (adjusted intervention effect -3.16 defined daily dose/100 patient-days; 95% CI, -8.33 to 0.04; p = 0.05). Monthly antimicrobial costs decreased from $3195.56 to $1998.59 (adjusted intervention effect -$642.35; 95% CI, -$905.85 to -$378.84; p < 0.001) and total antifungal costs were unchanged from $1771.86 to $2027.54 (adjusted intervention effect -$355.27; 95% CI, -$837.88 to $127.33; p = 0.15). Mortality remained unchanged, with no consistent effects on antimicrobial resistance and candidemia. CONCLUSIONS: Antimicrobial stewardship in ICUs with coaching plus audit and feedback is associated with sustained improvements in antimicrobial consumption and cost. ICUs with high antimicrobial consumption or expenditure should consider implementing antimicrobial stewardship programs.

Prospective audit and feedback on antibiotic use in neonatal intensive care: a retrospective cohort study.

BACKGROUND: Antimicrobial stewardship programs potentially lead to appropriate antibiotic use, yet the optimal approach for neonates is uncertain. Such a program was implemented in a tertiary care neonatal intensive care unit in October 2012. We evaluated the impact of this program on antimicrobial use and its association with clinical outcomes. METHODS: In a retrospective cohort study, we examined 1580 neonates who received antimicrobials in the 13-months before and 13-months during program implementation. Prospective audit and feedback was given 5 days a week on each patient who was receiving antibiotic. Pharmacy and microbiology data were linked to clinical data from the local Canadian Neonatal Network database. The primary outcome was days of antibiotic therapy per 1000 patient-days; secondary outcomes included mortality, necrotizing enterocolitis, and antibiotic duration for culture-positive and culture-negative late-onset sepsis. The breadth of antibiotic exposure was compared using the Antibiotic Spectrum Index. RESULTS: Overall antibiotic use decreased to 339 days of therapy per 1000 patient-days from 395 (14%, P < 0.001), without an increase in mortality. There was no difference in duration of therapy in culture-negative or culture-positive sepsis, rates of necrotizing enterocolitis, or breadth of antibiotic exposure. Fewer antibiotic starts occurred during program implementation (63% versus 59%, P < 0.001). The use of narrow-spectrum agents decreased (P < 0.001) whereas the use of cefotaxime increased (P = 0.016) during program implementation. CONCLUSIONS: Daily prospective audit and feedback was not associated with a change in antibiotic duration or clinical outcomes, however there were fewer babies started on antibiotics, suggesting that additional interventions are required to inform and sustain changes in antibiotic prescribing practices.

Use of a structured panel process to define antimicrobial prescribing appropriateness in critical care.

BACKGROUND: Antimicrobial prescribing is frequently reported as appropriate or inappropriate, particularly in the ICU. However, the definitions used are non-standardized and lack validity and reliability. OBJECTIVES: To develop standardized definitions of appropriateness for antimicrobial prescribing in the critical care setting. METHODS: We used consensus-based modified Delphi and RAND appropriateness methodology to develop criteria to define appropriateness of antimicrobial prescribing. A multiphased approach with an online questionnaire followed by a facilitated in-person meeting was utilized and included clinicians from a variety of practice areas (e.g. surgeons, infectious diseases specialists, intensivists, transplant specialists and pharmacists). RESULTS: There were a total of 23 criteria agreed upon to define the following categories of antimicrobial prescribing: appropriate; effective but unnecessary; inappropriate; and under-treatment. CONCLUSIONS: These standardized criteria for appropriateness may be generalizable to other patient populations and utilized with other tools to adjudicate prescribing practices.

Engaging Nurses in Optimizing Antimicrobial Use in ICUs: A Qualitative Study.

Antimicrobial stewardship programs (ASPs) have predominately involved infectious diseases physicians and pharmacists with little attention to the nurses. To achieve optimal success of ASPs, engagement of nurses to actively participate in initiatives, strategies, and solutions to combat antibiotic resistance across the health care spectrum is required. In this context, the experiences of local ASP teams engaging nurses in appropriate antimicrobial use were explored to inform future strategies to enhance their involvement in ASPs.

A National Survey of Critical Care Physicians' Knowledge, Attitudes, and Perceptions of Antimicrobial Stewardship Programs.

OBJECTIVE: Antimicrobial stewardship is a process designed to optimize antimicrobial therapy by ensuring patients get the right antimicrobials at the right dose and at the right time. Antimicrobial stewardship programs (ASPs) are increasingly being implemented in health care institutions, are required by some accreditation bodies, and have the potential for maximum impact in intensive care units (ICUs). We administered a survey to critical care physicians across Canada to better understand their knowledge, attitudes, and perceptions on the utility of ASPs in improving patient care. DESIGN, SETTING, AND PATIENTS: We distributed a Web-based survey to physicians who attend in Canadian ICUs. Respondents were identified through the membership lists of multiple critical care organizations. Content validity, utility, clarity, and test-retest reliability were evaluated prior to distribution. Survey items assessed ASP knowledge, attitudes, and experiences. Attitudes toward ASPs were assessed on a 5-point Likert-type scale. MEASUREMENTS AND MAIN RESULTS: The survey was completed by 185 physicians, with a response rate of 29% (n = 185/634) for all physicians contacted. A majority (74%) of respondents reported that there was at least 1 component of an ASP at their institution. Most (86%) respondents agreed or strongly agreed that the patients in their ICU benefit from an ASP, with 81% reporting the ASP increases their knowledge of appropriate antimicrobial use in the ICU setting. Only 11% of respondents reported they felt that time spent interacting with the ASP team was an inefficient use of their time, and only 7% expressed concern that the ASP negatively affected their autonomy. CONCLUSION: Based on our survey results, Canadian intensivists are supportive of antimicrobial stewardship in ICUs and feel that ASPs provide a valuable service to both patients and clinicians.

Impact of Infectious Disease Consultation on Quality of Care, Mortality, and Length of Stay in Staphylococcus aureus Bacteremia: Results From a Large Multicenter Cohort Study.

BACKGROUND: We assessed the impact of infectious disease (ID) consultation on management and outcome in patients with Staphylococcus aureus bacteremia (SAB). METHODS: A retrospective cohort study examined consecutive SAB patients from 6 academic and community hospitals between 2007 and 2010. Quality measures of management including echocardiography, repeat blood culture, removal of infectious foci, and antibiotic therapy were compared between ID consultation (IDC) and no ID consultation (NIDC) groups. A competing risk model with propensity score adjustment was used to compare in-hospital mortality and time to discharge. RESULTS: Of 847 SAB patients, 506 (60%) patients received an ID consultation and 341 (40%) patients did not. Echocardiography was done for 371 (73%) IDC and 191 (56%) NIDC patients (P < .0001) in hospital. Blood cultures were repeated within 2-4 days of bacteremia in 207 (41%) IDC and 107 (31%) NIDC patients (P = .0058). The infectious foci removal rate was not statistically different between the 2 groups. For empiric therapy, 474 (94%) IDC and 297 (87%) NIDC patients received appropriate antibiotics (P = .0013). For patients who finished the planned course of antibiotics, 285 of 422 (68%) IDC and 141 of 262 (54%) NIDC patients received the appropriate duration of antibiotic therapy (P = .0004). In hospital, 204 (24%) patients died: 104 of 506 (21%) IDC and 100 of 341 (29%) NIDC patients. Matched by propensity score, ID consultation had a subdistribution hazard ratio of 0.72 (95% confidence interval [CI], .52-.99; P = .0451) for in-hospital mortality and 1.28 (95% CI, 1.06-1.56; P = .0109) for being discharged alive. CONCLUSIONS: ID consultation is associated with better adherence to quality measures, reduced in-hospital mortality, and earlier discharge in patients with SAB.

Recall of ICU Stay in Patients Managed With a Sedation Protocol or a Sedation Protocol With Daily Interruption.

OBJECTIVES: To 1) describe factual, emotional, and delusional memories of ICU stay for patients enrolled in the SLEAP (Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol) trial; 2) compare characteristics of patients with and without ICU recall, and patients with and without delusional memories; and 3) determine factors associated with delusional memories 28 days after ICU discharge. DESIGN: Prospective cohort. SETTING: Sixteen North American medical and surgical ICUs. PATIENTS: Critically ill, mechanically ventilated adults randomized in the SLEAP trial. INTERVENTIONS: Post-ICU interviews on days 3, 28, and 90 using the validated ICU Memory Tool. MEASUREMENTS AND MAIN RESULTS: Overall, 289 of 297 ICU survivors (97%) (146 protocolized sedation and 143 protocolized sedation plus daily interruption patients) were interviewed at least once. Because there were no differences in recall status or types of memories between the two sedation groups, we present the findings for all patients rather than by study group. On days 3, 28, and 90, 28%, 26%, and 36% of patients, respectively, reported no recall of being in the ICU (overall perception, self-reported) (p = 0.75). Mean daily doses of benzodiazepines and opioids were lower in patients with no ICU recall than those with recall (p < 0.0001 for both). Despite one third of patients reporting no recall of ICU stay on day 3, 97% and 90% reported at least one factual and one emotional memory from ICU, respectively. Emotional memories declined with time after ICU discharge, particularly panic and confusion. Delusional memories 28 days after discharge were common (70%) yet unrelated to delirium (p = 0.84), recall status (p = 0.15), total dose of benzodiazepine (p = 0.78), or opioid (p = 0.21). Delusional memories were less likely with longer duration of mechanical ventilation (odds ratio, 0.955; 95% CI, 0.91-1.00; p = 0.04). CONCLUSIONS: Recall of ICU stay and types of memories reported were not influenced by the trial sedation strategy. Lack of ICU recall and delusional memories were common after ICU discharge despite the use of sedation strategies that promoted wakefulness.

Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults.

OBJECTIVE: Delirium is common during critical illness and associated with adverse outcomes. We compared characteristics and outcomes of delirious and nondelirious patients enrolled in a multicenter trial comparing protocolized sedation with protocolized sedation plus daily sedation interruption. DESIGN: Randomized trial. SETTING: Sixteen North American medical and surgical ICUs. PATIENTS: Four hundred thirty critically ill, mechanically ventilated adults. INTERVENTIONS: All patients had hourly titration of opioid and benzodiazepine infusions using a validated sedation scale. For patients in the interruption group, infusions were resumed, if indicated, at half of previous doses. Delirium screening occurred daily; positive screening was defined as an Intensive Care Delirium Screening Checklist score of 4 or more at any time. MEASUREMENTS AND MAIN RESULTS: Delirium was diagnosed in 226 of 420 assessed patients (53.8%). Coma was identified in 32.7% of delirious compared with 22.7% of nondelirious patients (p = 0.03). The median time to onset of delirium was 3.5 days (interquartile range, 2-7), and the median duration of delirium was 2 days (interquartile range, 1-4). Delirious patients were more likely to be male (61.1% vs 46.6%; p = 0.005), have a surgical/trauma diagnosis (21.2% vs 11.0%; p = 0.030), and history of tobacco (31.5% vs 16.2%; p = 0.002) or alcohol use (34.6% vs 20.9%; p = 0.009). Patients with positive delirium screening had longer duration of ventilation (13 vs 7 d; p < 0.001), ICU stay (12 vs 8 d; p < 0.0001), and hospital stay (24 vs 15 d; p < 0.0001). Delirious patients were more likely to be physically restrained (86.3% vs 76.7%; p = 0.014) and undergo tracheostomy (34.6% vs 15.5%; p < 0.0001). Antecedent factors independently associated with delirium onset were restraint use (hazard ratio, 1.87; 95% CI, 1.33-2.63; p = 0.0003), antipsychotic administration (hazard ratio, 1.67; 95% CI, 1.005-2.767; p = 0.047), and midazolam dose (hazard ratio, 0.998; 95% CI, 0.997-1.0; p = 0.049). There was no difference in delirium prevalence or duration between the interruption and control groups. CONCLUSION: In mechanically ventilated adults, delirium was common and associated with longer duration of ventilation and hospitalization. Physical restraint was most strongly associated with delirium.

Comparative effectiveness of cefazolin versus cloxacillin as definitive antibiotic therapy for MSSA bacteraemia: results from a large multicentre cohort study.

OBJECTIVES: We compared the effectiveness of cefazolin versus cloxacillin in the treatment of MSSA bacteraemia in terms of mortality and relapse. METHODS: A retrospective cohort study examined consecutive patients with Staphylococcus aureus bacteraemia from six academic and community hospitals between 2007 and 2010. Patients with MSSA bacteraemia who received cefazolin or cloxacillin as the predominant definitive antibiotic therapy were included in the study. Ninety-day mortality was compared between the two groups matched by propensity scores. RESULTS: Of 354 patients included in the study, 105 (30%) received cefazolin and 249 (70%) received cloxacillin as the definitive antibiotic therapy. In 90 days, 96 (27%) patients died: 21/105 (20%) in the cefazolin group and 75/249 (30%) in the cloxacillin group. Within 90 days, 10 patients (3%) had a relapse of S. aureus infection: 6/105 (6%) in the cefazolin group and 4/249 (2%) in the cloxacillin group. All relapses in the cefazolin group were related to a deep-seated infection. Based on the estimated propensity score, 90 patients in the cefazolin group were matched with 90 patients in the cloxacillin group. In the propensity score-matched groups, cefazolin had an HR of 0.58 (95% CI 0.31-1.08, P = 0.0846) for 90 day mortality. CONCLUSIONS: There was no significant clinical difference between cefazolin and cloxacillin in the treatment of MSSA bacteraemia with respect to mortality. Cefazolin was associated with non-significantly more relapses compared with cloxacillin, especially in deep-seated S. aureus infections.

Usefulness of previous methicillin-resistant Staphylococcus aureus screening results in guiding empirical therapy for S aureus bacteremia.

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is an important infection. Methicillin-resistant S aureus (MRSA) screening is performed on hospitalized patients for infection control purposes. OBJECTIVE: To assess the usefulness of past MRSA screening for guiding empirical antibiotic therapy for SAB. METHODS: A retrospective cohort study examined consecutive patients with confirmed SAB and previous MRSA screening swab from six academic and community hospitals between 2007 and 2010. Diagnostic test properties were calculated for MRSA screening swab for predicting methicillin resistance of SAB. RESULTS: A total of 799 patients underwent MRSA screening swabs before SAB. Of the 799 patients, 95 (12%) had a positive and 704 (88%) had a negative previous MRSA screening swab. There were 150 (19%) patients with MRSA bacteremia. Overall, previous MRSA screening swabs had a positive likelihood ratio of 33 (95% CI 18 to 60) and a negative likelihood ratio of 0.45 (95% CI 0.37 to 0.54). Diagnostic accuracy differed depending on mode of acquisition (ie, community-acquired, nosocomial or health care-associated infection) (P<0.0001) and hospital (P=0.0002). At best, for health care-associated infection, prior MRSA screening swab had a positive likelihood ratio of 16 (95% CI 9 to 28) and a negative likelihood ratio of 0.27 (95% CI 0.17 to 0.41). CONCLUSIONS: A negative prior MRSA screening swab cannot reliably rule out MRSA bacteremia and should not be used to guide empirical antibiotic therapy for SAB. A positive prior MRSA screening swab greatly increases likelihood of MRSA, necessitating MRSA coverage in empirical antibiotic therapy for SAB.

HISTORIQUE: La bactériémie à Staphylococcus aureus (BSA) est une infection grave. Les patients hospitalisés subissent un dépistage du S. aureus résistant à la méthicilline (SARM) afin de prévenir les infections. OBJECTIF: Évaluer l'utilité d'un dépistage antérieur du SARM pour orienter l'antibiothérapie empirique de la BSA. MÉTHODOLOGIE: Les chercheurs ont effectué une étude de cohorte rétrospective dans six hôpitaux universitaires et hôpitaux généraux entre 2007 et 2010 auprès de patients consécutifs atteints d'une BSA confirmée ayant déjà subi un prélèvement de dépistage du SARM. Ils ont calculé les propriétés des tests diagnostiques par prélèvement pour diagnostiquer le SARM et prédire la résistance de la BSA à la méthicilline. RÉSULTATS: Au total, 799 patients avaient déjà subi des prélèvements pour dépister le SARM avant une BSA. De ce nombre, 95 (12 %) ont présenté un résultat positif et 704 (88 %) avaient déjà subi un prélèvement pour dépister le SARM. Cent cinquante patients (19 %) avaient une bactériémie à SARM. Dans l'ensemble, les prélèvements antérieurs pour dépister le SARM avaient un ratio de probabilité positif de 33 (95 % IC 18 à 60) et négatif de 0,45 (95 % IC 0,37 à 0,54). La précision diagnostique différait en fonction du mode d'acquisition (origine non nosocomiale, origine nosocomiale ou association aux soins de santé) (P<0,0001) et de l'hôpital (P=0,0002). Dans le meilleur des cas, en présence d'une infection associée aux soins de santé, un prélèvement antérieur pour dépister un SARM s'associait à un ratio de probabilité positif de 16 (95 % IC 9 à 28) et négatif de 0,27 (95 % IC 0,17 à 0,41). CONCLUSIONS: Un prélèvement antérieur négatif au SARM ne permet pas d'écarter une bactériémie par le SARM avec fiabilité et ne devrait pas orienter l'antibiothérapie empirique de la BSA. Un prélèvement antérieur positif au SARM accroît considérablement la probabilité de SARM, ce qui oblige à en tenir compte pour l'antibiothérapie empirique de la BSA.

Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial.

CONTEXT: Protocolized sedation and daily sedation interruption are 2 strategies to minimize sedation and reduce the duration of mechanical ventilation and intensive care unit (ICU) stay. We hypothesized that combining these strategies would augment the benefits. OBJECTIVE: To compare protocolized sedation with protocolized sedation plus daily sedation interruption in critically ill patients. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial of 430 critically ill, mechanically ventilated adults conducted in 16 tertiary care medical and surgical ICUs in Canada and the United States between January 2008 and July 2011. INTERVENTION: Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption (n = 214). Using validated scales, nurses titrated infusions to achieve light sedation. For patients receiving daily interruption, nurses resumed infusions, if indicated, at half of previous doses. Patients were assessed for delirium and for readiness for unassisted breathing. MAIN OUTCOME MEASURE: Time to successful extubation. Secondary outcomes included duration of stay, doses of sedatives and opioids, unintentional device removal, delirium, and nurse and respiratory therapist clinical workload (on a 10-point visual analog scale [VAS]). RESULTS: Median time to successful extubation was 7 days in both the interruption and control groups (median [IQR], 7 [4-13] vs 7 [3-12]; interruption group hazard ratio, 1.08; 95% CI, 0.86-1.35; P = .52). Duration of ICU stay (median [IQR], 10 [5-17] days vs 10 [6-20] days; P = .36) and hospital stay (median [IQR], 20 [10-36] days vs 20 [10-48] days; P = .42) did not differ between the daily interruption and control groups, respectively. Daily interruption was associated with higher mean daily doses of midazolam (102 mg/d vs 82 mg/d; P = .04) and fentanyl (median [IQR], 550 [50-1850] vs 260 [0-1400]; P < .001) and more daily boluses of benzodiazepines (mean, 0.253 vs 0.177; P = .007) and opiates (mean, 2.18 vs 1.79; P < .001). Unintentional endotracheal tube removal occurred in 10 of 214 (4.7%) vs 12 of 207 patients (5.8%) in the interruption and control groups, respectively (relative risk, 0.82; 95% CI, 0.36-1.84; P = .64). Rates of delirium were not significantly different between groups (53.3% vs 54.1%; relative risk, 0.98; 95% CI, 0.82-1.17; P = .83). Nurse workload was greater in the interruption group (VAS score, 4.22 vs 3.80; mean difference, 0.41; 95% CI, 0.17-0.66; P = .001). CONCLUSION: For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00675363.

Evaluating and prioritizing antimicrobial stewardship programs for nursing homes: A modified Delphi panel.

BACKGROUND: Antibiotic use in nursing homes is often inappropriate, in terms of overuse and misuse, and it can be linked to adverse events and antimicrobial resistance. Antimicrobial stewardship programs (ASPs) can optimize antibiotic use by minimizing unnecessary prescriptions, treatment cost, and the overall spread of antimicrobial resistance. Nursing home providers and residents are candidates for ASP implementation, yet guidelines for implementation are limited. OBJECTIVE: To support nursing home providers with the selection and adoption of ASP interventions. DESIGN AND SETTING: A multiphase modified Delphi method to assess 15 ASP interventions across criteria addressing scientific merit, feasibility, impact, accountability, and importance. This study included surveys supplemented with a 1-day consensus meeting. PARTICIPANTS: A 16-member multidisciplinary panel of experts and resident representatives. RESULTS: From highest to lowest, 6 interventions were prioritized by the panel: (1) guidelines for empiric prescribing, (2) audit and feedback, (3) communication tools, (4) short-course antibiotic therapy, (5) scheduled antibiotic reassessment, and (6) clinical decision support systems. Several interventions were not endorsed: antibiograms, educational interventions, formulary review, and automatic substitution. A lack of nursing home resources was noted, which could impede multifaceted interventions. CONCLUSIONS: Nursing home providers should consider 6 key interventions for ASPs. Such interventions may be feasible for nursing home settings and impactful for improving antibiotic use; however, scientific merit supporting each is variable. A multifaceted approach may be necessary for long-term improvement but difficult to implement.

Using Scorecard Feedback to Improve Quantitative Blood Loss Measurement at Birth.

OBJECTIVE: To increase the percentage of cases in which quantitative blood loss (QBL) was documented by labor and delivery nurses for women giving birth. DESIGN: Quality improvement project. SETTING/LOCAL PROBLEM: Labor and delivery unit of a community hospital in which a previous implementation of QBL measurement was not sustained. PARTICIPANTS: Labor and delivery nurses were the focus of the intervention, but the entire multidisciplinary team became involved. INTERVENTION/MEASUREMENTS: Based on literature supporting the use of scorecard feedback to stimulate performance improvement, weekly blinded individual scorecards showing the percentage of births attended by each labor and delivery nurse with QBL documented and a run chart showing the percentage of all births with QBL documented were posted on the unit and discussed during huddles for 12 weeks. Data on blood product administration were collected, and charts comparing QBL and estimated blood loss (EBL) volumes documented were shared with nurses and physicians. RESULTS: Over 12 weeks, the percentage of births with QBL documented increased from 22.7% to 80.0%. Consistent with previous reports comparing QBL and EBL volumes at birth, there was a significant difference between the mean QBL volume (mean = 482.20 ml, standard deviation = 358.03) and the mean EBL volume (mean = 313.15 ml, standard deviation = 211.91; p < .001) for total births. The mean QBL volume was also greater than the mean EBL volume for vaginal and cesarean births, but those differences were not statistically significant. There was no increase in blood product administration associated with the increase in QBL documentation. CONCLUSION: Discussing weekly scorecards and a run chart of QBL measurement was associated with an increase in documentation of QBL by labor and delivery nurses. Planning this project and discussing the results engaged the entire multidisciplinary team in more consistent measurement of QBL. The increased level of QBL documentation has been sustained for longer than 1 year.

Structure of Antimicrobial Stewardship Programs in Leading US Hospitals: Findings of a Nationwide Survey.

BACKGROUND: To examine antibiotic stewardship program (ASP) structure among high-performing hospitals and determine which components of the 2016 Infectious Diseases Society of America (IDSA)/Society for Hospital Epidemiology of America (SHEA) ASP guidelines are implemented at each site. METHODS: A survey of the highest-ranking hospitals, compiled from the 2015-2016 US News and World Report's Best Hospital Rankings, was conducted from August to December 2016. This corresponded to 138 adult and 62 pediatric unique hospitals. We inquired as to which components of the 2016 IDSA/SHEA ASP guidelines were implemented at each site. Appropriate persons at each hospital were emailed surveys after telephone or email conversations confirmed that they belonged to that hospital's ASP. RESULTS: Overall, 101 of 200 hospitals responded (51%). Of these, 82% (n = 83/101) had an active ASP, and 59% (n = 47/80) were active for more than 5 years. Most report to a committee rather than to an individual (n = 68/80, 85%), do not have their own budget (n = 42/80, 53%), and selectively implement IDSA/SHEA recommendations. Additionally, the majority of ASPs in top hospitals follow aspects of The Joint Commission Standards for Antimicrobial Stewardship, which were released after the survey was administered. CONCLUSIONS: Of leading US hospitals responding to our survey, >80% had an ASP, and most implemented the majority of commitments, interventions, and optimization strategies suggested by IDSA/SHEA. Understanding the structure of ASPs in these hospitals will assist other hospitals in program implementation.

Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis.

BACKGROUND: Echocardiography is important for the diagnosis of infective endocarditis (IE), for which transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE). METHODS: A systematic review and meta-analysis of observational studies was performed with the objective of evaluating diagnostic properties of TTE, with transesophageal findings of IE as the reference standard in patients with suspected IE. RESULTS: The literature search yielded 377 unique articles, of which 16 met the inclusion criteria. The 16 studies included 2,807 patients, of whom 793 (28%) had vegetations on TEE. For detecting vegetations, harmonic TTE had sensitivity of 61% (95% CI, 45%-75%) and specificity of 94% (95% CI, 85%-98%) with a negative likelihood ratio (NLR) of 0.42 (95% CI, 0.26-0.61). NLR for harmonic TTE can be improved by including only patients without prosthetic valves (NLR = 0.36; 95% CI, 0.22-0.55) or by having strict criteria for conclusively negative results on TTE (NLR = 0.17; 95% CI, 0.10-0.28). In the setting of patients without prosthetic valves, harmonic TTE had likelihood ratios of 0.14 (95% CI, 0.09-0.23) for a conclusively negative result, 0.66 (95% CI, 0.53-0.81) for an indeterminate result, and 14.60 (95% CI, 3.37-70.40) for a positive result. CONCLUSIONS: Modern harmonic TTE still has the potential to miss many vegetations detected on TEE. When limited to patients without prosthetic valves, a conclusively negative TTE under optimal view greatly decreases likelihood of IE. All other transthoracic results are not useful for ruling out IE, and subsequent TEE is almost always required.

Clinical predictors and clinical prediction rules to estimate initial patient risk for infective endocarditis in Staphylococcus aureus bacteraemia: a systematic review and meta-analysis.

OBJECTIVES: We conducted a meta-analysis to summarize diagnostic properties of risk factors and clinical prediction rules for diagnosing infective endocarditis (IE) in Staphylococcus aureus bacteraemia (SAB). METHODS: We searched MEDLINE, Embase, and the Cochrane Database from inception to 6 January 2016 to identify studies evaluating risk factors and clinical prediction rules for IE in SAB patients. Pooled estimates of diagnostic properties for main risk factors were calculated using a bivariate random effects model. RESULTS: Of 962 articles identified, 30 studies were included. These involved 16 538 SAB patients including 1572 IE cases. Risk factors with positive likelihood ratio (PLR) greater than 5 included embolic events (PLR 12.7, 95% CI 9.2-17.7), pacemakers (PLR 9.7, 95% CI 3.7-21.2), history of previous IE (PLR 8.2, 95% CI 3.1-22.0), prosthetic valves (PLR 5.7, 95% CI 3.2-9.5), and intravenous drug use (PLR 5.2, 95% CI 3.8-6.9). The only clinical factor with negative likelihood ratio (NLR) less than 0.5 was documented clearance of bacteraemia within 72 hours (NLR range 0.32-0.35). Of the nine published clinical prediction rules for ruling out IE, five had an NLR below 0.1. CONCLUSIONS: SAB patients with high-risk features (embolic events, pacemakers, prosthetic valves, previous IE, or intravenous drug use) should undergo a trans-esophageal echocardiography (TEE) for IE. Clinical prediction rules show promise in safely ruling out endocarditis, but require validation in future studies.

Chest CT scans are frequently abnormal in asymptomatic patients with newly diagnosed acute myeloid leukemia.

Chest computed tomography (CT) findings of nodules, ground glass opacities, and consolidations are often interpreted as representing invasive fungal infection in individuals with febrile neutropenia. We assessed whether these CT findings were present in asymptomatic individuals with acute myeloid leukemia (AML) at low risk of invasive fungal disease. A retrospective study of consecutive asymptomatic adult patients with newly diagnosed AML over a 2-year period was performed at a tertiary care oncology center. Radiology reports of baseline chest CTs were reviewed. Of 145 CT scans, the majority (88%) had pulmonary abnormalities. Many (70%) had one or both of unspecified opacities (52%) and nodules (49%). Ground glass opacities (18%) and consolidations (12%) occurred less frequently. Radiologists suggested pneumonia as a possible diagnosis in 32% (n = 47) of scans. Chest CT may result in over-diagnosis of invasive fungal disease in individuals with febrile neutropenia if interpreted without correlation to the patients' clinical status.

Retention of retrospective print journals in the digital age: trends and analysis.

PURPOSE: The issue of retaining retrospective print journals is examined in light of the shift to electronic titles, the reallocation of library budgets from print to electronic, and the changing research practices of today's library users. This article also examines the evolving role of the physical library and its impact on space allocation. METHODS: To determine current practice and opinion, a survey of health sciences librarians and academic librarians was conducted. To demonstrate the use patterns of older journal issues, citation analyses and interlibrary loan statistics were examined. RESULTS: All methods indicate that recent material is accessed more frequently than older material, with a significant drop in use of materials greater than 15 years old. Materials greater than 20 years old constituted less than 5% of interlibrary loans and less than 9% of articles noted in the citation analysis. CONCLUSIONS: It is possible to eliminate older years of a print journal collection without a large impact on the needs of researchers. Librarians' preference to maintain full runs of journal titles may be motivated by reasons outside of actual usage or patrons needs.

Prevalence, risk factors, and outcomes associated with physical restraint use in mechanically ventilated adults.

PURPOSE: The purpose was to describe characteristics and outcomes of restrained and nonrestrained patients enrolled in a randomized trial of protocolized sedation compared with protocolized sedation plus daily sedation interruption and to identify patient and treatment factors associated with physical restraint. METHODS: This was a post hoc secondary analysis using Cox proportional hazards modeling adjusted for center- and time-varying covariates to evaluate predictors of restraint use. RESULTS: A total of 328 (76%) of 430 patients were restrained for a median of 4 days. Restrained patients received higher daily doses of benzodiazepines (105 vs 41 mg midazolam equivalent, P < .0001) and opioids (1524 vs 919 µg fentanyl equivalents, P < .0001), more days of infusions (benzodiazepines 6 vs 4, P < .0001; opioids 7 vs 5, P = .02), and more daily benzodiazepine boluses (0.2 vs 0.1, P < .0001). More restrained patients received haloperidol (23% vs 12%, P = .02) and atypical antipsychotics (17% vs 4%, P = .003). More restrained patients experienced unintentional device removal (26% vs 3%, P < .001) and required reintubation (8% vs 1%, P = .01). In the multivariable analysis, alcohol use was associated with decreased risk of restraint (hazard ratio, 0.22; 95% confidence interval, 0.08-0.58). CONCLUSIONS: Physical restraint was common in mechanically ventilated adults managed with a sedation protocol. Restrained patients received more opioids and benzodiazepines. Except for alcohol use, patient characteristics and treatment factors did not predict restraint use.

A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success.

BACKGROUND: Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. "Antimicrobial stewardship" is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs. OBJECTIVE: To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians' attitudes toward and behaviours related to antimicrobial prescribing. METHODS: In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013. RESULTS: The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards' credibility and their ability to influence the uptake of effective antimicrobial use. CONCLUSIONS: Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.

CONTEXTE: L'utilisation inappropriée d'antimicrobiens est liée au développement et à la propagation de pathogènes résistants aux médicaments, en plus d'être associée à une augmentation de la morbidité, de la mortalité, de la durée du séjour à l'hôpital et des coûts des soins de santé. « Gérance des antimicrobiens ¼ est le terme générique désignant une stratégie d'application des connaissances fondée sur des données probantes qui comporte des activités exhaustives d'amélioration de la qualité pour : optimiser l'utilisation des antimicrobiens, améliorer les résultats thérapeutiques, freiner l'émergence de la résistance aux antimicrobiens, diminuer les infections nosocomiales (notamment par Clostridium difficile) et réduire les coûts des soins de santé. OBJECTIFS: Évaluer les perceptions et l'expérience des chefs des programmes de gérance des antimicrobiens par rapport à l'attitude et aux habitudes des cliniciens quant à la prescription d'antimicrobiens. MÉTHODES: Dans la présente étude qualitative, des entrevues semi-structurées ont été réalisées auprès de 6 responsables de la gérance des antimicrobiens (2 médecins et 4 pharmaciens) dans 3 centres hospitaliers universitaires entre juin et août 2013. RÉSULTATS: Les entrevues ont permis de dégager trois thèmes clés : obtenir le concours des bonnes personnes, établir des relations collégiales et démontrer un bilan convaincant le plus rapidement possible. Les résultats de l'étude ont permis d'expliquer le rôle joué par les chefs de programme et autres responsables de la gérance des antimicrobiens ainsi que les mécanismes qu'ils ont utilisés pour influencer les autres cliniciens à entreprendre une utilisation réellement efficace des antimicrobiens. Les résultats ont aussi mis en évidence les méthodes employées par des membres de l'équipe de gérance des antimicrobiens pour adapter leurs stratégies en fonction du contexte local et des parties prenantes des services participants; pour obtenir davantage de crédibilité en démontrant les effets du programme sur les résultats cliniques et les coûts; et pour amener les hauts dirigeants à soutenir le programme et à y investir, ce qui augmente la crédibilité des responsables de la gérance des antimicrobiens et accroît leur capacité à influencer l'adoption d'une utilisation réellement efficace des antimicrobiens. CONCLUSIONS: Ensemble, ces résultats aident à mieux comprendre les méthodes et mécanismes d'influence employés par les responsables de la gérance des antimicrobiens pour faire en sorte que les cliniciens fassent un meilleur usage des antimicrobiens, ce qui permettra ensuite de guider la mise en œuvre d'une future gérance des antimicrobiens et de stratégies relatives au changement organisationnel dans les hôpitaux.