Impact of an infectious disease physician-led carbapenem postprescription feedback on prescribing behavior in a Japanese tertiary hospital: A before-after study.

INTRODUCTION: There is an insufficient number of infectious disease (ID) physicians in Japan. Hence, we considered a strategy to implement antimicrobial stewardship under these resource-limited settings. METHODS: We compared carbapenem consumption, measured as days of therapy per 100 patient-days, between 24-month baseline and 12-month intervention periods. During the intervention period, an ID physician provided daily advises to prescribers against prolonged carbapenem use (≥14 days). Additionally, we sent all doctors a table containing the weekly point prevalence aggregate of carbapenem use of each department for 7-13 and ≥ 14 days via e-mail. RESULTS: Among the 1241 carbapenem courses during the intervention period, the ID physician provided a total of 96 instances of feedback regarding carbapenem use for ≥14 days, with an acceptance rate of 76%. After the initiation of the intervention, the trend in monthly carbapenem consumption changed (coefficient: -0.62; 95% CI: -1.15 to -0.087, p = 0.024), and its consumption decreased (coefficient: -0.098; 95% CI: -0.16 to -0.039, p = 0.002) without an increase in the consumption of broad-spectrum antimicrobials or in-hospital mortality. Interestingly, the monthly number of carbapenem courses, but not the duration of carbapenem use, significantly decreased (coefficient: -3.02; 95% CI: -4.63 to -1.42, p = 0.001). The carbapenem-related annual estimated savings after the intervention was $83,745, with a 22% cost reduction. CONCLUSIONS: Our ID physician-led daily intervention with weekly feedback regarding long-term carbapenem use was effective in reducing antimicrobial consumption. Such feedback may be useful in changing the prescribing behavior and promoting appropriate antimicrobial usage even in resource-limited settings.

Streamlining Hospital Treatment of Prosthetic Joint Infection.

BACKGROUND: Prosthetic joint infection (PJI) is associated with significant morbidity, mortality, and costs. We developed a fast-track PJI care system using an infectious disease physician to work directly with the TJA service and coordinate in the treatment of PJI patients. We hypothesized that streamlined care of patients with hip and knee PJI decreases the length of the acute hospital stay without increasing the risk of complication or incorrect antibiotic selection. METHODS: A single-center retrospective chart review was performed for all patients treated operatively for PJI. A cohort of 78 fast-track patients was compared to 68 control patients treated before the implementation of the program. Hospital length of stay (LOS) and cases of antibiotic mismatch were primary outcomes. Secondary outcomes, including 90-day readmissions, reoperations, mortality, rate of reimplantation, and 12-month reimplant survival, were compared. Cox regressions were analyzed to assess the effects on LOS of patient demographics and the type of surgery performed. RESULTS: Average hospital LOS from infection surgery to discharge was significantly lower in the fast-track cohort (3.8 vs 5.7 days; P = .012). There were no episodes of antibiotic mismatch in the fast-track group vs 1 recorded episode in the control group. No significant differences were noted comparing 90-day complications, reimplantation rate, or 12-month reimplant survival rates. CONCLUSION: Through the utilization of an orthopedic-specific infectious disease physician, a fast-track PJI protocol can significantly shorten hospital LOS while remaining safe. Streamlining care pathways may help decrease the overall healthcare costs associated with treating PJI.

HIV primary care by the infectious disease physician in the United States - extending the continuum of care.

Models of care for people living with HIV (PLWH) have varied over time due to long term survival, development of HIV-associated non-AIDS conditions, and HIV specific primary care guidelines that differ from those of the general population. The objectives of this study are to assess how often infectious disease (ID) physicians provide primary care for PLWH, assess their practice patterns and barriers in the provision of primary care. We used a 6-item survey electronically distributed to ID physician members of Emerging Infections Network (EIN). Of the 1248 active EIN members, 644 (52%) responded to the survey. Among the 644 respondents, 431 (67%) treated PLWH. Of these 431 responders, 326 (75%) acted as their primary care physicians. Responders who reported always/mostly performing a screening assessment as recommended per guidelines were: (1) Screening specific to HIV (tuberculosis 95%, genital chlamydia/gonorrhoea 77%, hepatitis C 67%, extra genital chlamydia/gonorrhoea 47%, baseline anal PAP smear for women 36% and men 34%); (2) Primary care related screening (fasting lipids 95%, colonoscopy 95%, mammogram 90%, cervical PAP smears 88%, depression 57%, osteoporosis in postmenopausal women 55% and men >50 yrs 33%). Respondents who worked in university hospitals, had <5 years of ID experience, and those who cared for more PLWH were most likely to provide primary care to all or most of their patients. Common barriers reported include: refusal by patient (72%), non-adherence to HIV medications (43%), other health priorities (44%), time constraints during clinic visit (43%) and financial/insurance limitations (40%). Most ID physicians act as primary care providers for their HIV infected patients especially if they are recent ID graduates and work in university hospitals. Current screening rates are suboptimal. Interventions to increase screening practices and to decrease barriers are urgently needed to address the needs of the aging HIV population in the United States.

The infectious diseases physician in the future of healthcare: not only about antibiotic prescribing.

The uncertainties of healthcare payment and delivery reform on income and care process have created a sense of foreboding, concern, and fear that a career in medicine is not what it used to be and that a career in infectious diseases in particular may no longer be viable. Fears have been raised that the need for infectious diseases consultation and management will be curtailed because we provide cognitive services that are not perceived as being needed in a health system filled with intensivists, hospitalists, and skilled nursing facility physicians. Now is the time for us to reframe our role in the health system that is evolving to a process of care focused on population health and patient safety that pays providers for value they bring to achieve those goals. Specific suggestions are made to enhance the infectious diseases physician's profile with the intent of encouraging debate, discussion, and action.

Rational Use of Antibiotics and Education Improved Aeromonas Necrotizing Fasciitis Outcomes in Taiwan: A 19-Year Experience.

BACKGROUND: Aeromonas necrotizing fasciitis (NF) causes high rates of amputation and mortality, even after aggressive surgical debridement and antibacterial therapy. This study investigated the effects of rational use of antibiotics and education by infectious disease (ID) physicians on Aeromonas NF treatment outcomes. METHODS: Retrospective review for conducted for four years (period I, without an ID physician, December 2001 to December 2005) and 15 years (period II, with an ID physician, January 2006 to March 2021). In period II, the hospital-wide computerized antimicrobial approval system (HCAAS) was also implemented. A pretest-posttest time series analysis compared the two periods. Differences in clinical outcomes, demographics, comorbidities, signs and symptoms, laboratory findings, Aeromonas antibiotic susceptibility, and antibiotic regimens were compared between the two periods. RESULTS: There were 19 patients in period I and 53 patients in period II. Patients had a lower rate of amputation or mortality in period II (35.8%) compared with period I (63.2%). Forty-four patients (61.1%) had polymicrobial infections. In the emergency room, the rate of misdiagnosis decreased from 47.4% in period I to 28.3% in period II, while effective empiric antibiotic usage increased from 21.1% in period I to 66.0% in period II. After the ID physician's adjustment, 69.4% received monotherapy in period II compared to 33.3% in period I. CONCLUSIONS: Because Aeromonas NF had a high mortality rate and was often polymicrobial, choosing an antibiotic regimen was difficult. Using the HCAAS by an experienced ID physician can improve rational antibiotic usage and clinical outcomes in Aeromonas NF.

Trend in industry payments to infectious disease physicians in the United States: a seven-year analysis of nonresearch payments from the Open Payments Database between 2014 and 2020.

OBJECTIVE: To evaluate the trend in nonresearch payments made by the industries to the infectious disease physicians in the United States since the launch of the Open Payments Database and during the COVID-19 pandemic. METHODS: Descriptive analysis was performed for the nonresearch payments made to all infectious disease physicians listed in the Open Payments Database between 2014 and 2020. Using the generalized estimating equation models with panel data of monthly and yearly payment per physician, the payment trend since the inception of the Open Payments Database and during the early stage of the COVID-19 pandemic were evaluated. RESULTS: A total of 7901 (81.5%) infectious disease physicians received $156 837 987 in nonresearch payments between 2014 and 2020. Median annual payments were $197 to $220. Monthly nonresearch per-physician payments and number of physicians with payments rapidly decreased by 58.6% (95% CI: 49.7%‒65.9%, p < 0.001) and by 54.4% (95% CI: 52.7%‒56.1%, p < 0.001) at the beginning of the COVID-19 pandemic, respectively. However, the per-physician payments and number of physicians with payments slightly increased every month right after onset of the pandemic. Both per-physician payments and the number of physicians with payments decreased by 2.6% (95% CI: 0.45‒4.7, p 0.018) and 2.0% (95% CI: 1.6%‒2.4%, p < 0.001) since the inception of the Open Payments Database, respectively. DISCUSSION: The nonresearch payments and number of infectious disease physicians accepting payments had decreased since the inception of the Open Payments Database. Furthermore, the non-research payments to infectious disease physicians suddenly decreased by more than half due to the COVID-19 pandemic.

Experience of ultrasound performed by infectiologists, an innovating approach for the management of patients.

INTRODUCTION: Ultrasound imaging has many clinical applications, but there is a lack of data about its use by infectiologists. The aim of this study was to describe ultrasound performed routinely by infectiologists and to assess the diagnostic performance of ultrasound with aspirate and fluid analysis in prosthetic joint infections. METHODS: Retrospective study between 1st June 2019 and 1st June 2020 in an infectious and tropical diseases unit in a tertiary University Hospital. RESULTS: One hundred and thirty-one ultrasounds were performed on 127 patients by the infectious diseases team. These included 64 musculoskeletal ultrasounds (31 in native joints and 33 in prosthetic joints including 15 knees, 13 hips and 5 spacers) and 33 led to a fluid aspirate. Fourteen lung ultrasounds were done, 11 confirmed pneumopathy and 7 resulted in pleural puncture. Twenty-three vascular ultrasounds were done, 17 to insert a catheter, and four to perform a blood test. Five ultrasounds explored adenopathy, of which one node tuberculosis and one Bartonella infection were diagnosed. In prosthetic joint infections, sensitivity and specificity of ultrasound with fluid aspirate and analysis were respectively 100% and 100% for the knee and 40% and 100% for the hip. CONCLUSION: Ultrasound performed by infectiologists is useful and contributes to a faster diagnosis. Furthermore, the specificity of ultrasound with aspirate and fluid analysis is very high in prosthetic joint infection. Ultrasound training courses should be considered for infectiologists including residents.

Antimicrobial stewardship without infectious disease physician for patients with candidemia: A before and after study.

BACKGROUND: Little is known about the effects of antimicrobial stewardship team (AST) without infectious disease physician (IDP) on clinical outcome in patients with candidemia. METHODS: We conducted a before and after study involving patients with hospital-acquired candidemia at a tertiary hospital without IDPs. The AST consisted of physicians, pharmacists, nurse, microbiologist, and administrative staff. A candidemia care bundle was developed based on the Infectious Disease Society of America (IDSA) guideline. The non-IDP AST provided recommendations to the attending physicians whose patients developed candidemia during hospitalization. The primary outcome was 30-day all-cause mortality, while the secondary outcomes were adherence to the IDSA guidelines regarding the management of candidemia. Data of up to 3 years of preintervention and 3 years of intervention period were analyzed. RESULTS: By 30 days, 11 of 46 patients (23.9%) in the intervention group and 7 of 30 patients (23.3%) in the preintervention group died (adjusted hazard ratio for the intervention group: 0.68 [95% CI 0.24-1.91]). The non-IDP AST was associated with appropriate empirical antifungal therapy (100% vs 60.0%; proportion ratio 1.67 [95% CI 1.24-2.23]), appropriate duration of treatment (84.7% vs 43.3%; 1.96 [1.28-3.00]), removal of central venous catheters (94.4% vs 70.8%; 1.33 [1.02-1.74]), and ophthalmological examination (93.5% vs 63.3%; 1.48 [1.12-1.96]). CONCLUSIONS: Although we found no significant difference in 30-day mortality, the non-IDP AST was associated with improved adherence to guidelines for management of candidemia.

Postprescription review improves in-hospital antibiotic use: a multicenter randomized controlled trial.

Although review of antibiotic therapy is recommended to optimize antibiotic use, physicians do not always perform it. This trial aimed to evaluate the impact of a systematic postprescription review performed by antimicrobial stewardship program (ASP) infectious disease physicians (IDP) on the quality of in-hospital antibiotic use. A multicenter, prospective, randomized, parallel-group trial using the PROBE (Prospective Randomized Open-label Blinded Endpoint) methodology was conducted in eight surgical or medical wards of four hospitals. Two hundred forty-six patients receiving antibiotic therapy prescribed by ward physicians for less than 24 hours were randomized to receive either a systematic review by the ASP IDP at day 1 and days 3 to 4 (intervention group, n = 123) or no systematic review (usual care, n = 123). The primary outcome measure was appropriateness of antimicrobial therapy, a composite score of appropriateness of antibiotic use at days 3 to 4 and appropriate treatment duration, adjudicated by a blinded committee. Analyses were performed on an intention-to-treat basis. In the intervention group, appropriateness of antimicrobial therapy was more frequent (55/123, 44.7% vs. 35/123, 28.5%; odds ratio 2.03, 95% confidence interval 1.20-3.45). Antibiotic treatment duration was lower in the intervention group (median (interquartile range) 7 (3-9) days vs. 10 (7-12) days; p 0.003). ASP IDP counseling to change therapy was more frequent at days 3 to 4 than at day 1 (114/123; 92.7% vs. 24/123; 19.5%, p <0.001). Clinical outcome was similar between groups. This study suggests that a systematic postprescription antibiotic review performed at days 1 and 3 to 4 results in higher quality of antibiotic use and lower antibiotic duration. This trial was registered at ClinicalTrials.gov (NCT01136200).

The impact of infectious disease specialists on antibiotic prescribing in hospitals.

Given the current bacterial resistance crisis, antimicrobial stewardship programmes are of the utmost importance. We present a narrative review of the impact of infectious disease specialists (IDSs) on the quality and quantity of antibiotic use in acute-care hospitals, and discuss the main factors that could limit the efficacy of IDS recommendations. A total of 31 studies were included in this review, with a wide range of infections, hospital settings, and types of antibiotic prescription. Seven of 31 studies were randomized controlled trials, before/after controlled studies, or before/after uncontrolled studies with interrupted time-series analysis. In almost all studies, IDS intervention was associated with a significant improvement in the appropriateness of antibiotic prescribing as compared with prescriptions without any IDS input, and with decreased antibiotic consumption. Variability in the antibiotic prescribing practices of IDSs, informal (curbside) consultations and the involvement of junior IDSs are among the factors that could have an impact on the efficacy of IDS recommendations and on compliance rates, and deserve further investigation. We also discuss possible drawbacks of IDSs in acute-care hospitals that are rarely reported in the published literature. Overall, IDSs are valuable to antimicrobial stewardship programmes in hospitals, but their impact depends on many human and organizational factors.