Repeat tracheal aspirate cultures in pediatric intensive care patients: Frequency, resistance, and antimicrobial use.

OBJECTIVE: To evaluate the clinical impact and features associated with repeat tracheal aspirate (TA) cultures in children admitted to the intensive care unit. DESIGN: Retrospective cohort study. SETTING: A 338-bed freestanding, tertiary pediatric academic medical center with pediatric medical intensive care unit (PICU) and cardiac intensive care units (CICU). PATIENTS: Children ≤18 years of age who were admitted to either the PICU or CICU who had ≥2 TA cultures in a single intensive care admission. METHODS: Patients with ≥2 TA cultures between 2018 and 2019 were included in this study. The following information was collected: patient demographics, clinical data summarizing patient condition at the time of culture collection, number of TA cultures per patient, antibiotic usage, and microbiologic data. Descriptive statistics established the frequency of TA collection, time between culturing, clinical reasoning for collection, antibiotic exposure, and development of multidrug-resistant organisms (MDRO). RESULTS: Sixty-three patients had repeat TA cultures and accounted for 252 TA cultures during the study period. Most patients with repeat TA cultures were admitted to the PICU (71%) and were male (65%). A median of 3 TA cultures per patient were obtained with 50% of repeat cultures occurring within 7 days from the previous culture. Sixty-six percent of patients had the same organism cultured on ≥2 TA cultures. Most antibiotics were not modified or continued to treat the results of the TA culture. CONCLUSIONS: Repeat TA cultures frequently show the same pathogens, and results do not often influence antibiotic selection or usage. Repeat TA cultures did demonstrate the development of MDROs.

Infection preventionists in public health, consultant and academic roles: Results from the 2020 APIC MegaSurvey.

BACKGROUND: Infection preventionists (IPs) work and practice in a variety of roles across many practice settings. While the health care-based IP role has been well studied, less is known about IPs who work in public health, consultant, and academic roles. METHODS: Data were collected as a subset of the Association for Professionals in Infection Prevention and Control and Epidemiology 2020 MegaSurvey. Descriptive and bivariate analyses were performed to compare the responses of 147 IPs working in public health, consulting, or academic roles. RESULTS: Respondents identified their primary IP role as public health (40%), consulting (39%), or academic (21%). Most were White and non-Hispanic females working in long-term care, acute care, and outpatient settings. Most had over 11 years of experience in health care before IP, with nursing being the most common. More consultants were certified in infection control (74%). While half of the respondents in public health reported being certified in infection control, and a third had 6 or more years of experience in infection prevention and control, they reported the lowest annual salary and satisfaction with total compensation. DISCUSSION: These findings highlight the characteristics and contributions of infection prevention and control in nontraditional roles and settings. Certification and fair compensation are crucial factors for professional development and job satisfaction. CONCLUSIONS: These insights can guide future education, recruitment, and retention strategies for IPs in public health, consulting, and academic roles.

APIC Megasurvey 2020: Methodology and overview of results.

BACKGROUND: In 2015, The Association for Professionals in Infection Control and Epidemiology (APIC) conducted the first MegaSurvey of its members to understand key aspects of their practice. Given the evolving role of Infection preventionists (IPs), it is important to understand changes in and the current practice environments of IPs, their demographics, the organizations in which they practice and the relative importance of different domains of IP practice. METHODS: The MegaSurvey 2020 was a cross-sectional, electronic survey of IPs conducted by APIC between January 21 and February 28, 2020. Descriptive statistics were calculated to describe the participants in terms of their characteristics, practice setting, compensation and IP competencies. RESULTS: 2,030 APIC members (response rate 13%) participated in the study. Results indicated that the demographic characteristics of IPs remained the same between the 2015 and 2020 surveys. Similar to 2015 data, slightly less than half of respondents are currently certified and plan to recertify. Less than 50% of IPs reported feeling adequately satisfied with their overall compensation. IPs reported spending the largest proportion of their time on surveillance and epidemiologic investigations and the least amount of time on employee and occupational health, cleaning and sterilization and education/research. CONCLUSIONS: As the healthcare industry continues to evolve, public health emergencies persist, and regulatory requirements expand, the results of the APIC MegaSurvey can inform future educational initiatives, the development of programs and ongoing hiring and retention strategies for this critical profession.

Stewardship 2.0: Embracing elements of implementation science to enhance everyday antimicrobial Stewardship efforts.

This article explores the utility of implementation science (IS) as a method to promote the effective uptake of antimicrobial stewardship processes. Elements of IS can be readily incorporated into QI work and used as a platform to extend stewardship reach. As stewards are stretched to do more, IS can be a potential vehicle to ensure that our collective work is impactful, sustainable, and contributes more broadly to clinically relevant improvements.

Socioeconomic differences in antibiotic use for common infections in pediatric urgent-care centers-A quasi-experimental study.

OBJECTIVE: To investigate differences in the rate of firstline antibiotic prescribing for common pediatric infections in relation to different socioeconomic statuses and the impact of an antimicrobial stewardship program (ASP) in pediatric urgent-care clinics (PUCs). DESIGN: Quasi-experimental. SETTING: Three PUCs within a Midwestern pediatric academic center. PATIENTS AND PARTICIPANTS: Patients aged >60 days and <18 years with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, or skin and soft-tissue infections who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis requiring systemic antibiotics. INTERVENTION: We used national guidelines to determine the appropriateness of antibiotic choice in 2 periods: prior to (July 2017-July 2018) and following ASP implementation (August 2018-December 2020). We used multivariable regression analysis to determine the odds ratios of appropriate firstline agent by age, sex, race and ethnicity, language, and insurance type. RESULTS: The study included 34,603 encounters. Prior to ASP implementation in August 2018, female patients, Black non-Hispanic children, those >2 years of age, and those who self-paid had higher odds of receiving recommended firstline antibiotics for all diagnoses compared to male patients, children of other races and ethnicities, other ages, and other insurance types, respectively. Although improvements in prescribing occurred after implementation of our ASP, the difference within the socioeconomic subsets persisted. CONCLUSIONS: We observed socioeconomic differences in firstline antibiotic prescribing for common pediatric infections in the PUCs setting despite implementation of an ASP. Antimicrobial stewardship leaders should consider drivers of these differences when developing improvement initiatives.

Multinational consensus antimicrobial stewardship recommendations for children managed in hospital settings.

Children are entitled to receive antibiotic therapy that is based on evidence and best practice, but might be overlooked in hospital programmes designed to achieve antimicrobial stewardship [AMS]. This failure to include children could be because children make up small proportion of patients in most hospitals, and are cared for by specialised paediatric staff. We reviewed the evidence and consulted experts in three global regions to develop ten recommendations for good-practice in hospital AMS programmes for children. We performed a review of scientific research, published between Jan 1, 2007, and Oct 17, 2019, concerning AMS, and formed a multinational expert group comprising members from the USA, Canada, the UK, Belgium, Switzerland, Australia, and Aotearoa New Zealand to develop the recommendations. These recommendations aim to help health-care workers who care for children in these regions to deliver best-practice care. We surveyed health-care workers with expertise in antibiotic therapy for children across these regions, and found that the recommendations were considered both very important and generally feasible. These recommendations should be implemented in hospitals to improve antibiotic therapy for children and to stimulate research into future improvements in care.

Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship.

Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.

A novel framework to guide antibiotic stewardship nursing practice.

BACKGROUND: There is a pervasive view among some nurses and health care disciplines that antibiotic stewardship (AS) is solely a physician or pharmacist responsibility. There is an urgent need to alter this view so that nurses can seize every opportunity to prevent patient harm from antibiotics and optimize antibiotic use. One challenge to achieving full nurse engagement as equal members of the AS team is lack of an organizing framework to illustrate relationships of phenomena and concepts inherent to adoption of AS nursing practices. METHODS: We sought to create a framework derived from the peer-reviewed literature, systematic and scoping reviews, and professional standards, consensus statements and white papers. The emerging framework went through multiple iterations as it was vetted with nurse clinicians, scholars and educators, physicians, pharmacists, infection preventionists and AS subject matter experts. RESULTS: Our evidence-based Antibiotic Stewardship Nursing Practice SCAN-P Framework provides the much-needed context and clarity to help guide local-level nurses to participate in and lead AS nursing practice. CONCLUSIONS: Nurses worldwide are ideally situated to provide holistic person-centered care, advocate for judicious use of antibiotics to minimize antibiotic resistance, and be AS educators of their patients, communities and the general public. The Antibiotic Stewardship Nursing Practice SCAN-P Framework provides a tool to do so.

Outpatient antimicrobial stewardship programs in pediatric institutions in 2020: Status, needs, barriers.

OBJECTIVE: To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP). DESIGN: Cross-sectional study. SETTING: Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP). PARTICIPANTS: Antimicrobial stewardship leaders from the above institutions. METHODS: An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals. RESULTS: Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%). CONCLUSIONS: Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology.

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Considerations for implementation: Pediatric outpatient antimicrobial stewardship program.

It is encouraging that most acute care centers have formal antimicrobial stewardship (AS) programs; though, most antibiotic use occurs in outpatient settings where access to infectious diseases specialists are limited. Stewardship programs often target dichotomous populations (adult or pediatric), but most children receive care in nonacademic, community outpatient settings. We propose 3 considerations for adult providers and infection preventionists seeking to incorporate outpatient AS elements and implement quality improvement initiatives that optimize pediatric care.

Integration of a Lean Daily Management System into an Antimicrobial Stewardship Program.

Growing demands and limited guidance on efficient use of resources to advance stewardship initiatives challenge antimicrobial stewardship programs (ASP). METHODS: The primary aim was to incorporate a Lean Readiness and Metrics Board (RMB) into ASP and assess team member accountability and satisfaction with weekly 15-minute huddle participation within 1 year of implementation. ASP team survey data were analyzed for comments regarding Lean integration, team communication, and productivity. The second aim was to develop 5 shared metrics associated with quality, people, delivery, safety, and stewardship and evaluate ASP team productivity by assessing the impact of projects targeted at each specific metric. Pharmacist-physician ASP scheduling conflicts were addressed through identified rounding times under the "People" metric. The "Quality" metric assessed ASP intervention disagreement rate and collaborations that occurred to reduce disagreement. ASP tracked the number of individuals educated by ASP monthly through the "Delivery" metric. RESULTS: Since August 2018, ASP replaced hour-long monthly meetings with weekly huddles at the RMB. On average, 14 members (88%) of the ASP participate weekly. Team members report improvement in communication and satisfaction with Lean integration. Metric utilization enhanced productivity. For the metrics under "People," "Quality," and "Delivery," reduced scheduling conflicts occurred, the ASP intervention disagreement rate decreased (37.0%-25.6%; P < 0.001), and the ASP educated an average of 79 learners per month. CONCLUSIONS: Weekly huddles at the RMB enhanced communication and team accountability while visually displaying program needs, progress, and achievements. The RMB helps to ensure ongoing institutional commitment, and Lean methods show promise for evaluating and improving ASP productivity.

Implementation of a nurse-driven antibiotic engagement tool in 3 hospitals.

BACKGROUND: Nurses are key in implementing antibiotic stewardship; however, standardized processes are lacking. METHODS: This feasibility study tested implementation of a nurse-driven antibiotic engagement tool (AET) that addressed antibiotic indication, duration, discontinuation, and intravenous to oral conversion. An investigator-developed survey measured nurse satisfaction, confidence, and understanding of antibiotic plan of care among 4 clinical units. Mann-Whitney U was used to compare differences between time periods. Nonparametric summary distributions assessed AET use. RESULTS: Results from 121 surveys were available; 71 (36%) presurvey, 50 (24%) postsurvey. Thirteen registered nurses reported satisfaction or agreement with AET use: (1) ease (median: 4 [2.25, 4]); (2) time (median: 4 [3.5, 4.5]); (3) helped facilitate asking questions (median: 4 [3, 4]); (4) helped find antibiotic information (median: 4 [2.5, 4]); and (5) increased confidence in antibiotic discussions (median 4 [3, 4]). Planned duration of antibiotic therapy was unclear to nurses 13.9% of the time with nurses identifying duration discrepancies in 22.8% of submitted AETs. CONCLUSIONS: The AET promoted interprofessional conversation. Use was higher in settings where leaders and nurse influencers were involved in stewardship promotion. Clarifying antibiotic duration is a prime area for future nursing antibiotic stewardship efforts.

Nurses as antimicrobial stewards: Recognition, confidence, and organizational factors across nine hospitals.

BACKGROUND: There are national calls to engage nurses as antimicrobial stewards, but it is unknown how patient safety culture influences nurses' antimicrobial stewardship (AS) involvement. METHODS: Cross-sectional survey to determine bedside nurses' recognition and performance confidence in AS. Nine hospitals ranged in size from 42 to 562 beds serving pediatric and adult populations in 2 different metropolitan areas. Composite scores for nursing practices, performance confidence, and organizational factors were developed and correlated. Analysis of variance (ANOVA) with Tukey HSD post-hoc tests and nonparametric (Kruskal-Wallis) tests with Bonferroni adjusted P values for multiple comparisons were used to evaluate differences by clinical unit and years of clinical experience. Free text comments were categorized by theme. RESULTS: A total of 558 nurses participated (13% response rate). A significant positive association rs = 0.454, P < .001 was found between nurses' beliefs about nursing practices that contribute to AS processes and their confidence to perform. Ninety one nurses provided comments with 50 statements indicating the primary barrier to stewardship were organizational factors including perceived lack of a safety culture. CONCLUSIONS: Nurses identified a professional role in AS processes, though safety culture inhibited their involvement. These findings can help enhance the inclusion of nurses in AS efforts.

Infection preventionists role in antimicrobial stewardship: Survey of APIC members.

The primary job responsibility of infection preventionists (IPs) is to lead organizational initiatives that prevent and control health care-associated infections. Increasingly, IPs are participating in activities that support antimicrobial stewardship programs (ASPs). We conducted a survey of Association of Professionals in Infection Control and Epidemiology members practicing in acute care facilities to determine the degree of their involvement in ASP activities.

Policies and practices of SHEA Research Network hospitals during the COVID-19 pandemic.

To understand hospital policies and practices as the COVID-19 pandemic accelerated, the Society for Healthcare Epidemiology of America (SHEA) conducted a survey through the SHEA Research Network (SRN). The survey assessed policies and practices around the optimization of personal protection equipment (PPE), testing, healthcare personnel policies, visitors of COVID-19 patients in relation to procedures, and types of patients. Overall, 69 individual healthcare facilities responded in the United States and internationally, for a 73% response rate.

Integrating bedside nurses into antibiotic stewardship: A practical approach.

Nurses view patient safety as an essential component of their work and have reported a general interest in embracing an antibiotic steward role. However, antibiotic stewardship (AS) functions have not been formally integrated into nursing practice despite nurses' daily involvement in clinical activities that impact antibiotic decisions (e.g., obtaining specimens for cultures, blood drawing for therapeutic drug monitoring). Recommendations to expand AS programs to include bedside nurses are generating support at a national level, yet a practical guidance on how nurses can be involved in AS activities is lacking. In this review, we provide a framework identifying selected practices where nurses can improve antibiotic prescribing practices through appropriate obtainment of Clostridioides difficile tests, appropriate urine culturing practices, optimal antibiotic administration, accurate and detailed documentation of penicillin allergy histories and through the prompting of antibiotic time outs. We identify reported barriers to engagement of nurses in AS and offer potential solutions that include patient safety principles and quality improvement strategies that can be used to mitigate participation barriers. This review will assist AS leaders interested in advancing the contributions of nurses into their AS programs by discussing education, communication, improvement models, and workflow integration enhancements that strengthen systems to support nurses as valued partners in AS efforts.

Integrating staff nurses in antibiotic stewardship: Opportunities and barriers.

BACKGROUND: Nursing has been called for greater participation in antibiotic stewardship. Although many of the functions that are integral to successful stewardship are within the scope of bedside nurses, data evaluating nursing engagement in stewardship are limited. The objective of this study was to identify nurses' roles and confidence in engaging in stewardship practices by conducting a survey of pediatric staff nurses employed at a 354-bed freestanding children's hospital with a well-established prospective audit and feedback stewardship program. METHODS: An investigator-developed online survey was used to assess 10 identified practices that fall within the responsibility of inpatient nurses and contribute to the stewardship process. RESULTS: One hundred and eighty nurses participated in the study. Nurses were highly confident assessing for an adverse drug reaction history, obtaining cultures prior to antibiotics, and participating in patient education. They were less confident in reviewing microbiology results to determine antibiotic appropriateness. Clinical practice and hospital culture influenced perceptions of the nursing role in stewardship. Reported barriers to stewarding included nurses not included in rounds, interdisciplinary power differentials, and nursing input not actively sought. CONCLUSIONS: Barriers to nurse engagement were identified and could be addressed by improving education in microbiology and principles of antibiotic use along with more consistent inclusion of nurses in bedside rounds while also cultivating an environment where nurse contribution is actively sought.