Prospective antimicrobial stewardship interventions by multidisciplinary teams to reduce neonatal antibiotic use in South Africa: the Neonatal Antimicrobial Stewardship (NeoAMS) study.

BACKGROUND: Hospitalised neonates are vulnerable to infection and have high rates of antibiotic utilisation. METHODS: Fourteen South African neonatal units (seven public, seven private sector) assembled multidisciplinary teams involving neonatologists, microbiologists, pharmacists, and nurses to implement prospective audit and feedback neonatal antimicrobial stewardship (NeoAMS) interventions. The teams attended seven online training sessions. Pharmacists conducted weekday antibiotic prescription reviews in the neonatal intensive care unit and/or neonatal wards providing feedback to the clinical teams. Anonymised demographic and NeoAMS interventions data were aggregated for descriptive purposes and statistical analysis. FINDINGS: During the 20-week NeoAMS intervention in 2022, 565 neonates were enrolled. Pharmacists evaluated seven hundred antibiotic prescription episodes; rule-out sepsis (180; 26%) and culture-negative sepsis (138; 20%) were the most frequent indications for antibiotic prescription. For infection episodes with an identified pathogen, only 51% (116/229) of empiric treatments provided adequate antimicrobial coverage. Pharmacists recommended 437 NeoAMS interventions (0·6 per antibiotic prescription episode), with antibiotic discontinuation (42%), therapeutic drug monitoring (17%), and dosing (15%) recommendations most frequent. Neonatal clinicians' acceptance rates for AMS recommendations were high (338; 77%). Mean antibiotic length of therapy decreased by 24% from 9·1 to 6·9 days (0·1 day decrease per intervention week; p=0·001), with the greatest decline in length of therapy for culture-negative sepsis (8·2 days (95%CI 5·7-11·7) to 5·9 days (95% CI 4·6-7·5); p=0·032). INTERPRETATION: This neonatal AMS programme was successfully implemented in heterogenous and resource-limited settings. Pharmacist-recommended AMS interventions had high rates of clinician acceptance. The NeoAMS intervention significantly reduced neonatal antibiotic use, particularly for culture-negative sepsis. FUNDING: A grant from Merck provided partial support.

Recommendations to Improve Quality of Probiotic Systematic Reviews With Meta-Analyses.

Importance: Systematic reviews and meta-analyses often report conflicting results when assessing evidence for probiotic efficacy, partially because of the lack of understanding of the unique features of probiotic trials. As a consequence, clinical decisions on the use of probiotics have been confusing. Objective: To provide recommendations to improve the quality and consistency of systematic reviews with meta-analyses on probiotics, so evidence-based clinical decisions can be made with more clarity. Evidence Review: For this consensus statement, an updated literature review was conducted (January 1, 2020, to June 30, 2022) to supplement a previously published 2018 literature search to identify areas where probiotic systematic reviews with meta-analyses might be improved. An expert panel of 21 scientists and physicians with experience on writing and reviewing probiotic reviews and meta-analyses was convened and used a modified Delphi method to develop recommendations for future probiotic reviews. Findings: A total of 206 systematic reviews with meta-analysis components on probiotics were screened and representative examples discussed to determine areas for improvement. The expert panel initially identified 36 items that were inconsistently reported or were considered important to consider in probiotic meta-analyses. Of these, a consensus was reached for 9 recommendations to improve the quality of future probiotic meta-analyses. Conclusions and Relevance: In this study, the expert panel reached a consensus on 9 recommendations that should promote improved reporting of probiotic systematic reviews with meta-analyses and, thereby, assist in clinical decisions regarding the use of probiotics.

Surveillance and Stewardship: Where Infection Prevention and Antimicrobial Stewardship Intersect.

Colonization with multidrug-resistant organisms (MDROs) is a risk factor for subsequent infection. Surveillance for MDROs, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Enterobacterales, and carbapenemase-producing organisms, is commonly conducted in hospitals to prevent spread of MDROs, in part to reduce the potential for additional infections. Although colonization is a risk factor for infection, data on colonization with various MDROs are often not considered when selecting anti-infective therapy. There are conflicting data on the strength of the positive and negative predictive values of the colonization test results to guide therapeutic strategies. Defining therapeutic strategies for patients with complicated or drug-resistant infections or to select antimicrobial prophylaxis before performing prostate biopsies often falls under the purview of the antimicrobial stewardship team. Should colonization data, which are often present in the patient's medical record from routine infection prevention measures, be reviewed before selecting therapy for infections or for prophylaxis? In this perspective, we will explore the intersection of infection control and antimicrobial stewardship activities.

Global collaborations in antimicrobial stewardship: All hands on deck.

Tackling antimicrobial resistance (AMR) through antimicrobial stewardship (AMS) interventions is a key objective within the World Health Organization (WHO)'s Global Action on AMR. We outline the reasons why global collaborations for AMS are needed. We provide examples of global collaborations, and we offer considerations when starting on a global health journey focused on AMS.

Gaps and barriers in the implementation and functioning of antimicrobial stewardship programmes: results from an educational and behavioural mixed methods needs assessment in France, the United States, Mexico and India.

Background: Evidence shows limited adherence to antimicrobial stewardship (AMS) principles. Objectives: To identify educational gaps and systemic barriers obstructing adherence to AMS principles. Methods: A mixed-methods study combining a thematic analysis of qualitative interviews (January-February 2021) and inferential analysis of quantitative surveys (May-June 2021) was conducted. Participants from France, the USA, Mexico and India were purposively sampled from online panels of healthcare professionals to include infectious disease physicians, infection control specialists, clinical microbiologists, pharmacologists or pharmacists expected to apply AMS principles in their practice setting (e.g. clinic, academic-affiliated or community-based hospital). A gap analysis framework guided this study. Results: The final sample included 383 participants (n = 33 interviews; n = 350 surveys). Mixed-methods findings indicated suboptimal knowledge and skills amongst participants to facilitate personal and collective application of AMS principles. Survey data indicated a gap in ideal versus current knowledge of AMS protocols, especially amongst pharmacologists (Δ0.95/4.00, P < 0.001). Gaps in ideal versus current skill levels were also measured and were highest amongst infectious control specialists (Δ1.15/4.00, P < 0.001), for convincing hospital executives to allocate resources to AMS programmes. Already existing systemic barriers (e.g. insufficient dedicated time/funding/training) were perceived as being aggravated during the COVID-19 pandemic (72% of survey participants agreed). Reported gaps were highest in India and France. Conclusions: The educational needs of professionals and countries included in this study can inform future continuous professional development activities in AMS. Additional funding should be considered to address perceived systemic barriers. Local assessments are warranted to validate results and suitability of interventions.

Private Practice Dentists Improve Antibiotic Use After Dental Antibiotic Stewardship Education From Infectious Diseases Experts.

Background: Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts. Methods: Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists. Results: Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs. Conclusions: After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States.

Global resilience and new strategies needed for antimicrobial stewardship during the COVID-19 pandemic and beyond.

Resilience is having the ability to respond to adversity proactively and resourcefully. The coronavirus disease 2019 (COVID-19) pandemic's profound impact on antimicrobial stewardship programs (ASP) requires clinicians to call on their own resilience to manage the demands of the pandemic and the disruption of ASP activities. This article provides examples of ASP resilience from pharmacists and physicians from seven countries with different resources and approaches to ASP-The United States, The United Kingdom, Canada, Nigeria, Lebanon, South Africa, and Colombia. The lessons learned pertain to providing ASP clinical services in the context of a global pandemic, developing new ASP paradigms in the face of COVID-19, leveraging technology to extend the reach of ASP, and conducting international collaborative ASP research remotely. This article serves as an example of how resilience and global collaboration is sustaining our ASPs by sharing new "how to" do antimicrobial stewardship practices during the COVID-19 pandemic.

Surgeons, Infectious Diseases, and Twitter Hit a Home Run for Antibiotic Stewardship.

Many infectious diseases (ID) clinicians join Twitter to follow other ID colleagues or "like" people. While there is great value in engaging with people who have similar interests, there is equal value in engaging with "unlike" or non-ID people. Here, we describe how Twitter connected an ID pharmacist with a pediatric surgeon, a vice chair of surgery, a surgeon chief medical officer from Spain, and a surgical intensive care unit pharmacist. This Twitter collaboration resulted in several scholarly activities related to antibiotic resistance and antibiotic stewardship and served as a conduit for global collaboration.

Duration of Antibiotic Therapy for General Medicine and General Surgery Patients Throughout Transitions of Care: An Antibiotic Stewardship Opportunity for Noninfectious Disease Pharmacists.

BACKGROUND: Overuse of antibiotics from the inpatient to outpatient setting is an antibiotic stewardship initiative where noninfectious disease (ID) pharmacists can have a large impact. Our purpose was to evaluate antibiotic durations across transitions of care from the inpatient to outpatient setting. METHODS: This is a single-center, retrospective cohort analysis evaluating antibiotic durations from the inpatient and outpatient setting in adult patients admitted to general surgery and medicine services at an academic medical center between January 1, 2017 and September 20, 2017. The primary outcome was to assess total antibiotic duration for patients with uncomplicated and complicated urinary tract infections (UTI, cUTI), community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP). Outpatient electronic discharge prescriptions were used to calculate intended antibiotic duration upon transitions of care. Excessive duration of therapy was defined as >3 days-UTI, >5 days-CAP, and >7 days-cUTI or HAP. RESULTS: One hundred and one patients met inclusion criteria. Overall, most of the patients (81%) had antibiotics longer than recommended with only 3% receiving less than the recommended duration. Median total duration of therapy compared with recommended duration specified in national guidelines was UTI: 10 days [7 -10], cUTI: 12 days [7.5-12.5], CAP: 7 days [7 -9], HAP: 10 days [8 -12]. The median antibiotic duration was shorter in patients with no cultures or culture negative results compared with patients with positive cultures for all indications (UTI: 10.3 vs 10.8 days, cUTI: 9 vs 12 days, CAP: 8 vs 9.1 days, HAP: 10.5 vs 19.8 days). Overall, the recommended duration of antibiotics was completed while inpatient in 34.7%, but varied by infection. More patients with UTI or cUTI completed recommended duration of therapy while inpatient vs for CAP or HAP (53.8% vs 28%, P = .03). Eighty percent of those with UTI, 18.2% with cUTI, 25.6% with CAP, and 31.2% with HAP had already received the recommended duration of treatment, or more, on day of hospital discharge. CONCLUSIONS: The median duration of antibiotic therapy for all indications evaluated was longer than recommended in national guidelines. Opportunities for stewardship by non-ID pharmacists to impact postdischarge antimicrobial use at transitions of care have been identified.

A global point prevalence survey of antimicrobial use in neonatal intensive care units: The no-more-antibiotics and resistance (NO-MAS-R) study.

BACKGROUND: Global assessment of antimicrobial agents prescribed to infants in the neonatal intensive care unit (NICU) may inform antimicrobial stewardship efforts. METHODS: We conducted a one-day global point prevalence study of all antimicrobials provided to NICU infants. Demographic, clinical, and microbiologic data were obtained including NICU level, census, birth weight, gestational/chronologic age, diagnoses, antimicrobial therapy (reason for use; length of therapy), antimicrobial stewardship program (ASP), and 30-day in-hospital mortality. FINDINGS: On July 1, 2019, 26% of infants (580/2,265; range, 0-100%; median gestational age, 33 weeks; median birth weight, 1800 g) in 84 NICUs (51, high-income; 33, low-to-middle income) from 29 countries (14, high-income; 15, low-to-middle income) in five continents received ≥1 antimicrobial agent (92%, antibacterial; 19%, antifungal; 4%, antiviral). The most common reasons for antibiotic therapy were "rule-out" sepsis (32%) and "culture-negative" sepsis (16%) with ampicillin (40%), gentamicin (35%), amikacin (19%), vancomycin (15%), and meropenem (9%) used most frequently. For definitive treatment of presumed/confirmed infection, vancomycin (26%), amikacin (20%), and meropenem (16%) were the most prescribed agents. Length of therapy for culture-positive and "culture-negative" infections was 12 days (median; IQR, 8-14) and 7 days (median; IQR, 5-10), respectively. Mortality was 6% (42%, infection-related). An NICU ASP was associated with lower rate of antibiotic utilization (p = 0·02). INTERPRETATION: Global NICU antibiotic use was frequent and prolonged regardless of culture results. NICU-specific ASPs were associated with lower antibiotic utilization rates, suggesting the need for their implementation worldwide. FUNDING: Merck & Co.; The Ohio State University College of Medicine Barnes Medical Student Research Scholarship.

The Role of Antibiotic Stewardship and Telemedicine in the Management of Multidrug-Resistant Infections.

This article summarizes the literature describing how antimicrobial stewardship and telemedicine interventions affect antimicrobial resistance. Discussion includes why we need stewardship, how to collaborate with team members, and the evidence of stewardship's and telemedicine's impact on resistance.

Global contributions of pharmacists during the COVID-19 pandemic.

Throughout the SARS-CoV-2 (COVID-19) global pandemic, pharmacists were rarely mentioned as essential frontline health care providers by the news media, the public, or politicians. Around the world, pharmacists are working on the frontlines of health care every day providing essential health care services during the pandemic. Pharmacists are medication experts providing patient care in a variety of settings including hospitals, clinics, community pharmacies, long-term care, physician offices, and national and public health. In this paper, we describe how pharmacists from high and low-middle income countries contributed to essential patient care and well-being of the public during the COVID-19 pandemic. While the news media, the public, and politicians often overlooked pharmacists as essential frontline health care providers, we hope that this list of contributions by pharmacists from nine countries in this article can help to change this perspective.

A pharmacist-led prospective antibiotic stewardship intervention improves compliance to community-acquired pneumonia guidelines in 39 public and private hospitals across South Africa.

INTRODUCTION: Pharmacists in low-middle-income countries (LMIC) are few and lack antibiotic stewardship (AS) training. The ability was assessed of non-specialised pharmacists to implement stewardship interventions and improve adherence to the South African community-acquired pneumonia (CAP) guideline in public and private hospitals. METHODS: This was a multicentre, prospective cohort study of adult CAP patients hospitalised between July 2017 and July 2018. A CAP bundle was developed of seven process measures (diagnostic and AS) that pharmacists used to audit compliance and provide feedback. CAP bundle compliance rates and change in outcome measures [mortality, length of stay (LOS) and infection-related (IR)-LOS] during pre- and post-implementation periods were compared. RESULTS: In total, 2464 patients in 39 hospitals were included in the final analysis. Post-implementation, overall CAP bundle compliance improved from 47·8% to 53·6% (confidence interval [CI] 4·1-7·5, p<0·0001), diagnostic stewardship compliance improved from 49·1% to 54·6% (CI 3·3-7·7, p<0·0001) and compliance with AS process measures from 45·3% to 51·6% (CI 4·0-8·6, p<0·0001). Improved compliance with process measures was significant for five (2 diagnostic, 3 AS) of seven components: radiology, laboratory, antibiotic choice, duration and intravenous to oral switch. There was no difference in mortality between the two phases, [4·4%(55/1247) vs. 3·9%(47/1217); p=0·54], median LOS or IR LOS 6·0 vs. 6·0 days (p=0·20) and 5·0 vs. 5·0 days (p=0·40). CONCLUSION: Non-specialised pharmacists in public and private hospitals implemented stewardship interventions and improved compliance to SA CAP guidelines. The methodology of upskilling and a shared learning stewardship model may benefit LMIC countries.

Opportunities for antimicrobial stewardship among carbapenem-treated patients in 18 North American hospitals.

Here we describe the characteristics of carbapenem use at 18 hospitals across North America. Adult inpatients treated with a carbapenem for ≥24 h were included in this multicentre, retrospective, cross-sectional study. Outcomes evaluated included classification of therapy as empirical or definitive, discharge disposition and 30-day re-admission. A total of 621 patients were included in this study. Of these, 467 patients (75.2%) received a carbapenem empirically, among whom negative cultures occurred in 313 (67.0%) and 93% were eligible for de-escalation of therapy. In-hospital mortality occurred in 72 patients (11.6%) and 549 patients (88.4%) were discharged. Of the 549 patients who were discharged, 349 patients (63.6%) went home and 30-day infection-related re-admission occurred in 95 patients (17.3%). This population represents a significant need for carbapenem stewardship. Institutional guidelines should focus on four common disease states (respiratory, genitourinary, intra-abdominal and bloodstream), and diagnostic stewardship should be employed to aid in rapid de-escalation of carbapenem therapy. Additional studies aiming to identify antimicrobial stewardship techniques that may help to optimise carbapenem therapy and increase education about the importance of utilising carbapenem-sparing regimens are required.