Status and Challenge of Antifungal Stewardship at the Osaka Metropolitan University Hospital.

Antifungal stewardship (AFS), compared with antimicrobial stewardship (AS), requires more advanced knowledge, skills, and multidisciplinary collaboration in its implementation. Therefore, fewer facilities are performing AFS compared with AS. At our hospital, we started AS and AFS in 2014. Our AFS programs include the following: i) interventions for patients with yeast-positive blood cultures, ii) introduction of a conditional antifungal notification system, and iii) commencement of AS team rounds. AFS for filamentous fungi includes bronchoscopy and microbial identification, including genetic and drug susceptibility testing. These AFS activities have improved several processes and outcome measures. However, our AFS team has faced several problems owing to the impact of COVID-19. This review introduces the practice of AFS, which we initiated at our hospital in 2014, and presents the current problems.

Defeating the Silent Enemy: Antimicrobial Resistance Looming as the Next Global Pandemic.

Antibiotics are the magic bullets that have saved millions worldwide. Enormous and irresponsible use of antibiotics has led to resistance to antibiotics, which is a matter of global health concern. The superbugs are responsible for life-threatening infections, treatment failure, and high mortality worldwide. The urgent healthcare threat caused by antimicrobial resistance (AMR) to nonfermenting gram-negative bacteria is being increasingly acknowledged worldwide. Antibiotic resistance found in organisms in hospital settings is now increasingly found in the community. Although antimicrobial stewardship requiring a multidisciplinary approach is developing rapidly at the hospital level, it needs more attention at the community level. New therapeutics are certainly required, but the major challenge is rapidly identifying resistant infections and tailoring treatment. This review highlights the crisis that reflects the current scenario of AMR, common resistant pathogens, and the major challenges in the fight against AMR. It also discusses potential methods and strategies to address the intricacies of antibiotic resistance.

Rapid respiratory microbiological point-of-care-testing and antibiotic prescribing in primary care: Protocol for the RAPID-TEST randomised controlled trial.

BACKGROUND: Antibiotics are prescribed for over 50% of respiratory tract infections in primary care, despite good evidence of there being no benefit to the patient, and evidence of over prescribing driving microbial resistance. The high treatment rates are attributed to uncertainty regarding microbiological cause and clinical prognosis. Point-of-care-tests have been proposed as potential antibiotic stewardship tools, with some providing microbiological results in 15 minutes. However, there is little research on their impact on antibiotic use and clinical outcomes in primary care. METHODS: This is a multi-centre, individually randomised controlled trial with mixed-methods investigation of microbial, behavioural and antibiotic mechanisms on outcomes in patients aged 12 months and over presenting to primary care in the UK with a suspected respiratory tract infection, where the clinician and/or patient thinks antibiotic treatment may be, or is, necessary. Once consented, all participants are asked to provide a combined nose and throat swab sample and randomised to have a rapid microbiological point-of-care-test or no point-of-care-test. For intervention patients, clinicians review the result of the test, before contacting the patient to finalise treatment. Treatment decisions are made as per usual care in control group patients. The primary outcome is whether an antibiotic is prescribed at this point. All swab samples are sent to the central laboratory for further testing. Patients are asked to complete a diary to record the severity and duration of symptoms until resolution or day 28, and questionnaires at 2 months about their beliefs and intention to consult for similar future illnesses. Primary care medical records are also reviewed at 6-months to collect further infection consultations, antibiotic prescribing and hospital admissions. The trial aims to recruit 514 patients to achieve 90% power with 5% significance to detect a 15% absolute reduction in antibiotic prescribing. Qualitative interviews are being conducted with approximately 20 clinicians and 30 participants to understand any changes in beliefs and behaviour resulting from the point-of-care-test and generate attributes for clinician and patient discrete choice experiments. DISCUSSION: This trial will provide evidence of efficacy, acceptability and mechanisms of action of a rapid microbiological point-of-care test on antibiotic prescribing and patient symptoms in primary care. TRIAL REGISTRATION: ISRCTN16039192, prospectively registered on 08/11/2022.

Knowledge and attitude of healthcare prescribers and pharmacists toward antimicrobial stewardship program and the barriers for its implementation.

BACKGROUND: Antimicrobial stewardship (ASP) is considered a key prevention strategy in addressing the worldwide concern of accelerating antimicrobial resistance. Limited research is available regarding healthcare providers' knowledge and attitude toward antimicrobial stewardship and the barriers for its implementation. METHODS: The present cross-sectional study was conducted on pharmacists and healthcare prescribers (HCPs) in different hospital sites across Jordan. A validated survey was used to evaluate HCPs and pharmacists' knowledge, and attitudes towards ASP and the barriers for its implementation. Logistic and linear regression were conducted to identify the factors associated with knowledge and attitude toward ASP, respectively. RESULTS: A total of 603 participants, 69 (11.4%) pharmacists and 534 (88.6%) HCPs completed the study questionnaire, with a response rate of 80.4%. The overall mean knowledge about ASP was 7.16 out of 10, ranging from 0 to 10 (SD 2.22). Being a pharmacist and increased awareness/familiarity about ASP were associated with improved ASP knowledge. The overall average attitude score was = 3.8 ± 0.49 (range: 1.8-4.8). Results revealed that being a pharmacist and improved knowledge were associated with improved attitude toward ASP. Lack of specialized staff with expertise in ASP and lack of access to education and training programs were the major barriers hinder ASP implementation. CONCLUSION: Despite the reasonable knowledge and the positive attitude toward the ASP, several barriers were reported, particularly by the pharmacists. Therefore, promoting the presence of adequately skilled healthcare personnel, creating easily accessible online courses, and establishing a comprehensive database of ASP resources are all suggested approaches to improve the application of ASP in healthcare settings.

Simplified Spectrum Score (S3) app for pathogen-agnostic antimicrobial drug spectrum ranking to assess for antimicrobial de-escalation events.

Antimicrobial/antibiotic de-escalation (ADE) is a key feature of antimicrobial stewardship programs (ASP) that relies mainly on individual panels for determining ADE events based on subjective ranking of antibiotics' spectrum activity. The lack of consensus among ASP experts leads to reproducibility issues in the measure of this clinical outcome, making difficult to assess its real impact on patient care. The S3 score (Simplified Spectrum Score) app was developed to allow an objective ranking of antibiotics. Ranking was achieved by developing a database harboring pairs of bacteria-antibiotics for which each molecule was assigned a score based on published and clinically validated data from a recognized international committee. S3 score shows a strong correlation relationship and substantial agreement to a clinically validated spectrum score, and its framework enables any person to use it for ADE detection without assuming prior knowledge or training. In addition, its design enables regular updates and sustainability.

Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review.

Inappropriate antibiotic choice or duration of therapy for urinary tract infections (UTIs) in outpatients is common and is a major contributor to antibiotic overuse. Most studies on outpatient antibiotic stewardship for UTIs follow a pre-design or post-design with a multifaceted intervention; these trials generally have found improvement in appropriateness of antibiotic use for UTI. Audit and feedback was one of the most commonly employed strategies across these trials but may not be sustainable. Future research on antibiotic stewardship for UTIs in outpatients should measure both effectiveness and implementation success.

Reducing Treatment of Asymptomatic Bacteriuria: What Works?

Asymptomatic bacteriuria is common, but usually benign. Inappropriate antimicrobial treatment of asymptomatic bacteriuria contributes to negative antimicrobial outcomes. Optimizing antimicrobial use for bacteriuria is a component of antimicrobial stewardship programs and includes key practices of dissemination and implementation of guidelines, laboratory practices which support stewardship, and programs to monitor and implement optimal antimicrobial treatment for urinary infection. These activities vary in their effectiveness, costs, and complexity to institute. Stewardship strategies targeting unique populations with a high prevalence of bacteriuria and for whom symptom assessment is not straightforward need to be further developed and evaluated to support optimal stewardship.

System-wide approaches to antimicrobial therapy and antimicrobial resistance in the UK: the AMR-X framework.

Antimicrobial resistance (AMR) threatens human, animal, and environmental health. Acknowledging the urgency of addressing AMR, an opportunity exists to extend AMR action-focused research beyond the confines of an isolated biomedical paradigm. An AMR learning system, AMR-X, envisions a national network of health systems creating and applying optimal use of antimicrobials on the basis of their data collected from the delivery of routine clinical care. AMR-X integrates traditional AMR discovery, experimental research, and applied research with continuous analysis of pathogens, antimicrobial uses, and clinical outcomes that are routinely disseminated to practitioners, policy makers, patients, and the public to drive changes in practice and outcomes. AMR-X uses connected data-to-action systems to underpin an evaluation framework embedded in routine care, continuously driving implementation of improvements in patient and population health, targeting investment, and incentivising innovation. All stakeholders co-create AMR-X, protecting the public from AMR by adapting to continuously evolving AMR threats and generating the information needed for precision patient and population care.

Antimicrobial stewardship and molecular diagnostics: a symbiotic approach to combating resistance in the ED and ICU.

PURPOSE OF REVIEW: This review aims to evaluate the incorporation of rapid molecular diagnostics (RMD) in antimicrobial stewardship programs (ASPs) in the management of patients in the emergency department (ED) and intensive care unit (ICU), highlighting a shift from conventional microbiological diagnostic tests to RMD strategies to optimize antimicrobial use and improve patient outcomes. RECENT FINDINGS: Recent advances in RMD have demonstrated the superior accuracy of RMD in identifying pathogens, combined with shorter turnaround times. RMD allows speeding up of antimicrobial decision making in the ED and facilitates faster escalation when empirical therapy was inappropriate, as well as more efficient de-escalation of empirical therapy later in the course of the treatment. Implementation of RMD however may be challenging. SUMMARY: RMD hold great value in simplifying patient management and mitigating antimicrobial exposure, particularly in settings with high levels of antimicrobial resistance where the use of broad-spectrum antimicrobials is high. While the impact on the use of antimicrobials is significant, the impact on patient outcomes is not yet clear. Successful integration of RMD in clinical decision making in the ED and ICU requires a team approach and continued education, and its use should be adapted to the local epidemiology and infrastructure.

Antibiotic management programme in a tertiary intensive care unit: effects of a carbapenem-restricted period on clinical and laboratory parameters and costs of infections.

BACKGROUND: Carbapenems are antibiotics used for serious infections. The consumption of carbapenems has increased worldwide due to increasing microbial resistance. AIM: To investigate the effects of a carbapenem-restricted antimicrobial stewardship programme (ASP) on changes in the resistance profiles of infectious agents, the amount of antibiotics used, length of stay in the intensive care unit (ICU), mortality, and costs. METHODS: Patients hospitalized in ICU between July 1st, 2020 and May 1st, 2021 were divided into two periods: the carbapenem-non-restricted period (CNRP); and the carbapenem-restricted period (CRP) in which alternative antibiotics to carbapenems were preferred during infection. The defined daily dose (DDD) per 100 patient-day methodology was used to calculate the antibiotic consumption. FINDINGS: Of the 572 patients included in the study, 62.2% were male, and mean age was 70.5 years. In the blood culture the most frequently Gram-negative agent was Acinetobacter baumannii (25%). A. baumannii bloodstream infections with multidrug-resistant and extensively drug resistant micro-organisms were significantly different between the two periods (CNRP: 95.6% (N = 22), CRP: 66.6% (N = 8); P = 0.04). There was a gradual decrease in the incidence density and rate of nosocomial infection (P = 0.06), and a significant decrease in meropenem consumption between the two periods (CNRP vs CRP: 21.19 vs 6.37 DDD per 100 patient-days respectively; P = 0.007). ASP yielded US$8,600 of antibiotic cost savings and a total of 14% patient cost savings (P < 0.05) per patient. CONCLUSION: Combining an effective ASP with a comprehensive infection control programme may mitigate the emergence of antimicrobial-resistant bacteria.

A Prospective Quasi-Experimental Study of Multifaceted Interventions Including Computerized Drug Utilization Evaluation to Improve an Antibiotic Stewardship Program.

OBJECTIVE: This study aimed to determine and evaluate interventions that improve an antibiotic stewardship program (ASP) in reduction of the amount of antibiotic use and errors in drug utilization evaluation (DUE) form completion. METHODS: A prospective quasi-experimental study was conducted to evaluate the effectiveness of the multifaceted interventions (preauthorization with computerized DUE, self-supervised checklists, and short active reminders of the antibiotic guidelines recommendations) incorporating an ASP among hospitalized internal medicine patients in a Thai tertiary care center. The preintervention period was from January to December 2018, and the postintervention period was from February 2019 to January 2020. RESULTS: A total of 9188 and 9787 patient data were analyzed during the preintervention and postintervention periods, respectively. The overall median antibiotic use (defined daily dose/1000 bed-days) was significantly decreased in the postintervention period compared with the preintervention period (867.68 versus 732.33; P < 0.001). The reduction in antibiotic use was predominantly observed among broad-spectrum antibiotics, including cefoperazone/sulbactam (15.35 versus 9.75; P = 0.04), cefepime (13.09 versus 6.37; P = 0.003), ciprofloxacin (32.99 versus 17.83; P < 0.001), piperacillin/tazobactam (99.23 versus 91.93; P = 0.03), meropenem (2.01 versus 0.99; P < 0.001), imipenem/cilastatin (9.53 versus 4.59; P = 0.04), and colistin (74.70 versus 22.34; P < 0.0001). The overall rate of errors in DUE form completion was significantly decreased after the intervention (40% versus 28%; P < 0.001). The incidence of carbapenem-resistant Enterobacteriaceae infections/colonization was significantly lower in the postintervention period (0.27 versus 0.12/1000 bed-days; P = 0.02). CONCLUSIONS: The study multifaceted interventions incorporating ASP were associated with significant reduction in the amount of broad-spectrum antibiotic use, DUE form completion errors, and incidence of carbapenem-resistant Enterobacteriaceae infection/colonization.

Antibiotic Prescribing Patterns for Respiratory Tract Illnesses Following the Conclusion of an Education and Feedback Intervention in Primary Care.

BACKGROUND: A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback. METHODS: RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A χ2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing. RESULTS: We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P < .001) but remained lower than the 35.2% pre-intervention rate (P < .001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10-1.30; P < .05) and tier 3 (OR, 1.20; 95% CI: 1.12-1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59-0.73 tier 2; OR, 0.68; 95% CI: 0.61-0.75 tier 3). CONCLUSIONS: The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects.

Diagnostic uncertainty and decision-making in home-based primary care: A qualitative study of antibiotic prescribing.

BACKGROUND: Evaluating infection in home-based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision-making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision-making by exploring the perspectives of clinicians in home-based primary care. METHODS: Clinicians from the Department of Veterans Affairs Home-Based Primary Care Program were recruited. Semi-structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes. RESULTS: Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home-based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow-up) and those that inhibited prescribing (perceptions of antibiotic-associated harms, willingness to trial non-pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms). CONCLUSIONS: Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home-based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings.

Strategically reducing carbapenem-resistant Acinetobacter baumannii through PDCA cycle-driven antibiotic management.

PURPOSE: With the escalating global challenge of antibiotic resistance, particularly the resistance rate of Acinetobacter baumannii, the need to rationalize carbapenem antibiotic use in clinical settings has become paramount. Our study tapped into a fishbone diagram to uncover the irrationalities in applying these antibiotics and highlight potential influencing factors. METHODS: Based on these analyses, we initiated targeted intervention strategies. A PDCA cycle-based scientific management approach was implemented through the combined efforts of our antimicrobial stewardship team and relevant departments. RESULTS: Our study showed a significant post-intervention increase in the rational use of carbapenem antibiotics (P < 0.01) and a concurrent decrease in the detection of carbapenem-resistant Acinetobacter baumannii. CONCLUSION: Our findings underscore that carbapenem usage can be effectively minimized with the continuous refinements offered by the PDCA cycle, leading to a reduction in multidrug-resistant bacteria, thus fostering rational drug use in healthcare.

Effective Approaches to Diagnostic Stewardship of Syndromic Molecular Panels.

BACKGROUND: Syndromic molecular panels for the diagnosis of gastroenteritis, meningitis/encephalitis, and pneumonia are becoming routinely used for patient care throughout the world. CONTENT: These rapid, sample-to-answer assays have great potential to improve patient care, infection control, and antimicrobial stewardship. However, diagnostic stewardship is essential for their optimal use and accuracy, and interventions can be applied at all phases of the diagnostic process. SUMMARY: The aim of this review article is to describe effective approaches to diagnostic stewardship for syndromic molecular panels to ensure appropriate test utilization and quality assured results.

Implementation of antimicrobial stewardship programs: A study of prescribers' perspective of facilitators and barriers.

BACKGROUND: Despite promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs), there remains limited knowledge on how to implement ASPs in peculiar settings for a more elaborate impact. This study explored prescriber experiences and perceptions of the usefulness, and feasibility of strategies employed for the implementation of antimicrobial stewardship (AMS) interventions as well as challenges encountered. METHODS: This is a cross-sectional mixed-method survey of prescribers' perspective of the facilitators and barriers of implementing ASP. The quantitative approach comprised of a semi-structured questionnaire and data collected were analyzed using SPSS version 26 while the qualitative approach used focus group discussions followed by content analysis. RESULTS: Out of the thirty people that participated in the workshop, twenty-five completed the questionnaires which were analyzed. The respondents included 15 (60.0%) medical doctors and 10 (40.0%) pharmacists. The mean age of the respondents was 36.39±7.23 years with mean year of practice of 9.48±6.01 years. Majority of them (84.0%) were in a position to provide input on the implementation of AMS in their facilities, although their managements had the final decision. The pharmacists (100%) were more likely to agree that antibiotic resistance was a problem for their practice than the medical doctors (78.6%) while equal number (80.0%) of respondents (pharmacists and medical doctors) believed that inappropriate prescribing was a problem. Having a specialized and dedicated team with effective monitoring was recognized as crucial for effective ASP while inadequate personnel was identified as a major barrier. We identified stakeholder's engagement, policies and regulation, as well as education as themes for improving AMS in the country. CONCLUSION: The results gave insight into the prescribers' perspective on the facilitators and barriers to antimicrobial stewardship; challenges and possible solutions to implementing ASPs in health facilities in Lagos State. We further identified pertinent contextual factors that need to be addressed when developing ASPs in healthcare facilities in a resource-poor setting.

Perceptions of antibiotic stewardship programmes and determinants of antibiotic prescribing patterns among physicians in tertiary hospitals in Bangladesh: implications for future policy and practice.

BACKGROUND: The concerning growth of antimicrobial resistance (AMR) renders common infections life-threatening due to irrational antibiotic use and a lack of effective antimicrobial stewardship programmes (ASPs). AIM: To investigate the awareness, perceptions and practices of physicians regarding ASPs, AMR and antibiotic prescribing in tertiary care hospitals in Bangladesh. METHODS: This hospital-based cross-sectional survey was conducted in 11 tertiary care hospitals across Bangladesh between September 2020 and January 2021. A semi-structured questionnaire was administered through face-to-face interviews for data collection. Descriptive and multi-variate analyses were performed using STATA Version 13. RESULTS: In total, 559 physicians were enrolled in this survey. Overall, 40.6% [95% confidence interval (CI) 36.5-44.8] of physicians reported being aware of ASPs, and this figure was higher in public hospitals compared with private hospitals (43.8% vs 27.1%). None of the study hospitals had any ASP initiatives. More than half (55.1%) of the participants were willing to receive feedback from an ASP on their antibiotic selection. Only 30.9% of respondents stated that they wait for the findings of microbiological tests before prescribing antibiotics, although challenges included empiric use of broad-spectrum antibiotics, delayed laboratory results and the existence of drug-resistant patients. In contrast, physicians aware of ASPs were 33% (adjusted odds ratio 0.67, 95% CI 0.45-0.98; P=0.033) less likely to wait for laboratory results before prescribing antibiotics. However, 42.5% of physicians considered patient affordability of purchasing antibiotics when prescribing. CONCLUSIONS: Physicians' fundamental knowledge of ASPs and rational antibiotic prescription were found to fall short of the standard. Context-specific and integrated ASP activities, availability and use of guidelines, and improved laboratory facilities are required to battle AMR in Bangladesh.

Pragmatic Expansion of a Neonatal Antibiotic Stewardship Program in a Community Health Care System.

BACKGROUND: Previously published neonatal antibiotic stewardship efforts have been primarily implemented in single centers. Piedmont Athens Regional began work to decrease antibiotic use in the NICU with spread to the newborn nursery (NBN) and, subsequently, 13 other NICUs and NBNs throughout a health care system over a 4-year period. METHODS: This quality improvement initiative was conducted in the context of a multicenter learning collaborative from 2016 to 2019. The primary aim was a 10% reduction in antibiotic days per 1000 patient days (antibiotic utilization rate [AUR]) among newborns in the NICU and NBN at each hospital by December 2018. Change ideas were implemented by using plan-do-study-act cycles. The primary outcome measure was AUR with a balancing measure of antibiotic restarts. RESULTS: Piedmont Athens Regional decreased the NICU AUR by 46% and NBN AUR by 83%. Piedmont Healthcare decreased the NICU AUR by 40% and NBN AUR by 74%. Seven of 8 NICUs and 5 of 7 NBNs achieved a >10% reduction in AUR and 8 of 8 intervention hospitals showed a sustained drop in AUR in the NBN, NICU, or both during the 1.5-year postobservation period. Decreases in antibiotic initiation resulted in 335 fewer antibiotic courses in the NICU and 189 fewer infants started on antibiotics in the NBN in 2020 versus 2017. CONCLUSIONS: This initiative achieved reductions in AUR across multiple hospitals in the network. The system-wide approach facilitated information technology (IT) and electronic health record modifications. Common drivers of NICU improvement were involvement for at least 2 years, multidisciplinary teams, and the highest baseline AUR. The common driver of nursery improvement was the implementation of a neonatal sepsis risk calculator.