How does the antimicrobial stewardship provider role affect prospective audit and feedback acceptance for restricted antibiotics in a Canadian tertiary-care center?

Of 731 restricted antimicrobial prescriptions subject to antimicrobial stewardship program (ASP) prospective audit and feedback (PAF) over a 3-year period, 598 PAF recommendations (82%) were fully accepted. Physician auditors had an increased odds of PAF recommendation acceptance, reinforcing the complementary role of the ASP physician in the multidisciplinary ASP team.

Antimicrobial stewardship, procalcitonin testing, and rapid blood-culture identification to optimize sepsis care in critically ill adult patients: A quality improvement initiative.

We examined the effect of an antimicrobial stewardship program (ASP), procalcitonin testing and rapid blood-culture identification on hospital mortality in a prospective quality improvement project in critically ill septic adults. Secondarily, we have reported antimicrobial guideline concordance, acceptance of ASP interventions, and antimicrobial and health-resource utilization.

Efficacy and safety of antimicrobial stewardship prospective audit and feedback in patients hospitalised with COVID-19 (COVASP): a pragmatic, cluster-randomised, non-inferiority trial.

BACKGROUND: The COVID-19 pandemic has been associated with increased antimicrobial use despite low rates of bacterial co-infection. Prospective audit and feedback is recommended to optimise antibiotic prescribing, but high-quality evidence supporting its use for COVID-19 is absent. We aimed to study the efficacy and safety of prospective audit and feedback in patients admitted to hospital for the treatment of COVID-19. METHODS: COVASP was a prospective, pragmatic, non-inferiority, small-unit, cluster-randomised trial comparing prospective audit and feedback plus standard of care with standard of care alone in adults admitted to three hospitals in Edmonton, AB, Canada, with COVID-19 pneumonia. All patients aged at least 18 years who were admitted from the community to a designated study bed with microbiologically confirmed SARS-CoV-2 infection in the preceding 14 days were included if they had an oxygen saturation of 94% or lower on room air, required supplemental oxygen, or had chest-imaging findings compatible with COVID-19 pneumonia. Patients were excluded if they were transferred in from another acute care centre, enrolled in another clinical trial that involved antibiotic therapy, expected to progress to palliative care or death within 48 h of hospital admission, or managed by any member of the research team within 30 days of enrolment. COVID-19 unit and critical care unit beds were stratified and randomly assigned (1:1) to the prospective audit and feedback plus standard of care group or the standard of care group. Patients were masked to their bed assignment but the attending physician and study team were not. The primary outcome was clinical status on postadmission day 15, measured using a seven-point ordinal scale. We used a non-inferiority margin of 0·5. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, NCT04896866, and is now closed. FINDINGS: Between March 1 and Oct 29, 2021, 1411 patients were screened and 886 were enrolled: 457 into the prospective audit and feedback plus standard of care group, of whom 429 completed the study, and 429 into the standard of care group, of whom 404 completed the study. Baseline characteristics were similar for both groups, with an overall mean age of 56·7 years (SD 17·3) and a median baseline ordinal scale of 4·0 (IQR 4·0-5·0). 301 audit and feedback events were recorded in the intervention group and 215 recommendations were made, of which 181 (84%) were accepted. Despite lower antibiotic use in the intervention group than in the control group (length of therapy 364·9 vs 384·2 days per 1000 patient days), clinical status at postadmission day 15 was non-inferior (median ordinal score 2·0 [IQR 2·0-3·0] vs 2·0 [IQR 2·0-4·0]; p=0·37, Mann-Whitney U test). Neutropenia was uncommon in both the intervention group (13 [3%] of 420 patients) and the control group (20 [5%] of 396 patients), and acute kidney injury occurred at a similar rate in both groups (74 [18%] of 421 patients in the intervention group and 76 [19%] of 399 patients in the control group). No intervention-related deaths were recorded. INTERPRETATION: This cluster-randomised clinical trial shows that prospective audit and feedback is safe and effective in optimising and reducing antibiotic use in adults admitted to hospital with COVID-19. Despite many competing priorities during the COVID-19 pandemic, antimicrobial stewardship should remain a priority to mitigate the overuse of antibiotics in this population. FUNDING: None.

Rotating opportunistic prevalence audit: A new pragmatic audit method is effective at identifying misuse of ciprofloxacin in a large academic hospital.

The rotating opportunistic prevalence audit (ROPA) methodology is described with ciprofloxacin prescriptions in adults hospitalized at a tertiary-care center. Prescription appropriateness was assessed. ROPA captured 82% of all ciprofloxacin prescriptions; 69% were inappropriate. ROPA is feasible and may overcome resource barriers of prospective audit and feedback.

Antimicrobial resistance (AMR) in COVID-19 patients: a systematic review and meta-analysis (November 2019-June 2021).

BACKGROUND: Pneumonia from SARS-CoV-2 is difficult to distinguish from other viral and bacterial etiologies. Broad-spectrum antimicrobials are frequently prescribed to patients hospitalized with COVID-19 which potentially acts as a catalyst for the development of antimicrobial resistance (AMR). OBJECTIVES: We conducted a systematic review and meta-analysis during the first 18 months of the pandemic to quantify the prevalence and types of resistant co-infecting organisms in patients with COVID-19 and explore differences across hospital and geographic settings. METHODS: We searched MEDLINE, Embase, Web of Science (BioSIS), and Scopus from November 1, 2019 to May 28, 2021 to identify relevant articles pertaining to resistant co-infections in patients with laboratory confirmed SARS-CoV-2. Patient- and study-level analyses were conducted. We calculated pooled prevalence estimates of co-infection with resistant bacterial or fungal organisms using random effects models. Stratified meta-analysis by hospital and geographic setting was also performed to elucidate any differences. RESULTS: Of 1331 articles identified, 38 met inclusion criteria. A total of 1959 unique isolates were identified with 29% (569) resistant organisms identified. Co-infection with resistant bacterial or fungal organisms ranged from 0.2 to 100% among included studies. Pooled prevalence of co-infection with resistant bacterial and fungal organisms was 24% (95% CI 8-40%; n = 25 studies: I2 = 99%) and 0.3% (95% CI 0.1-0.6%; n = 8 studies: I2 = 78%), respectively. Among multi-drug resistant organisms, methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and multi-drug resistant Candida auris were most commonly reported. Stratified analyses found higher proportions of AMR outside of Europe and in ICU settings, though these results were not statistically significant. Patient-level analysis demonstrated > 50% (n = 58) mortality, whereby all but 6 patients were infected with a resistant organism. CONCLUSIONS: During the first 18 months of the pandemic, AMR prevalence was high in COVID-19 patients and varied by hospital and geography although there was substantial heterogeneity. Given the variation in patient populations within these studies, clinical settings, practice patterns, and definitions of AMR, further research is warranted to quantify AMR in COVID-19 patients to improve surveillance programs, infection prevention and control practices and antimicrobial stewardship programs globally.

Efficacy and safety of antimicrobial stewardship prospective audit and feedback in patients hospitalized with COVID-19: A protocol for a pragmatic clinical trial.

BACKGROUND: The use of broad-spectrum antibiotics is widespread in patients with COVID-19 despite a low prevalence of bacterial co-infection, raising concerns for the accelerated development of antimicrobial resistance. Antimicrobial stewardship (AMS) is vital but there are limited randomized clinical trial data supporting AMS interventions such as prospective audit and feedback (PAF). High quality data to demonstrate safety and efficacy of AMS PAF in hospitalized COVID-19 patients are needed. METHODS AND DESIGN: This is a prospective, multi-center, non-inferiority, pragmatic randomized clinical trial evaluating AMS PAF intervention plus standard of care (SOC) versus SOC alone. We include patients with microbiologically confirmed SARS-CoV-2 infection requiring hospital admission for severe COVID-19 pneumonia. Eligible ward beds and critical care unit beds will be randomized prior to study commencement at each participating site by computer-generated allocation sequence stratified by intensive care unit versus conventional ward in a 1:1 fashion. PAF intervention consists of real time review of antibacterial prescriptions and immediate written and verbal feedback to attending teams, performed by site-based AMS teams comprised of an AMS pharmacist and physician. The primary outcome is clinical status at post-admission day 15 measured using a 7-point ordinal scale. Patients will be followed for secondary outcomes out to 30 days. A total of 530 patients are needed to show a statistically significant non-inferiority, with 80% power and 2.5% one-sided alpha assuming standard deviation of 2 and the non-inferiority margin of 0.5. DISCUSSION: This study protocol presents a pragmatic clinical trial design with small unit cluster randomization for AMS intervention in hospitalized COVID-19 that will provide high-level evidence and may be adopted in other clinical situations. TRIAL REGISTRATION: This study is being performed at the University of Alberta and is registered at ClinicalTrials.gov (NCT04896866) on May 17, 2021.

Procalcitonin measurement in West Nile virus neuroinvasive disease: A first case series.

West Nile virus neuroinvasive disease (WNV-NID) is challenging to diagnose. Procalcitonin (PCT) is a useful diagnostic test to identify bacterial infections. We present four cases of WNV-NID with serum PCT measurements. Methods: Daily (days 1-7) serum PCT (bioMérieux) was examined for critically ill patients with sepsis enrolled in a provincial sepsis study. Patients with identified WNV-NID are descriptively analyzed in this case series. PCT values of ≥0.5 ng/mL were suggestive of bacterial infection. Results: Four patients with WNV-NID were identified. Those with viral infections alone had consistently low PCT values ranging from 0.09 ng/mL to 0.34 ng/mL. Those with documented bacterial co-infections had initially elevated PCT levels that decreased by more than 50% with antimicrobial therapy. Conclusion: These cases are the first to report serial PCT measurements in confirmed cases of WNV-NID and support a low serum PCT in WNV-NID.

La maladie neuro-invasive causée par le virus du Nil occidental (MNI-VNO) est difficile à diagnostiquer. La procalcitonine (PCT) est un test diagnostique utile pour dépister les infections bactériennes. Les auteurs présentent quatre cas de MNI-VNO assortis de mesures de PCT sérique. Méthodologie : Les chercheurs ont procédé à l'examen quotidien (jours 1 à 7) du PCT sérique (bioMérieux) chez des patients gravement malades et atteints de sepsis recrutés dans une étude provinciale du sepsis. Les patients retenus à cause d'une MNI-VNO établie font l'objet d'une analyse descriptive dans cette série de cas. Les valeurs de PCT de 0,5 ng/mL ou plus étaient évocatrices d'une infection bactérienne. Résultats : Quatre patients atteints d'une MNI-VNO ont été retenus. Ceux qui n'étaient atteints que d'une infection virale obtenaient des valeurs de PCT faibles, de 0,09 ng/mL à 0,34 ng/mL. Ceux qui étaient atteints de co-infections bactériennes démontrées commençaient par obtenir des taux élevés de PCT, qui diminuaient de plus de 50 % après un traitement antimicrobien. Conclusion : Ces cas sont les premiers à faire état des mesures sérielles de la PCT dans des cas confirmés de MNI-VNO et à soutenir une faible PCT sérique en présence de MNI-VNO.

Gonococcal and Chlamydial Cases of Pelvic Inflammatory Disease at 2 Canadian Sexually Transmitted Infection Clinics, 2004 to 2014: A Retrospective Cross-sectional Review.

One hundred thirteen patients with gonococcal and chlamydial pelvic inflammatory disease were reviewed at 2 Canadian sexually transmitted infection clinics. Most patients (81%) with pelvic inflammatory disease were diagnosed as having chlamydia alone. Three treatment failures were seen in patients treated with ofloxacin.

Retrospective Review of Gonococcal and Chlamydial Cases of Epididymitis at 2 Canadian Sexually Transmitted Infection Clinics, 2004-2014.

Fifty-seven cases of gonococcal and chlamydial infections complicated by acute epididymitis seen at 2 Alberta STI clinics from 2004 to 2014 were reviewed. The majority responded to treatment recommended by national guidelines. Three of 6 treatment failures were not treated according to guidelines.

Estimating patient-borne water and electricity costs in home hemodialysis: a simulation.

BACKGROUND: Home hemodialysis is associated with lower costs to the health care system compared with conventional facility-based hemodialysis because of lower staffing and overhead costs, and by transferring the treatment cost of utilities (water and power) to the patient. The purpose of this study was to determine the utility costs of home hemodialysis and create a formula such that patients and renal programs can estimate the annual patient-borne costs involved with this type of treatment. METHODS: Seven common combinations of treatment duration and dialysate flows were replicated 5 times using various combinations of home hemodialysis and reverse osmosis machines. Real-time utility (electricity and water) consumption was monitored during these simulations. A generic formula was developed to allow patients and programs to calculate a more precise estimate of utility costs based on individual combinations of dialysis intensity, frequency and utility costs unique to any patient. RESULTS: Using typical 2014 utility costs for Edmonton, the most expensive prescription was for nocturnal home hemodialysis (8 h at 300 mL/min, 6 d/wk), which resulted in a utility cost of $1269 per year; the least expensive prescription was for conventional home hemodialysis (4 h at 500 mL/min, 3 d/wk), which cost $420 per year. Water consumption makes up most of this expense, with electricity accounting for only 12% of the cost. INTERPRETATION: We show that a substantial cost burden is transferred to the patient on home hemodialysis, which would otherwise be borne by the renal program.