It takes a village: decreasing inappropriate antibiotic prescribing for upper respiratory tract infections.

Objective: Prescribing of antibiotics for viral upper respiratory infections (URIs) remains a pressing public health problem. We sought to reduce inappropriate prescribing of antibiotics for URIs in Mayo Clinic Arizona. Design: Single-center, quasi-experimental, and retrospective cohort study. Setting: Emergency medicine and all primary care departments. Methods: The interventions included sharing baseline prescribing data, education, resources, and quarterly peer comparison reports. Encounters with diagnostic codes for respiratory infections commonly caused by viruses were categorized as Tier 3 (ie, never appropriate to prescribe antibiotics). Our goal was to reduce inappropriate prescribing for Tier 3 encounters by 22% in 2022. Results: Department education was completed by June 2022. The annual antibiotic prescribing rate for Tier 3 encounters was reduced by 29%, from a baseline rate of 23.6% in 2021 to 16.4% in 2022 (P < .001). The posteducation prescribing rate was 13.1%. Repeat respiratory-related healthcare contact within 14 days of Tier 3 encounters did not differ between patients prescribed and not prescribed an antibiotic in all of 2022 (4.7% antibiotic vs 4.2% no antibiotic, P = .595) or during the posteducation period (3.7% vs 4.6%, P = .604). Conclusion: A multi-faceted intervention, which included baseline education, syndrome-specific order panels, resources for symptomatic management, and peer comparison reports, resulted in significant reduction of inappropriate antibiotic prescribing for URIs.

Tixagevimab/cilgavimab for the prevention of COVID-19 in solid organ transplant recipients.

Tixagevimab/cilgavimab (tix/cil) received emergency use authorization in December 2021 for pre-exposure prophylaxis against COVID-19 in moderately to severely immunocompromised patients. Our study aimed to describe the incidence of COVID-19 infection and assess the immunologic risks associated with tix/cil in kidney, pancreas, liver, and heart transplant recipients. Retrospective chart review was completed to provide descriptive analysis. Outcomes data included COVID-19 infection, severity of COVID-19 infection, graft function, and rejection. Safety outcomes included cardiovascular (CV) and hypersensitivity events post tix/cil administration. A total of 410 transplant patients were included in the analysis: 20 heart, 92 liver, 243 kidney, 25 simultaneous pancreas/kidney, 23 simultaneous liver/kidney, and seven simultaneous heart/kidney. Twenty-seven (6.5%) patients tested positive for COVID-19 via PCR or antigen test post tix/cil. No apparent difference was observed in patients testing positive for COVID-19 by type of organ transplant (p = .122). Twenty-five of the 27 patients testing positive for COVID-19 reported symptomatic infection, only nine of whom were hospitalized. No patients were mechanically ventilated and no deaths due to COVID-19 occurred. No significant changes in graft function were observed. Clinically significant rejection was diagnosed and treated in four patients. COVID-19 breakthrough infection rates remained low in immunocompromised solid organ transplant recipients who received tix/cil. No significant immunologic risks were observed.

Evaluation of Multisite Programmatic Bundle to Reduce Unnecessary Antibiotic Prescribing for Respiratory Infections: A Retrospective Cohort Study.

Background: The aim of this study was to evaluate the frequency of unnecessary antibiotic prescribing for Tier 3 upper respiratory infection (URI) syndromes across the Mayo Clinic Enterprise before and after a multifaceted antimicrobial stewardship intervention, and to determine ongoing factors associated with antibiotic prescribing and repeat respiratory healthcare contact in the postintervention period. Methods: This was a quasi-experimental, pre/post, retrospective cohort study from 1 January 2019 through 31 December 2022, with 12-month washout during implementation from 1 July 2020 through 30 June 2021. All outpatient encounters, adult and pediatric, from primary care, urgent care, and emergency medicine specialties with a Tier 3 URI diagnosis were included. The intervention was a multifaceted outpatient antibiotic stewardship bundle. The primary outcome was the rate of antibiotic prescribing in Tier 3 encounters. Secondary outcomes included 14-day repeat healthcare contact for respiratory indications and factors associated with persistent unnecessary prescribing. Results: A total of 165 658 Tier 3 encounters, 96 125 in the preintervention and 69 533 in the postintervention period, were included. Following intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Repeat 14-day respiratory healthcare contact in the no antibiotic group was lower postintervention (9.9.% vs 9.4%; P = .004). Multivariable models indicated that increasing patient age, Charlson comorbidity index, and primary diagnosis selected were the most important factors associated with persistent unnecessary antibiotic prescribing. Conclusions: Outpatient antibiotic stewardship initiatives can reduce unnecessary antibiotic prescribing for Tier 3 URIs without increasing repeat respiratory healthcare contact. Advancing age and number of comorbidities remain risk factors for persistent unnecessary antibiotic prescribing.

Mixed methods evaluation of handshake antimicrobial stewardship on adult inpatient medicine floors.

Objective: To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital. Design: Retrospective observational study. Setting: 1,278-bed academic hospital. Patients: Adults admitted to non-ICU medicine services. Interventions: A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention. Results: The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality. Conclusion: The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.

A Broad Spectrum of Possibilities: Spectrum Scores as a Unifying Metric of Antibiotic Utilization.

Days of therapy (DOT) currently serve as the standard antimicrobial utilization metric. However, by assigning the same weight to each agent rather than accounting for differences in spectrum of activity, DOT ignore key differences between agents that are fundamental to infectious diseases and critical to antimicrobial stewardship. Spectrum scoring assigns numeric values to individual antibiotic agents to quantify their spectrum of activity, allowing for the normalization of antibiotic utilization data. When used in conjunction with traditional metrics, spectrum scores may offer further clarity to antibiotic utilization; however, issues related to development, application, and standardization of spectrum scores remain. Despite these challenges, the potential applications of spectrum scores are vast. Here, we summarize existing data and explore the future of spectrum scoring, including application to both data analysis and routine patient care, use in inpatient and outpatient settings, integration within the electronic medical record, and opportunities for future research.

Persistent Methicillin-Susceptible Bacteremia Rapidly Cleared with Cefazolin and Ertapenem Combination Therapy in a Patient with COVID-19.

Methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections (BSIs) are associated with significant morbidity and mortality. MSSA BSIs can rapidly disseminate, resulting in deep-seated infections, prolonged durations of bacteremia, and further metastases. Recently, cefazolin and ertapenem combination therapy has emerged as a potential therapeutic strategy to sterilize the blood in patients with persistent MSSA bacteremia. Here, we present a patient with COVID-19 pneumonia and concomitant MSSA BSI achieving blood culture sterilization within 24 hours of cefazolin and ertapenem combination therapy initiation following 11 days of positive blood cultures.

Assessment of Antibiotic De-escalation by Spectrum Score in Patients With Nosocomial Pneumonia: A Single-Center, Retrospective Cohort Study.

BACKGROUND: Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) cause significant mortality. Guidelines recommend empiric broad-spectrum antibiotics followed by de-escalation (DE). This study sought to assess the impact of DE on treatment failure. METHODS: This single-center retrospective cohort study screened all adult patients with a discharge diagnosis code for pneumonia from 2016 to 2019. Patients were enrolled if they met predefined criteria for HAP/VAP ≥48 hours after admission. Date of pneumonia diagnosis was defined as day 0. Spectrum scores were calculated, and DE was defined as a score reduction on day 3 versus day 1. Patients with DE were compared to patients with no de-escalation (NDE). The primary outcome was composite treatment failure, defined as all-cause mortality or readmission for pneumonia within 30 days of diagnosis. RESULTS: Of 11860 admissions screened, 1812 unique patient-admissions were included (1102 HAP, 710 VAP). Fewer patients received DE (876 DE vs 1026 NDE). Groups were well matched at baseline, although more patients receiving DE had respiratory cultures ordered (56.6% vs 50.6%, P = .011). There was no difference in composite treatment failure (35.0% DE vs 33.8% NDE, P = .604). De-escalation was not associated with treatment failure on multivariable Cox regression analysis (hazard ratio, 1.13; 95% confidence interval, 0.96-1.33). Patients receiving DE had fewer antibiotic days (median 9 vs 11, P < .0001), episodes of Clostridioides difficile infection (2.2% vs 3.8%, P = .046), and hospital days (median 20 vs 22 days, P = .006). CONCLUSIONS: De-escalation and NDE resulted in similar rates of 30-day treatment failure; however, DE was associated with fewer antibiotic days, episodes of C difficile infection, and days of hospitalization.