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.

Review of Guidelines for Dental Antibiotic Prophylaxis for Prevention of Endocarditis and Prosthetic Joint Infections and Need for Dental Stewardship.

Dentists prescribe 10% of all outpatient antibiotic prescriptions, writing more than 25.7 million prescriptions per year. Many are for prophylaxis in patients with prosthetic joint replacements; the American Dental Society states that "in general," prophylactic antibiotics are not recommended to prevent prosthetic joint infections. Orthopedic surgeons are concerned with the risk of implant infections following a dental procedure and, therefore, see high value and low risk in recommending prophylaxis. Patients are "stuck in the middle," with conflicting recommendations from orthopedic surgeons (OS) and dentists. Unnecessary prophylaxis and fear of lawsuits amongst private practice dentists and OS has not been addressed. We review The American Heart Association/American College of Cardiology, American Dental Association, and American Association of Orthopedic Surgeons' guidelines on dental antibiotic prophylaxis for the prevention of endocarditis and prosthetic joint infections. We provide experience on how to engage private-practice dentists and OS in dental stewardship using a community-based program.

Trends in and Predictors of Carbapenem Consumption across North American Hospitals: Results from a Multicenter Survey by the MAD-ID Research Network.

We sought to define trends in and predictors of carbapenem consumption across community, teaching, and university-affiliated hospitals in the United States and Canada. We conducted a retrospective multicenter survey of carbapenem and broad-spectrum noncarbapenem beta-lactam consumption between January 2011 and December 2013. Consumption was tabulated as defined daily doses (DDD) or as days of therapy (DOT) per 1,000 patient days (PD). Multivariate mixed-effects models were explored, and final model goodness of fit was assessed by regressions of observed versus predicted values and residual distributions. A total of 20 acute-care hospitals responded. The centers treated adult patients (n = 19/20) and pediatric/neonatal patients (n = 17/20). The majority of the centers were nonprofit (n = 17/20) and not affiliated with medical/teaching institutions (n = 11/20). The median (interquartile range [IQR]) carbapenem consumption rates were 38.8 (17.4 to 95.7) DDD/1,000 PD and 29.7 (19.2 to 40.1) DOT/1,000 PD overall. Carbapenem consumption was well described by a multivariate linear mixed-effects model (fixed effects, R2 = 0.792; fixed plus random effects, R2 = 0.974). Carbapenem consumption increased by 1.91-fold/quarter from 48.6 DDD/1,000 PD (P = 0.004) and by 0.056-fold/quarter from 45.7 DOT/1,000 PD (P = 0.93) over the study period. Noncarbapenem consumption was independently related to increasing carbapenem consumption (beta = 0.31 for increasing noncarbapenem beta-lactam consumption; P < 0.001). Regular antibiogram publication and promotion of conversion from intravenous (i.v.) to oral (p.o.) administration independently affected carbapenem consumption rates. In the final model, 58.5% of the observed variance in consumption was attributable to between-hospital differences. Rates of carbapenem consumption across 20 North American hospitals differed greatly, and the observed differences were correlated with hospital-specific demographics. Additional studies focusing on the drivers of hospital-specific carbapenem consumption are needed to determine whether these rates are justifiable.

Eight Habits of Highly Effective Antimicrobial Stewardship Programs to Meet the Joint Commission Standards for Hospitals.

In an effort to decrease antimicrobial resistance and inappropriate antibiotic use, The Joint Commission (TJC) recently issued new antimicrobial stewardship standards, consisting of 8 elements of performance, applicable to hospitals effective January 1, 2017. These standards coincide with those recommended by the Infectious Diseases Society of America (IDSA) and the Society of Healthcare Epidemiology (SHEA) guidelines. Little guidance exists on the "how" from these guidance documents. We review the 8 standards and provide real-world experience from established antimicrobial stewardship programs (ASPs) on how institutions can comply with these guidelines to reduce inappropriate antibiotic usage, decrease antimicrobial resistance, and optimize patient outcomes. TJC antimicrobial stewardship standards demonstrate actions being taken at the national level to make quality and patient safety a priority.

An Automated, Pharmacist-Driven Initiative Improves Quality of Care for Staphylococcus aureus Bacteremia.

BACKGROUND: Infectious diseases (ID) consultation and antimicrobial stewardship intervention have been shown to improve the management of Staphylococcus aureus bacteremia (SAB). As the workload of antimicrobial stewardship programs (ASPs) continues to increase, ASPs must find a way to maximize the efficiency of the program while optimizing patient outcomes. The objective of this study was to evaluate the impact of incorporating health informatics into the management of SAB via a pharmacist-driven initiative. METHODS: Retrospective, single-center quasi-experimental study of hospitalized patients with SAB. During the intervention period, pharmacists were alerted to patients with SAB via a patient scoring tool integrated into the electronic medical record. Pharmacists utilized the scoring tool and the institution's evidence-based practice guideline to make standardized recommendations to promote adherence to SAB quality-of-care measures and encourage ID consultation. The primary outcome was overall compliance along with adherence to individual quality-of-care components. Secondary clinical outcomes were also analyzed. RESULTS: In sum, 84 patients were identified for study inclusion, 45 in the pre-intervention and 39 in the intervention group. As a whole, all 4 quality-of-care components for the management of SAB were significantly more frequently adhered to in the intervention group (68.9% vs 92.3%; P = .008). The incidence of ID consult improved significantly by almost 20% in the intervention group (75.6% vs 94.9%, P = .015). No statistically significant differences in duration of bacteremia, length-of-stay, infection-related length-of-stay, or readmission were observed between the groups. The incidence of all-cause mortality was 6-fold higher in the pre- intervention group compared to the intervention group (15.6% vs 2.6%, P = .063). CONCLUSION: An automated, pharmacist-driven intervention for the management of patients with SAB demonstrated a significant improvement in patients receiving an ID consult, targeted antimicrobial therapy, and adherence to all SAB quality-of-care measures. As antimicrobial stewardship becomes a mandatory aspect of healthcare in all hospitals in the United States, ASPs will be forced to find ways to provide more efficient, impactful, disease state-based patient care. Our study provides the framework for and data to support this intervention in one of the most clinically important infectious diseases.

Impact of the NAP-1 strain on disease severity, mortality, and recurrence of healthcare-associated Clostridium difficile infection.

OBJECTIVES: Studies are conflicting regarding the association of the North American pulsed-field gel electrophoresis type 1 (NAP1) strain in Clostridium difficile infection (CDI) and outcomes. We evaluated the association of NAP1 with healthcare-associated CDI disease severity, mortality, and recurrence at our academic medical center. METHODS: Healthcare-associated CDI cases were identified from November 1, 2011 through January 31, 2013. Multivariable regression models were used to evaluate the associations of NAP1 with severe disease (based on the Hines VA severity score index), mortality, and recurrence. RESULTS: Among 5424 stool specimens submitted to the Clinical Microbiology Laboratory, 292 (5.4%) were positive for C. difficile by polymerase chain reaction (PCR) on or after hospital day 4; 70 (24%) of these specimens also tested positive for NAP1. During the study period, 247 (85%) patients had non-severe disease and 45 (15%) patients had severe disease. Among patients with non-severe disease, 65 (26%) had NAP1 and among patients with severe disease, 5 (11%) had NAP1. After controlling for potential confounders, NAP1 was not associated with an increased likelihood of severe disease (adjusted odds ratio [aOR] = 0.35; 95% confidence interval [CI], 0.13-0.93), in-hospital mortality (aOR = 1.02; 95% CI, 0.53-1.96), or recurrence (aOR = 1.16, 95% CI, 0.36-3.77). CONCLUSIONS: The NAP1 strain did not increase disease severity, mortality, or recurrence in this study, although the incidence of NAP1-positive healthcare associated-CDI was low. The role of strain typing in outcomes and treatment selection in patients with healthcare-associated CDI remains uncertain.

International Mentoring Programs: Leadership Opportunities to Enhance Worldwide Pharmacy Practice.

Health-system and community pharmacy practice in the United States is experiencing transformational change; however, this transformation is lagging in the international arena. As a result, efforts are being made to provide support and education to the international pharmacy leaders and practitioners. This article describes one effort, the Mandela Washington Fellows Program, and suggests areas where pharmacy leaders can be involved to help advance the practice of pharmacy on an international level. The Mandela Washington Fellows Program for young Africa leaders consists of a US-Africa pharmacy-mentoring program identified ranging from educational opportunities to collaboration for implementation of patient care programs. The specifics of the mentoring program include daily meetings, clinic and ward rounds, round table discussions with mentors, and visits to various hospital care systems. Lessons were learned and strategies for sustaining the program are discussed. These types of programs represent leadership opportunities that may not be apparent to most pharmacy directors, but expanding their view to helping international pharmacists expand their practice only strengthens the professional goal of providing patient-centered pharmacy services.

Approaches to Modifying the Behavior of Clinicians Who Are Noncompliant With Antimicrobial Stewardship Program Guidelines.

Antimicrobial stewardship programs (ASPs) are a key national initiative to promote appropriate use of antibiotics and to reduce the burden of resistance. The dilemma of managing the outlier physician is especially complex. We outline strategies to establish a successful ASP that reviews appropriate efforts to achieve the goal of modifying outlier physicians' behavior. One must try to differentiate deviation from ASP norms from all other issues of outliers. Essential elements include identifying and understanding the local problems, planning, and achieving hospital administration and medical staff support. A successful ASP includes effective communication and acceptance of evidence-based recommendations, so that patient clinical outcomes will be optimized.

Correlation of Checkerboard Synergy Testing with Time-Kill Analysis and Clinical Outcomes of Extensively Drug-Resistant Acinetobacter baumannii Respiratory Infections.

We tested 76 extensively drug-resistant (XDR) Acinetobacter baumannii isolates by the checkerboard method using only wells containing serum-achievable concentrations (SACs) of drugs. Checkerboard results were correlated by time-kill assay and clinical outcomes. Minocycline-colistin was the best combination in vitro, as it inhibited growth in one or more SAC wells in all isolates. Patients who received a combination that inhibited growth in one or more SAC wells demonstrated better microbiological clearance than those who did not (88% versus 30%; P = 0.025). The checkerboard platform may have clinical utility for XDR A. baumannii infections.

Review of Twitter for infectious diseases clinicians: useful or a waste of time?

Twitter is a social networking service that has emerged as a valuable tool for healthcare professionals (HCPs). It is the only platform that allows one to connect, engage, learn, and educate oneself and others in real time on a global scale. HCPs are using social media tools to communicate, educate, and engage with their peers worldwide. Twitter allows HCPs to deliver easily accessible "real-time" clinical information on a global scale. Twitter has more than 500 million active users who generate more than 58 million tweets and 2.1 billion search queries every day. Here, we explain why Twitter is important, how and when an infectious diseases (ID) HCP should use Twitter, the impact it has in disseminating ID news, and its educational value. We also describe various tools within Twitter, such as Twitter Chat, that connect and bond HCPs on a specific topic. Twitter may help ID HCPs teach others about the global responsible use of antimicrobials in a world of escalating antimicrobial resistance.

Social Media As a Leadership Tool for Pharmacists.

The profession of pharmacy is currently experiencing transformational change in health system practice models with pharmacists' provider status. Gaining buy-in and support of stakeholders in medicine, nursing, and other advocates for patient care is critical. To this end, building momentum to advance the profession will require experimentation with and utilization of more efficient ways to disseminate relevant information. Traditional methods to communicate can be inefficient and painstakingly slow. Health care providers are turning to social media to network, connect, engage, educate, and learn. Pharmacy leaders can use social media as an additional tool in the leadership toolkit. This article of the Director's Forum shows how social media can assist pharmacy leaders in further developing patient-centered pharmacy services.

Bad bugs need old drugs: a stewardship program's evaluation of minocycline for multidrug-resistant Acinetobacter baumannii infections.

BACKGROUND: Minocycline is an "old-drug" with Food and Drug Administration approval for the treatment of infection due to Acinetobacter species. The purpose of this study is to describe an Antimicrobial Stewardship Program's evaluation of minocycline for the treatment of patients with multidrug resistant A. baumannii (MDR-AB) infections. METHODS: This study evaluated hospitalized adult patients (September 2010 through March 2013) who received minocycline intravenously (IV) for a MDR-AB infection. Clinical and microbiological outcomes were analyzed. Secondary outcomes included infection-related mortality, length of hospital stay (LOS), infection-related LOS, intensive care unit (ICU) LOS, mechanical ventilation days, and 30-day readmission. RESULTS: A total of 55 patients received minocycline. Median age was 56 (23-85) years, 65% were male with an APACHE II score of 21 (4-41). Clinical success was achieved in 40/55 (73%) patients treated with minocycline monotherapy (n = 3) or in combination with a second active agent (n = 52). Overall 43 (78%) patients demonstrated documented or presumed microbiologic eradication. Infection-related mortality was 25%. Hospital LOS was 31 (5-132) and infection-related LOS was 16 (2-43) days. Forty-seven (85%) patients were admitted to the ICU for a LOS of 18 (2-78) days. Thirty-nine (71%) patients required mechanical ventilation for 6 (2-29) days. One patient had a 30-day readmission. CONCLUSIONS: The response rate to minocycline monotherapy or in combination for the treatment of MDR-AB infections is encouraging as therapeutic options are limited. Prospective studies in patients with MDR-AB infections will help establish the role of minocycline alone or in combination with other antimicrobials.

Review of rapid diagnostic tests used by antimicrobial stewardship programs.

Rapid microbiologic tests provide opportunities for antimicrobial stewardship programs to improve antimicrobial use and clinical and economic outcomes. Standard techniques for identification of organisms require at least 48-72 hours for final results, compared with rapid diagnostic tests that provide final organism identification within hours of growth. Importantly, rapid microbiologic tests are considered "game changers" and represent a significant advancement in the management of infectious diseases. This review focuses on currently available rapid diagnostic tests and, importantly, the impact of rapid testing in combination with antimicrobial stewardship on patient outcomes.

Large retrospective evaluation of the effectiveness and safety of ceftaroline fosamil therapy.

Ceftaroline has been approved for acute bacterial skin infections and community-acquired bacterial pneumonia. Limited clinical experience exists for use outside these indications. The objective of this study was to describe the outcomes of patients treated with ceftaroline for various infections. Retrospective analyses of patients receiving ceftaroline ≥72 h from 2011 to 2013 were included. Clinical and microbiological outcomes were analyzed. Clinical success was defined as resolution of all signs and symptoms of infection with no further need for escalation while on ceftaroline treatment during hospitalization. A total of 527 patients received ceftaroline, and 67% were treated for off-label indications. Twenty-eight percent (148/527) of patients had bacteremia. Most patients (80%) were initiated on ceftaroline after receipt of another antimicrobial, with 48% citing disease progression as a reason for switching. The median duration of ceftaroline treatment was 6 days, with an interquartile range of 4 to 9 days. A total of 327 (62%) patients were culture positive, and the most prevalent pathogen was Staphylococcus aureus, with a frequency of 83% (271/327). Of these patients, 88.9% (241/271) were infected with methicillin-resistant S. aureus (MRSA). Clinically, 88% (426/484) achieved clinical success and hospital mortality was seen in 8% (40/527). While on ceftaroline, adverse events were experienced in 8% (41/527) of the patients and 9% (28/307) were readmitted within 30 days after discharge for the same infection. Patients treated with ceftaroline for both FDA-approved and off-label infections had favorable outcomes. Further research is necessary to further describe the role of ceftaroline in a variety of infections and its impact on patient outcomes.

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

BACKGROUND: Hospitalized neonates are vulnerable to infection and have high rates of antibiotic utilization. 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. Anonymized 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.