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Background: Our antibiotic stewardship program (ASP) has decreased inpatient fluoroquinolone (FQ) consumption using a prior-authorization process and physician-led audit and feedback. The objective of this project was to examine if the decrement in FQ use was associated with improvement in the FQ sensitivity rate of selected gram-negative organisms. Method: Quarterly days of therapy standardized to 1000 care-days (DOT/1000 CD) for ciprofloxacin, moxifloxacin, and levofloxacin were calculated as the measure of inpatient FQ consumption starting from quarter three of fiscal year 2012 to the end of fiscal year 2022. To evaluate resistance patterns, facility-level sensitivity rates for ciprofloxacin and levofloxacin against Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii were collected from the antibiogram published from calendar year 2012-2022. FQ sensitivities for the first half of the study period (2012-2016) were compared to the second half (2017-2022) using Chi-square tests. Results: Inpatient FQ consumption from 2012-2022 is summarized in Figure 1. After the initiation of the ASP in 2012, a gradual and steady decline in in-patient FQ use was observed. During the first four quarters, the average FQ use was 71.3 DOT/1000 CD. Lowest use was observed during 2020 calendar year, with average consumption of 19 DOT/1000 CD. FQ consumption then increased to 30.6 DOT/1000 CD (Q2-2021 to Q4-2022). Overall, there was a decrease of 40.7 DOT/1000 CD; a 56.16% decrease in FQ consumption over the 11-year period. E. coli and K. pneumoniae sensitivity to FQs remained stable over time with a mean of 77% and 95%, respectively (see Table 1). We observed statistically significant improvements in FQ sensitivity for P. aeruginosa from 75% to 89% (p-value Conclusions: We found differing effects of decreased inpatient FQ use on antibiogram sensitivities between four gram-negative organisms. Significant improvements in FQ sensitivity were observed in P. aeruginosa and A. Baumannii reverting to high level sensitivity but not for E. coli or K. pneumoniae. These data support the effectiveness of ASPs in reducing FQ use and improving some FQ sensitivities.
Background: The 2019 American Urological Association (AUA) best practice statement for Urologic Procedures and Antimicrobial Prophylaxis recommends single-dose peri-operative antimicrobial prophylaxis (e.g. cefazolin or trimethoprim/sulfamethoxazole) not to continue past closure of the incision for Class I and II genitourinary (GU) procedures even in the presence of asymptomatic bacteriuria (ASB). Class I and II GU procedures encompass the majority of urologic procedures which are clean procedures in low risk patients and clean-contaminated procedures, respectively. The objective of this study is to assess current urologic antimicrobial prophylaxis practices at a large academic medical center. Methods: This retrospective observational study included adults who underwent a urologic procedure from September-October 2024 to assess AUA guideline adherence. Patients with a history of renal transplant, documented concern for symptoms consistent with urinary tract infection prior to the procedure, or receiving antibiotics for another condition were excluded. Both inpatient and outpatient preprocedural, intra-operative and postprocedural antibiotics were evaluated. Pre-procedural urine cultures results, attending of record, and type of procedure were correlated with prophylaxis practices using a one way ANOVA. Results: Of the 80 patients reviewed 41.3% received only single dose pre-operative prophylaxis and 57.5% received Discussion:
Nearly half of patients who underwent urologic procedures had a prophylaxis duration of < 2 4 hours in concordance with the AUA best practice recommendations. Opportunities exist for optimizing agent selection education. No difference in length of prophylaxis was found to correlate between different procedures performed. The presence of pre-operative ASB and ordering attending were found to correlate with an increased duration of prophylaxis. A future institutional practice guideline and order set for urologic procedure antimicrobial prophylaxis may be necessary to optimize agent selection and duration for these GU procedures.
Background: Hospitals have been recognized as major drivers of the deleterious environmental impacts of human industry. Intravenous (IV) therapy and its associated preparation and administration materials account for a large component of the plastic waste produced by hospitals. Switch therapy refers to transitioning antimicrobials from the IV to the enteral (PO) route. Despite this being a well-established practice, it has not been studied extensively in the context of reducing hospital-generated plastic waste. This study investigated the waste which could be avoided through optimization of IV to PO switch therapy. Method: A retrospective cohort study was performed at a large academic center in a metropolitan area. We included all adult patients receiving an IV antimicrobial with a highly bioavailable PO equivalent between October 2023 and September 2024. For a randomly selected subset of each agent we determined the total number of days during which patients would have been eligible for PO conversion based on our institution’s policy. This was used to determine the mean potential IV days of therapy (DOT) saved for each agent. The mean IV DOT saved were then extrapolated to the total number of patients receiving the corresponding antimicrobial agent over the course of the year to calculate a final estimated annual IV DOT which could be saved through optimized IV to PO switch therapy. A carbon emissions estimation tool was then used to estimate the carbon dioxide equivalents of the solid waste generated from the IV DOT saved. Result: A total of 15,037 DOT of IV antimicrobials with a highly bioavailable PO alternative were administered over the course of a year, of which an estimated 9,694 (64%) IV DOT could have been saved had appropriate switch therapy been implemented (Figure). This amounts to 2,049 kilograms of solid waste, or 0.353 metric tons of CO2 equivalents, generated through unnecessary administration of IV antimicrobials. This is equivalent to 904 miles driven, 40 gallons of gasoline consumed, 389 pounds of coal burned, or the energy required to maintain 23,392 fully depleted phone batteries at full charge throughout one day. Conclusion: Optimizing the implementation of IV to PO antimicrobial therapy can be an effective way of decreasing a hospital’s impact on the environment through reduction of solid waste generation. Future work should prioritize implementing life cycle assessments to broaden our understanding of how the use and production of IV medications impact the environment.
Background: Infection is a common and highly morbid postoperative complication in victims of physical trauma. Current literature analyzing the infectious sequelae of physical trauma predominately comes from military data, where blast trauma, rather than blunt or penetrating trauma, is most common. The epidemiology and management of infectious sequelae of civilian trauma are poorly understood, as is perioperative antimicrobial management of trauma laparotomy. Methods: We performed a single-center retrospective chart review using data from University of Chicago’s electronic medical record (Epic) and the National Trauma Registry. Patients 16 years and older admitted for level 1-2 trauma who underwent laparotomy between 5/1/2018-3/18/2023 were included. Using informatics and manual chart review, we analyzed patient demographics, rates of infection, sites of infection, timing of infection from initial trauma event, and causative organisms. We compared patients based on mechanism of injury (blunt versus penetrating) and whether patients underwent damage control laparotomy (DCL)--where the abdomen is left in discontinuity after the initial laparotomy--or single laparotomy (SL). Results: 430 patients met criteria. The median age was 30. Patients were majority Black (80.9%) and male (80.9%). 80.5% of patients had penetrating trauma, of which 90% were gunshot wounds (GSW). 19.8% had blunt trauma, of which 89% were motor-vehicle crashes (MVC). 19 (4.4%) died during initial stabilization, 199 (46.3%) underwent single laparotomy, and 212 (49.3%) underwent DCL (Figure 1). Of patients that survived initial stabilization, 27 (6.6%) developed a bloodstream infection (BSI), of which 21 (77.8%) came from the DCL group (Figures 2, 3). 19% of BSI in the DCL group were caused by yeast. 30.7% of patients developed a culture-positive surgical site infection (SSI) or intra-abdominal infection (IAI), with a rate of 40.6% in the DCL group (Table 2). Yeast were isolated in 40.5% of patients with positive cultures, 86.3% of which were isolated in the DCL group, with an overall incidence of 20.8% in the entire DCL group. Median time from arrival to infection diagnosis was 11 days. Patients generally received empiric Piperacillin-tazobactam while the abdomen was in discontinuity. Conclusions: Infection in civilian trauma laparotomy often arises as SSI or IAI, and is most pronounced in the DCL population. Yeast represents an unexpectedly high proportion of causative organisms. Further research is required to assess whether yeast burden can be mitigated by either incorporating antifungal prophylaxis at time of initial laparotomy, or by shortening empiric post-laparotomy antibiotic courses.
Background: Up to 10% of children have penicillin allergy labels, although, when tested, >95% tolerate penicillin. These labels expose children to increased risks of harm through adulthood. Professional allergy societies recommend the proactive removal of low-risk penicillin allergy labels among children by history alone or following direct oral drug challenges. However, access to subspecialty allergy testing is limited and recent studies have demonstrated that direct oral amoxicillin challenges in low-risk populations can be safely performed in pediatric primary care settings. We aimed to identify prescribers’ attitudes towards penicillin allergy delabeling and barriers and enablers to penicillin allergy delabeling in pediatric primary offices. Method: We conducted a multisite qualitative study consisting of interviews and/or focus groups with 29 primary care prescribers at 10 primary care practices of two health systems in the northeast U.S. We analyzed data using conventional content analysis and grouped barriers and enablers to penicillin allergy delabeling according to the Capability, Opportunity, and Motivation domains of the COM-B Behavior Change Wheel. Results: Prescribers agreed that unnecessary penicillin allergy labels in children should be avoided and shared their experiences delabeling penicillin allergies from history alone and collaborating with parents to trial amoxicillin in children with low-risk penicillin allergies. Predominant barriers among prescribers to penicillin allergy delabeling included insufficient capability (suboptimal knowledge and skills in penicillin allergy delabeling), poor social and environmental opportunity (parent unwillingness to trial penicillin, lack of time, inadequate office space and resources), and poor motivation (tendency to accept reported penicillin allergies due to perception that consequences of penicillin allergy are rare and distant, inherent logistical difficulties to delabel, and lack of reasons to delabel). To facilitate penicillin allergy delabeling, participants recommended the implementation of a protocol and training in penicillin allergy delabeling, interventions to engage parents in delabeling, innovative approaches to address insufficient resources and infrastructures, and amplification of reasons for primary care prescribers to delabel. We provide representative quotes of the barriers and corresponding enablers to penicillin allergy delabeling in pediatric primary care in Table. Conclusion: There is precedent for penicillin allergy delabeling in pediatric primary care. Findings indicate that prescribers are inclined to delabel low-risk penicillin allergies if given the necessary education/training, parent support, resources, and infrastructure.
Background: Candida species are increasingly causing infections and are considered high priority fungal pathogens. Despite this, published data describing the clinical importance of Candida growth in the bile tract is limited to case reports and small cohorts. Our goal is to characterize treatment outcomes of patients who had Candida spp isolated from bile cultures obtained via Endoscopic Retrograde Cholangiopancreatography (ERCP) to determine the value of antifungal use in these cases. Methods: We performed a single-center retrospective cohort study of patients with bile cultures positive for Candida spp collected during ERCPs from January 2010 to December 2023. Patients were identified by cross-matching databases of patients who underwent ERCP and patients with Candida-positive bile cultures. The treatment cohort included patients who received antifungals within seven days of the first ERCP with Candida growth in bile cultures (principal ERCP) compared to a control cohort who did not. Patients with candidemia or deep-seated candida infection prior to the principal ERCP or insufficient chart data were excluded. The primary outcome was a composite of death and/or development of invasive candida infection within one year of the principal ERCP date. Kaplan Meier plots and log-rank tests were used to analyze the primary outcome. Results: A total of 266 patients were included out of 285 with 8 being excluded for insufficient records and 11 being excluded for invasive candidiasis within one year prior. The included patient population was 60.2% male, 79.7% white, 7.9% black, and 12.4% other/unknown race and had a mean age of 63.6 +/- 15.8 years. The most common species of Candida identified were C albicans (65.9%), C glabrata (17.4%), and C tropicalis (7.2%) with 27 patients (9.2%) having 2 isolates in their culture. There were 52 patients (19.5%) who received antifungals—46 fluconazole and 6 micafungin. At one year the primary endpoint occurred in 23 out of 53 patients (43.3%) in the antifungal group and 93 out of 213 patients (43.6%) in the control group. The primary outcome was plotted on a Kaplan Meier curve. The hazard ratio was 1.14 (0.71 to 1.85, 95% CI; p=0.574) which did not reach statistical significance. Additionally, antifungal initiation had no statistically significant impact on rehospitalization rates (p=0.602), relapse of bacterial cholangitis (p=0.230), or recurrent Candida-positive bile cultures (p=0.441) within one year. Conclusions: This retrospective study of the use of antifungals in patients with Candida growing from bile cultures following ERCP found no benefit in starting antifungal treatment.
Background: Antibiotic tracking and reporting are core components of nursing home (NH) antibiotic stewardship programs. Nevertheless, how NHs conduct these essential activities remains poorly understood. The objectives of this study were to understand how NHs capture information on antibiotic use (AU) and characterize how AU is reported in Wisconsin NHs. Methods: The Antibiotic Tracking and Reporting Inventory (ATARI), a survey instrument designed to characterize the structure and process of antibiotic tracking and reporting in NHs was developed and piloted through a mixed methods approach. The instrument is organized into three sections: facility demographics, structure and process of AU data collection, and types of AU measures reported and methods of generation. After coding into REDCap, the ATARI instrument was distributed to Wisconsin NHs (n = 328) in partnership with the Wisconsin Department of Health Services. Descriptive statistics were utilized to summarize information regarding antibiotic data collection, AU reporting, and NH characteristics. Results: One hundred and thirty-two responses were received, of which 98 completed the instrument in its entirety for a final response rate of approximately 30%. Figure 1 details NH characteristics, including size and information system employed by responding facilities. Responding NHs reported devoting approximately 10 hours per week doing line listing activities and 18 hours per month in developing and disseminating reports (Figure 2). Paper and facility-developed Excel-based tools were used to conduct line listing activities in a majority of NHs, and 32 NHs employed more than one tool for this purpose (Figure 2). A majority, approximately 84%, of NHs reported at least one measure of antibiotic initiation although there was variation in whether facilities employed starts, courses, and treatment measures (Figure 3). Nineteen NHs utilize one or more report tools. A majority of NHs employed rate adjustment and stratification of their initiation measure by indication as well as appropriateness in their reports (Figure 3). In contrast a minority, 39%, of NHs reported a treatment duration measure (Figure 3). Conclusions: Wisconsin NHs devote a considerable amount of time to tracking and reporting of AU and employ a variety of low-tech tools for this purpose. There is considerable variability in the types of AU measures monitored in NHs with a majority focused on antibiotic initiation measures and lesser focus on measuring duration of therapy. These results suggest a need for standardization of AU measures in NHs as well as information systems that improve the efficiency of their collection and reporting.
Background: Gram-positive bacteremia is a challenging cause of morbidity and mortality. Past publications have shown improved patient outcomes and increased adherence to recommended standards of care with infectious disease consultation (IDC) for Staphylococcus aureus bacteremia1. Enterococcus species are another common cause of gram-positive bacteremia with significant morbidity and mortality. This study aims to assess the impact of IDC on the care of patients with Enterococcal bacteremia. Methods: A retrospective chart review was performed on 227 inpatients with at least one blood culture growing an Enterococcus species between June 2022 and November 2023. Patient characteristics collected included age, Charlson Comorbidity index, presence of endocarditis, source of bacteremia, and consultation of the inpatient ID service. Outcomes assessed included in-hospital and 30-day mortality, 30-day re-admission rate, acquisition of repeat blood cultures to document clearance of bacteremia, transthoracic (TTE) and/or transesophageal echocardiography (TEE), and anti-Enterococcal antibiotic duration. Categorical variables were compared with Chi-square or Fisher’s exact tests. Continuous variables were compared with independent t-tests or Mann-Whitney U nonparametric tests. Results: Of 227 patients, 195 (85.8%) received IDC while 32 (14.2%) did not. Patients in both groups had similar Charlson comorbidity indices. 23 (11.7%) patients had Enterococcal endocarditis, all of whom received IDC (Table 1). Patients with IDC had a significantly higher rate of acquisition of clearance blood cultures (98.96% vs. 83.87%, p 76.80% vs. 56.25%, p = .014), and TEE (20.21% vs 0.0%, P = .005) (Table 2). There were no significant differences in in-hospital mortality, 30-day mortality, 30-day re-admission rate, or duration of anti-Enterococcal antibiotics. Conclusions: These results support the conclusion that patients with Enterococcal bacteremia who received IDC were more likely to be managed according to currently recommended standards of care. In this cohort, IDC did not have a statistically significant association with differences in mortality, re-admission rate, or antibiotic duration. Patients with Enterococcal bacteremia are likely to benefit from IDC, especially as they frequently have significant life-limiting co-morbidities complicating their care. References: Vogel M, Schmitz RP, Hagel S, Pletz MW, Gagelmann N, Scherag A, Schlattmann P, Brunkhorst FM. Infectious disease consultation for Staphylococcus aureus bacteremia - A systematic review and meta-analysis. J Infect. 2016 Jan;72(1):19-28. doi: 10.1016/j.jinf.2015.09.037. Epub 2015 Oct 9. PMID: 26453841.
Background: Antimicrobial resistance (AMR) is a pressing global public health issue, and the limited development of new antibiotics necessitates robust Antimicrobial Stewardship Programs (ASP). As a global healthcare leader, IHH Healthcare successfully implemented ASP across 80 hospitals in seven countries (Singapore, Malaysia, India, Brunei, Hong Kong, China, and Turkey), aligned with the Centre for Disease Control and Prevention (CDC) Hospital ASP Core Elements, World Health Organization, and national guidelines. Method: A three-phase ASP strategy was developed following a crosswalk analysis of ASP practices across the seven countries (See Table 1): Phase 1 (2023): ASP committee establishment, terms of reference, and adoption of evidence-based guidelines. Phase 2 (2024): Guideline compliance audits, antibiogram development, resistance pattern monitoring, post-prescription audits, therapy optimization, and education. Phase 3 (2025): Antimicrobial preauthorization, infection-based interventions, and antimicrobial timeouts within 48–72 hours of initiation. Quarterly ASP meetings facilitated progress tracking and shared learning. Key metrics included guideline adherence, resistance trends, and antimicrobial utilization. Results: By 2023, all countries have established ASP committees and adopted guidelines for infections and surgical prophylaxis (see Table 2). In 2024, Phase 2 implementation (see Table 3) showed that: Guideline compliance: Regular audits monitored antimicrobial use for appropriateness, quantity, duration, and type, achieving full compliance across facilities. Education: Comprehensive initiatives included patient education on completing antibiotic regimens and continuous education for healthcare professionals. Post-prescription audits: Standardized protocols ensured systematic audits, with findings and targeted interventions shared with stakeholders. Antibiogram and resistance monitoring: Standardized antibiogram protocols monitored resistance patterns, guiding treatment decisions and policy updates. A framework for tracking key resistance organisms and hospital-acquired infections was also established. Therapy optimization: Policies required prescribers to document antibiotic doses and indications, while IV-to-oral conversion protocols reduced costs and improved outcomes. Metrics like Days of Therapy and Defined Daily Doses measured impact, with dose optimization improving treatment for resistant organisms. Conclusion: IHH Healthcare is the first large international group to adopt and implement the U.S. CDC ASP elements across its network of foreign hospitals. By utilizing a phased approach, we have ensured consistent and effective implementation across diverse healthcare settings. To date, all 80 hospitals have successfully completed Phase 2 of the program and are on track to achieve Phase 3 milestones by 2025 (see Table 4). Early outcomes from this initiative underscore the significant value of standardized ASPs in enhancing patient safety, reducing AMR and fostering sustainable quality improvement.
Background: Multidrug resistance remains one of the top global health threats and has been rising over recent decades, jeopardizing patient outcomes and increasing healthcare costs. This underscores an urgent need to design tools to optimize antibiotic prescribing to target these pathogens. Antibiograms are an essential antimicrobial stewardship tool used to provide guidance for empiric antimicrobial selection and information on local resistance. However, facility-level antibiograms are limited to individual institutions and do not reflect regional variations in resistance. Previous studies have demonstrated the feasibility and importance of generating regional antibiograms to better inform regional infection prevention and spearhead antimicrobial stewardship initiatives. Regional antibiograms also offer a valuable resource for community hospitals and health centers with lower pathogen prevalence and limited access to infectious diseases-trained personnel. This study aims to curate a regional antibiogram to analyze and understand antimicrobial susceptibility and resistance patterns of targeted pathogens across Metro Atlanta. Methods: This descriptive study aimed to evaluate antibiograms from multiple hospitals across the Atlanta metropolitan area. In September 2019, flagship hospitals of five different health-systems within metro Atlanta were surveyed using a questionnaire to collect information on basic facility and microbiology laboratory characteristics. Three health-systems responded, providing inpatient antibiogram data from the 2019 calendar year. These data were combined to create a single, cumulative antibiogram with 18 clinically relevant combinations of microorganisms and antibiotics. In total, data from 10 different hospitals were aggregated to create one regional antibiogram. Results: Data from 10 hospitals were combined to create one regional antibiogram with 18 organisms and 21 antibiotics. The overall prevalence of methicillin-resistant Staphylococcus aureus (MRSA) was 45.1% and vancomycin-resistant Enterococcus (VRE) was 15.8%, carbapenem-resistant Acinetobacter baumannii (CRAB) was 13.2%, carbapenem-resistant enterobacterales (CRE) was 1.1%, and carbapenem-resistant Pseudomonas aeruginosa (CR-PA) was 13.3%. Carbapenem resistance rates were compared between carbapenem-restrictive (n=4) and carbapenem-non-restrictive (n=2) hospitals. The prevalence of CR-PA was significantly higher in carbapenem-non-restrictive hospitals compared to carbapenem-restrictive hospitals, 19.6% vs 11.6% (p < 0 .001). Conclusion: The development of a regional cumulative antibiogram to capture resistance patterns of targeted pathogens across multiple health-systems in a large metropolitan area is feasible. Data from a regional antibiogram is useful in assessing susceptibilities and can serve as a valuable antimicrobial stewardship tool for institutions without access to their own specific antibiogram. Additionally, implementation of targeted stewardship policies, such as carbapenem restriction, demonstrates promise to potentially slow the development of resistant pathogens, thereby improving patient outcomes.
Background: Variability in outpatient parenteral antimicrobial therapy (OPAT) management and challenges to providing recommended OPAT care can compromise patient safety and care quality. Little is known about how OPAT is currently delivered by healthcare systems across the United States (US), including within the Veteran’s Health Administration (VHA). We sought to understand and compare OPAT delivery at selected Veterans Affairs medical centers. Method: Using a qualitative methodology, we conducted semi-structured interviews with key informants involved in OPAT delivery at 6 VHA medical centers with different complexity levels in the Midwestern US. Facility complexity is determined by patient volume and complexity level along with the amount of teaching and research conducted at the facility. Interviews occurred between February and December 2024 with healthcare personnel (n=30), including primary care and infectious diseases physicians, pharmacists, nursing staff, care coordinators, and vascular access providers. Data collection focused on better understanding OPAT processes within key domains of decision-making, patient education, care coordination, and post-discharge management. We used rapid analysis and a summary matrix to compare practices across sites within each domain. Result: Our findings highlight significant variability among VHA medical centers that provide OPAT to Veteran patients. Three of the 6 medical centers had dedicated OPAT programs as evidenced by a multidisciplinary team with clearly delineated roles and responsibilities, and processes that may help mitigate adverse outcomes and improve communication between providers at all OPAT care points. These processes map to the key elements outlined in the Infectious Diseases Society of America (IDSA) practice guidelines for OPAT programs, and include determination of appropriate therapy, patient education, lab monitoring, and discontinuation of treatment. (Figure 1) Conversely, at the three VHA sites without evidence of a multidisciplinary OPAT team or program, most participants described poor communication and coordination, lack of support, and uncertainty among providers about who is responsible for OPAT care. This confusion extends to follow-up and discontinuation of treatment. OPAT key elements were lacking or poorly defined. A process map helps visualize the contrasts in care between sites with and without defined OPAT programs. (Figure 1) Conclusion: Despite its centralized healthcare system, VHA medical centers demonstrate highly variable processes with respect to OPAT care. In the absence of a clear OPAT policy or program, uncertainty among providers about roles and responsibilities may be greater. The presence of a dedicated multidisciplinary OPAT team may help improve communication and care coordination, thereby minimizing quality and safety concerns.
Background: Dichotomous outcomes rarely capture the range of potential outcomes important to patients and clinicians. To address this limitation, the Desirability of Outcome Ranking (DOOR) score was created to rank potential outcomes from least to most desirable. Currently, there is no standardized method to develop a DOOR score and data are limited on whether patients and their clinicians rank outcomes similarly. We aimed: (a) to develop a novel DOOR score for adults hospitalized with community-acquired pneumonia (CAP) by surveying patients and clinicians on their preferred outcome ranking and (b) to compare their relative DOOR rankings. Methods: We created nine clinical scenarios describing the spectrum of potential outcomes of patients with CAP two weeks after initial emergency department visit. To ascertain clinician DOOR score, we used a snowball sampling method to recruit a target of 25 clinicians in specialties that regularly treat CAP. For the patient DOOR score, we recruited patients hospitalized with CAP by reviewing electronic patient lists for adults hospitalized with pneumonia. Respondents were asked to rank the 9 cases from most to least desirable in REDCap. To create the final DOOR score, we used Friedman rank sum tests to combine/collapse DOOR outcomes with scores that did not significantly differ. We used the Mann Whitney U test to compare DOOR rankings between physicians and patients. Final study results were presented to a national hospital medicine patient and family advisory committee (PFAC) for their impressions. Results: 22 patients (71% response rate) and 25 clinicians responded to our DOOR survey. Their ranked order of DOOR outcomes is shown in Table 1. Combining non-significantly different DOOR outcomes resulted in collapsing of 6 cases into 2 categories for 5 overall DOOR scores that significantly differed from each other (Table 1 for final ranking). Patients and clinicians had significantly different preferred ranking for 6 DOOR cases. Our PFAC had several hypotheses as to why rankings differed (Table 2). Conclusion: We present a novel DOOR score derived from patient and clinician reported preferences for outcomes of hospitalized adult patients with CAP. Clinicians and patients differed in their perception of certain outcomes with patients ranking symptoms that were uncomfortable but not potentially life-threatening as less desirable than physicians. Physicians tended to rank quality linked metrics such as readmission as worse than patients. When designing future trials using DOOR scores, researchers should consider including patients in DOOR score design as their perspectives may differ from clinicians.
Background: Clinicians have variable prescribing practices for treating urinary tract infections (UTI), resulting in broader and longer treatment durations than necessary. In March 2023, guidelines for UTI treatment were developed and disseminated across our hospital system. Methods: We evaluated inpatients at Emory University Hospital (EUH) who received antibiotics with an indication of UTI between November 2022 and March 2024 to investigate implementation effect on treatment duration and choice. We characterized days of therapy (DOT) by performing interrupted time series analysis, adjusting for demographic and clinical variables. Additionally, we looked at percent use of guideline concordant antibiotics chosen before and after implementation. Results: A total of 978 cases of UTIs were evaluated pre-guideline implementation among 621 (63.5%) females with 490 (50.1%) Black patients. A total of 1420 cases of UTIs were evaluated post-guideline implementation among 843 (59.4%) females with 693 (48.8%) Black patients. With inpatient UTI DOT, following implementation there was an increase by 31.5 DOT/month with a sustained increase by 6.25 DOT/month with no statistically significant change. Total UTI DOT (including outpatient) showed a sustained decrease by 21.1 DOT/month with no overall statistical significance. With inpatient UTI guideline concordance, following implementation there was an increase by 2.5% per month with a sustained increase by 0.7% per month with no statistically significant change. Total UTI guideline concordance (including outpatient) showed a sustained increase by 1.4% per month with no overall statistical significance. Conclusion: Guideline implementation for UTI treatment did not lead to statically significant change in DOT or guideline concordant prescribing at EUH.
Background: Since 2013, the Australian Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) has provided a standardized framework for hospitals to assess the quality of antimicrobial prescribing. As part of the program’s continuous quality improvement, a revised appropriateness algorithm was developed and is scheduled for implementation in 2025. This study aims to validate this algorithm by evaluating accuracy and inter-rater reliability (IRR) in assessing guideline concordance and appropriateness. Methods: A prototype of the revised assessment algorithm was developed using Qualtrics®, including an assessment of antimicrobial-level guideline concordance, appropriateness and reasons for non-optimal prescribing, as well as overall indication-level guideline concordance and appropriateness. An eLearning module was developed to ensure consistency of training for assessors. Fourteen clinical vignettes (ten general and four specialist) across a range of real-world clinical scenarios and with varying levels of complexity were developed. Gold standard assessments were determined by an independent group of infectious diseases (ID) and antimicrobial stewardship (AMS) clinicians. Existing Hospital NAPS users were invited to participate. General vignettes were split into two equal groups and assigned to assessors in an alternating manner. Those with expertise in haematology/oncology or paediatrics were assigned additional specialist vignettes. Results were analyzed for accuracy against the gold standard, and for IRR using Fleiss’ Kappa coefficient. Results: A total of 102 assessors, across a range of professions, remoteness areas and years of auditing experience, completed their assigned vignettes. Assessors correctly identified the antimicrobial regimen for auditing in 91.9% of assessments, with incorrectly identified assessments excluded. A total of 681 antimicrobial-level and 534 indication-level assessments were analyzed. Figure 1 summarizes the accuracy and IRR for the main outcome measures of guideline concordance and appropriateness. Accuracy and IRR were higher for appropriateness compared with guideline concordance, and at the overall indication-level compared with the antimicrobial-level. Auditors correctly identified all gold-standard reasons for non-optimal prescribing in 68.3% of assessments. Across all measures, accuracy and IRR was higher amongst assessors with specialist ID/AMS experience compared to those without, from metropolitan compared with regional settings, and amongst those with 4 or more years of auditing experience. Pharmacists without ID/AMS expertise scored as highly as doctors and pharmacists with ID/AMS expertise. Conclusion: The revised Hospital NAPS algorithm provides a valid measure of guideline concordance and appropriateness. Higher accuracy and IRR were observed for appropriateness compared with guideline concordance, highlighting the importance of appropriateness as a measure for stewardship surveillance in reflecting quality of patient care.
Introduction: Although most rhinosinusitis cases are viral, misdiagnosis of an underlying bacterial cause is common, leading to excessive antibiotic utilization. Interventions to improve diagnosis and prescribing for sinusitis may reduce antimicrobial resistance and improve patient outcomes. Methods: Antibiotic prescriptions by 237 URMC Primary Care Network(PCN) clinicians between 9/1–11/31/2022 (baseline n=23,048) and 12/1/2023–2/29/2024 (post-intervention n=18,885) were extracted as part of a network-wide education and prescription feedback intervention focusing on antibiotic utilization rates, and guideline-concordant prescribing for sinusitis defined from local antibiograms and national guidelines. Random subsets of pre- and post-intervention prescriptions (250 each period for 90% power, Type I alpha=0.05) were systematically reviewed by two medical student or resident reviewers, with adjudication of discrepancies by infectious diseases-trained clinicians for 1) appropriate diagnosis of bacterial infection, 2) antibiotic selection, and 3) treatment duration. Charts were also reviewed for treatment failure requiring course extension, urgent care or emergency department utilization, hospital admission, and antibiotic-related toxicity during therapy or within 30 days of conclusion. Statistical analysis was performed in GraphPad and Excel ver. 2408. Results: Correct use of diagnostic criteria increased from 52.8% to 63.6% (p<0.01) post-intervention, a 10.8% absolute and 20.4% relative increase in appropriate diagnosis of bacterial sinusitis. Although rates of guideline-concordant treatment duration remained similar (74% vs. 74.4%, p=0.92), appropriate antibiotic selection increased from 71.6% to 85.6% (p< 0.01) (Fig. 1), and complete concordance of both spectrum and duration increased from 49.6% to 60.8% (p=0.012). Rates of antibiotic-associated adverse events requiring treatment discontinuation were similar pre- and post-intervention (Table 1). There were no Clostridium difficile infections. Health care contact beyond the prescribing office increased post-intervention (p < 0.01) (Table 1) but this was unrelated to sinusitis or antibiotic treatment complications (Fig. 2). Conclusions: A large-scale network intervention significantly improved use of diagnostic criteria and appropriate treatment of acute bacterial sinusitis without negatively impacting the incidence of treatment- or infection-related complications.
Background: It is estimated that 28% of all oral antibiotics prescribed in outpatient care in the United States are inappropriate.1 Most hospitals have established antimicrobial stewardship programs (ASPs) that focus on inpatient antimicrobial stewardship2,3 however, less is known about the engagement of hospital ASPs in outpatient clinics. The goal of this project was to explore the extent to which ASP activities in hospital affiliated clinics align with current guidance for outpatient antibiotic stewardship and challenges to applying hospital based interventions in outpatient settings. Methods: The study population comprised 288 hospitals that participated in two previous antimicrobial stewardship studies4. Hospitals needed to have an active outpatient ASP to be included. We conducted in-depth telephone interviews with ASP leaders from 28 diverse hospitals. We used MAXQDA 20225 for data analysis and the framework method6 to organize and analyze interview transcripts based on 4 CDC Core Elements for Outpatient Stewardship.7 Results: The sample included 11 large, 9 medium, 8 small hospitals with various outpatient settings (Figure 1). Commitment. Few hospital ASPs had a dedicated outpatient stewardship leader. Around half the hospitals included outpatient sub-committees or representatives on the ASP committee. Only one hospital had a formal stewardship lead at the clinics while others relied on local contacts and EHR system-based interventions. Tracking and reporting. Most hospitals in the sample reviewed outpatient specific data, though many had no data analyst or IT resources for outpatient data. Action. Hospitals in our sample differed widely regarding development of decision-support tools. Only some developed guidelines tailored to outpatient settings, a few of them distributed via CDSS requiring indications for prescriptions, whereas others simply made inpatient guidelines available to clinicians. Education. Only some hospital ASPs developed content tailored for outpatient. Key challenges for expansion of stewardship into outpatient settings included lack of funding, and dedicated staff; lack of clarity regarding best practices for measurement; and an outpatient EHR infrastructure that limited effective guideline distribution and measurement. Conclusions: Outpatient stewardship programs were aligned with current guidance, although frequently missing outpatient-specific committee representation, data and education. Few hospitals received additional resources for expansion into outpatient stewardship and most lacked dedicated leaders at clinics, putting additional burden on inpatient ASP leads. While some hospitals have developed guidelines, tracked prescriptions, and provided clinic or clinician feedback, there is need for investment in staff and EHR infrastructure to improve outpatient-specific guideline development, distribution and measurement.
