Identify incidence of enterococcal bacteremia and associated risk factors in ICU patients with SARS-CoV-2 infection.

Retrospective cohort study.

Veterans Affairs Medical Center, Oklahoma City, Oklahoma.

Adult ICU patients with SARS-CoV-2 and positive blood cultures for Enterococcus species between March 1, 2020 and February 28, 2022.

Durations of hospitalization, ICU stay, ventilation, site and duration of central line, receipt of steroids, tocilizumab, and antimicrobials were gathered by chart review. Patient location during a surge of bacteremia was noted and strains were identified by multilocus sequencing typing (MLST).

There were 70 episodes of enterococcal bacteremia in ICU patients with COVID-19 during a 2-year period. Patients had a median age of 72 years and 97% were male. Onset of bacteremia was 12 and 14 days after mechanical ventilation and central line placement, respectively. The median number of days to bacteremia diagnosis was 13 from admission to the ICU and 90-day mortality was 66.7% among patients admitted October to December of 2020. A large proportion of ICU patients developed enterococcal bacteremia during a COVID-19 surge (P < .00001) and an increased incidence of enterococcal bacteremia was seen September 2020—February 2021 (P < .0001) in hospitalized patients. A total of 5 unique Enterococcal strains among 13 bacteremia episodes were identified in patients with ICU beds in close proximity.

A high incidence of enterococcal bacteremia was observed in critically ill patients with SARS-CoV-2, especially during surges. Contributing factors may include environmental contamination, patient colonization, nonadherence to infection control practices, resource limitations, ICU design and use of mechanical ventilation, central lines and immunosuppressants. MLST can be used to identify clusters to address these contributing factors.

To examine the potential role of computerized clinical decision support systems (CDSS) in antimicrobial stewardship (AMS) and to identify significant challenges concerning their effectiveness and implementation.

Narrative review.

This review is based on existing literature regarding CDSS in AMS across various healthcare environments, such as hospitals and primary care facilities. The systems evaluated include both stand-alone tools and those integrated into electronic health records (EHR), featuring expert rule-based logic and new machine learning (ML) models. CDSS capabilities include prescribing guidance, alerts, resistance prediction, and de-escalation protocols.

CDSS are intended to aid in antimicrobial prescribing by integrating clinical guidelines with data specific to each patient. Despite their theoretical potential, their effectiveness is often hindered by inconsistent incorporation into clinical practices, low user engagement, and inadequate design. Many systems are reactive, not well-suited to user needs, or lack transparency in their recommendations. Evaluating these systems is challenging due to varied outcomes, poor methodological quality of studies, and the complexity of attributing causality in intricate care settings. Barriers to implementation include alert fatigue, perceived time constraints, poor fit with existing workflows, and resistance to change. Instances like the COMPASS trial demonstrate the disconnect between design and practical application, underscoring the necessity for user-focused development, clear reasoning, and a balanced approach between mandatory and advisory elements.

CDSS have the potential to improve antimicrobial use, but widespread impact is hindered by evaluation and implementation challenges. Realizing their value requires better integration, usability, and rigorous research frameworks tailored to complex healthcare settings.

Nurse practitioners, especially in remote rural areas in low- and middle-income countries, initiate treatment for numerous conditions including therapy against infections. For a sustained and meaningful reduction in antimicrobial resistance, nurse practitioners should confidently play a greater role as stewards of antibiotic therapy. Therefore, this study investigated the self-confidence level, perceptions, and professional development needs of nurse practitioners as stewards of antibiotic therapy in remote countryside areas in KwaZulu-Natal, South Africa.

Data collection took place at six healthcare facilities in rural areas in KwaZulu-Natal, South Africa. Questionnaires, with open-ended and 5-point Likert-scale-based items, were distributed to nurse practitioners employed, ie, participants, at the research sites.

One hundred and thirty (n = 130) participants filled and returned questionnaires; 31% (n = 41) and 69% (n = 89) were males and females, respectively. Over 64% (n = 83) of nurse practitioners were not aware of the extent of inappropriate utilization of antibiotics in South Africa, with a median of 3 (interquartile range (IQR 2–3). Over 70% (n = 91) of participants knew that inappropriate utilization of antimicrobials was harmful to patients, with a median of 4 (IQR 3–5). Only 30% (n = 39) of participants felt confident enough to play a meaningful role as stewards of antimicrobial therapy.

There is a need for continuous professional development programs on antimicrobial stewardship to enhance self-confidence among nurse practitioners in rural areas.

This study aimed to evaluate the role of oral antibiotic stepdown therapy in patients with uncomplicated streptococcal bacteremia. Streptococcus species are known pathogens in bloodstream infections (BSIs). Traditionally, BSIs were managed with intravenous (IV) antibiotics; however, growing literature supports oral antibiotics in invasive infections including BSIs.

This was a retrospective cohort study evaluating patients with streptococcal bacteremia between September 2019 and September 2021 at an academic safety-net hospital. Clinical outcomes were compared between patients completing treatment with IV antibiotics versus an oral stepdown regimen. The primary outcome, clinical failure, was a composite of BSI recurrence and infection-related readmission.

Adult patients with at least one positive blood culture for any Streptococcus species were included. Patients with polymicrobial BSIs or complicated bacteremia were excluded.

155 patients were included, 77 (49.7%) received a course of IV antibiotics and 78 (50.3%) received an oral antibiotic stepdown regimen. Clinical failure was not different between the IV and oral groups (15.6% vs. 15.4%, respectively; OR .99 [95% CI, .41 to 2.35]). No differences were observed in 30-day all-cause mortality. Patients that received oral antibiotics had a significantly shorter hospital length of stay by 6 days (6 vs 12 d, p < .01).

Our results suggest that an oral stepdown regimen for uncomplicated streptococcal BSIs is associated with similar outcomes compared to IV antibiotics. Furthermore, oral antibiotics may offer reduced length of stay and avoidance of outpatient central line placement in patients with uncomplicated streptococcal BSIs.

Compare the incidence of antibiotic prescribing for bronchitis and sinusitis before and after implementation of a multifaceted outpatient stewardship intervention.

Retrospective, quasi-experimental study.

Three primary care clinics within a Michigan health system.

Age 3 months and older who were diagnosed with acute bronchitis or rhinosinusitis.

Provider education paired with electronic health record order sentences for supportive care were implemented in September 2024. Patients diagnosed with bronchitis or sinusitis between October 2023 and January 2024 were included in the pre-intervention group (pre-ASP) while patients diagnosed between October 2024 and January 2025 were in the post-implementation group (post-ASP).

Total antibiotic prescribing for acute bronchitis and rhinosinusitis decreased significantly following the intervention (pre-ASP 65.6% vs post-ASP 53.9%, P = .024) and was driven by a significant reduction in prescribing for bronchitis post-ASP (36.7% vs 21.1%, P = .021). Antibiotic prescribing for rhinosinusitis decreased but did not reach statistical significance (94.4% vs 86.7%, P = .074). The relative reduction in antibiotic prescribing in the presence of a supportive care prescription for acute bronchitis was 51.2% (37.1% vs 18.1%, P = .018).

Supportive care order sentence implementation paired with provider education may be an effective outpatient stewardship practice to reduce antibiotic prescribing for URI.

Effective empiric therapy options for Staphylococcus aureus infections are limited by rising rates of resistance to non-beta lactam antimicrobial agents. The use of cumulative susceptibility testing results, antibiograms, are promoted as a tool for improving empiric therapy decisions, but it is unclear how much of the variation in antibiograms between facilities and the associated efficacy of antimicrobial agents is driven by underlying differences in patient characteristics such as comorbidities and prior antibiotic exposure.

Retrospective cohort study of 46,866 S. aureus specimens from outpatient settings of the Veterans Health Administration (VHA) from 2021 and 2022 linked to electronic health record information on patient comorbidities, prior antibiotic usage, age and gender.

Outpatient VHA clinics in the conterminous 48 states plus Washington, DC.

Hierarchical logistic regression of resistance outcomes among S. aureus specimens to determine how much variation in the likelihood of resistance to five commonly used classes of antibiotics existed after accounting for patient-level characteristics.

The likelihood of drug resistance significantly varies across the VHA’s outpatient facilities, over and above the patient case mixture seen at each facility. In particular, VHA facilities in the US South and West regions have high likelihood of antibiotic resistance after accounting for patient factors.

Suggest that community-level population or environmental characteristics are thus also associated with the likelihood of antimicrobial resistance in S. aureus. Integration of statistical and spatial analysis of antibiotic susceptibility testing results can help identify places with higher risk of drug-resistance, and thus populations facing limited treatment options, to ensure antibiotic stewardship or other policies have the greatest positive impact.

Antimicrobials are frequently prescribed to hospice patients despite limited data on their utility.1–3 The Palliative Performance Scale (PPS) has been used for survival prediction among cancer patients and further generalized to end-of-life (EOL) diagnoses.4 This study aims to identify characteristics associated with antimicrobial usage within 30 days of EOL in non-hospitalized outpatient hospice patients from a single center in the United States (US).

We analyzed data on 1,111 hospice deaths from 2019. From these data, patients were divided into two groups: those who received antimicrobials at EOL (n = 212) and equally randomly computer-generated control group who did not. Fisher’s exact test and Wilcoxon rank sum test were used for analysis. PPS was recorded and used to determine functional status; higher PPS equates to higher functional status. Multivariable logistic regression correlated patient characteristics with EOL antimicrobial status.

Higher PPS scores were significantly associated with increased likelihood of antimicrobial use (Odds Ratio [OR] 1.40, 95% Confidence Interval [CI] 1.16–1.70). Male patients (OR 0.60, 95% CI 0.40–0.90) and patients with cancer (OR 0.61, 95% CI 0.39–0.96) were associated with lower odds of receiving antimicrobials. No significant association was found with age, race/ethnicity, residence, illness, or code status.

The study identifies an association between PPS and antimicrobial prescribing near EOL. Tailoring antimicrobial use based on individual patient characteristics and goals may better align with hospice care objectives and aid in stewardship endeavors. Further research is needed to explore PPS as a potential tool to guide prescribing.

To determine the frequency and outcomes of early follow-up blood cultures (BCs) collected within 48 hours of patients being investigated for bacteremia in the emergency department (ED), as well as the number of new pathogens isolated.

Retrospective observational study of patients who had BCs collected in the ED between October 2019 and July 2020.

This study was conducted in a large, metropolitan ED with annual census of over 82,000 adult presentations. ED patients who had BCs collected during the study period were identified, and those who had BCs recollected within 48 hours were identified as having early follow-up BCs. The characteristics of these patients were compared to those without early follow-up BC collection. Logistic regression analyses were conducted to determine relationships between specific pathogens in EDBCs and early follow-up BC collection.

During the study period, 68,330 patients were treated in the ED, and BCs were collected from 1821 (2.7%). Of these, 449 (24.7%) had BCs recollected within 48 hours of their initial ED workup (early follow-up BCs) and were re-cultured 789 times across their collective stays. Five patients (1.1%) grew pathogens not isolated in EDBCs, all of which were susceptible to concurrent antimicrobials. No new pathogens were isolated in BCs taken >48 hours post ED workup.

Collection of early follow-up BCs was common. However, the rate of new pathogen growth was low and contributed minimally to patient management. Given associated costs and patient discomfort, the practice should be discouraged unless to clarify potential false positive results in ED BC.