Culture data may help determine antibiotic administration options for nonoperative complicated appendicitis. Variability exists in treatment strategies, from solely using intravenous therapy, including outpatient parenteral antibiotic treatment (OPAT), to transitioning to oral (PO) antibiotics. We hypothesize that most patients have an oral antibiotic option based on culture results and that there is no increased rate of readmission due to treatment failure with oral antibiotics.

This was a single-center retrospective cohort study reviewing antibiotic treatment of pediatric patients treated with nonoperative management for complicated appendicitis with abscesses percutaneously drained by Interventional Radiology (IR). We compared case-mix demographic variables, choice and route of antibiotic therapy, culture data, and clinical outcomes between those who exclusively received parenteral antibiotics therapy (PAT) and those who were switched to oral therapy (PO).

We identified 54 cases of nonoperative complicated appendicitis who underwent IR abscess drainage from 2014 to 2019. Forty-five [83%] patients completed therapy with PAT and 9 with PO; forty-six of 54 patients (85%) patients had an oral antibiotic(s) option based on sensitivities. Readmissions and complications included 6 (11%) patients. Three (50%) patients were readmitted due to antibiotic treatment failure with worsening of abscess formation, 2 due to PICC (peripherally inserted central catheters) issues, and 1 due to a drug reaction.

Most patients with nonoperative complicated appendicitis can be transitioned to oral antibiotic options based on the culture susceptibility profiles.

To identify institution-specific risk factors for extended-spectrum beta-lactamase (ESBL) bloodstream infections (BSI) to develop and validate a risk assessment scoring tool that can be utilized for hospitalized patients.

Single-center, retrospective, case-control study.

Tertiary teaching hospital.

Hospitalized adult and pediatric patients with E. coli or Klebsiella spp. BSI were stratified based on ESBL production between August 2019 to July 2021. Exclusion criteria included patients < 28 days old, a positive blood culture resulting prior to admission/after discharge or a polymicrobial and/or carbapenem-resistant BSI.

Multivariable logistic regression assessed predictors of ESBL in a derivation cohort. Predictors were applied to a novel validation BSI cohort using area under the receiver-operator characteristics curve (ROC AUC) to assess the reliability of identifying patients likely to harbor ESBL at the time of organism identification.

A total of 238 patients in the derivation cohort met inclusion criteria stratified as ESBL (n = 68) or non-ESBL (n = 170). Multivariable logistic regression demonstrated diabetes, 30-day history of invasive procedure or antibiotic use, and/or history of ESBL as independent predictors of ESBL. After creation of an ESBL risk assessment tool, the results were applied to a validation cohort of 170 patients. This model displayed good calibration and discrimination with a strong predictive power (Hosmer-Lemeshow χ2= 4.66, p = 0.19; ROC AUC = 0.88, 95% CI = 0.7909 – 0.974).

A validated ESBL risk assessment tool reliably identified hospitalized patients likely to harbor ESBL E. coli or Klebsiella spp. BSI upon organism identification.

To describe inpatient clinical pharmacists’ interventions on injectable antibiotics and assess their impact on prospective audit and feedback (PAF) by the antimicrobial stewardship program (ASP).

Retrospective cohort study.

Freestanding, quaternary-care, pediatric and obstetric hospital.

We identified all clinical pharmacist interventions (iVents) documented on injectable antibiotics from November 1, 2020, through October 31, 2022. PAF performed on injectable antibiotics during the same timeframe was captured. We reported characteristics of clinical pharmacist iVents on injectable antibiotics. We also compared the incidence of PAF recommendations (PAFR) between PAF cases with prior iVent documentation for the same patient and antibiotic and those without preceding iVent documentation.

A total of 5,277 iVents were documented on injectable antibiotic orders. Cefazolin had the highest volume of iVents (13%). Antibiotic dose optimization was the most frequent iVent type (34%). A total of 5,152 PAF were documented by ASP pharmacists on injectable antibiotics during the study period, with 1,782 (34%) resulting in a PAFR. A total of 999 PAF (19%) had a prior iVent; 4,153 PAF did not. Comparing the two groups, the incidence of a PAFR was significantly higher in the PAF with prior iVent group compared to the PAF without prior iVent group (383/999, 38% vs 1,399/ 4,153, 34%; P = 0.006). Antibiotic discontinuation was the most common type of PAFR in both groups.

Clinical pharmacists serve as ASP ambassadors, intervening on injectable antibiotic orders to improve prescribing. Future efforts to expand and incorporate clinical pharmacists in ASP initiatives are warranted.

To evaluate the connection between non-critically ill hospitalized patients and the acquisition of carbapenem-resistant Enterobacterales (CRE).

An observational prospective cohort study from January 2018 to December 2019.

A single tertiary referral center.

Non-critically ill subjects admitted to general medical wards who received antimicrobial therapy <48 h.

Rectal swab cultures at admission and weekly for CRE surveillance. CRE isolates were confirmed using carbapenem disk diffusion susceptibility and genotypic carbapenemase testing. Clinical characteristics and outcomes were also evaluated.

Of 110 subjects, 66.4% were women, the mean age was 67 years, and 336 bacterial isolates were detected from rectal swab cultures. 55 (16.4%) isolates from 25 subjects exhibited phenotypic resistance to carbapenem. Klebsiella pneumoniae (50.9%) and Escherichia coli (30.9%) were common CRE, harboring New Delhi metallo-beta-lactamase (NDM) (50.9%), oxacillinase-48 (OXA-48) (12.7%), and co-NDM/OXA-48 (20.0%). Subjects with acquired CRE had higher APACHE II scores (P = 0.030), received piperacillin-tazobactam (P = 0.004), underwent prolonged antimicrobial therapy (P = 0.009), and experienced longer hospital stays (P = 0.001) compared to CRE-negative subjects. None of the CRE-positive subjects developed an acquired infection.

Acquired CRE colonization is prevalent among non-critically ill patients. Factors such as disease severity, the type and duration of antimicrobial therapy, and the length of hospital stays may increase the risk of CRE acquisition in non-critically ill populations.

Socioeconomic deprivation has been associated with antibiotic overprescription in the US; however, prior studies could not quantify a causal relationship due to endogeneity. This study examines how socioeconomic deprivation is related to the rate of antibiotic days supplied to older Medicare Part D beneficiaries, utilizing an Instrumental Variable (IV) approach.

Data from the Medicare Part D and the Social Deprivation Index (SDI) repositories were analyzed. To address potential endogeneity and omitted variable bias in the relationship between SDI and antibiotic prescribing, we used the maximum Earned Income Tax Credit as an IV. Bivariate Moran’s I assessed the spatial correlation between SDI and antibiotic prescribing across geographic regions. The IV analysis then examined the relationship between predicted SDI and antibiotic days supplied (ln). Linear regression models estimated associations between SDI and its components, and antibiotic days supplied, adjusting for prescriber, beneficiary, and geographic factors.

Among 161,164, there was no significant spatial dependence between SDI and antibiotic days supplied (P = 0.0656). In the IV model, a one-unit increase in SDI was associated with a 0.582 (SE = 0.164, P < 0.0005) increase in antibiotic days supplied (ln). Higher unemployment and single-parent family rates were linked to increased antibiotic days supplied, while crowded housing was associated with a reduction.

This study identified that socioeconomic deprivation may influence antibiotic days supplied to Medicare Part D beneficiaries. Findings highlight the need for targeted public health interventions to address the socioeconomic factors contributing to excess antibiotic use.

To evaluate the impact of implementing a multi-step Clostridioides difficile infection (CDI) testing algorithm on hospital-onset (HO)-CDI rates and clinical outcomes.

Retrospective pre-intervention/post-intervention study.

Two academic hospitals in Pittsburgh, Pennsylvania.

In the pre-intervention period, a standalone polymerase chain reaction (PCR) assay was used for diagnosing CDI. In the post-intervention period, positive PCR assays were reflexed to a glutamate dehydrogenase antigen test and an enzyme immunoassay for toxin A/B.

The implementation of a multi-step testing algorithm resulted in a significant reduction in HO-CDI cases per 10,000 patient days from 5.92 to 2.36 (P < 0.001). Despite the decrease in reportable HO-CDI cases, there were no significant differences in clinical outcomes such as hospital length of stay, intensive care unit admissions, and treatment courses. In addition, there was a significant reduction in all-cause 30-day readmissions in the post-intervention group, though CDI-related readmissions remained similar.

The multi-step testing algorithm significantly reduced HO-CDI rates without compromising clinical outcomes. The study supports the use of a multi-step CDI testing algorithm to assist healthcare providers with CDI management decisions and potentially to reduce financial penalties burdened on healthcare systems.

Antimicrobial resistance (AMR) is a major global health threat with a projected 10 million deaths globally by 2050. Antimicrobial stewardship (AMS) programs are coordinated efforts involving doctors, nurses, pharmacists, and other healthcare providers. Understanding knowledge, attitudes, and practices of health providers is pivotal for implementing strategies to curb the spread of AMR. The aim of this study was to evaluate knowledge, attitudes, and practices surrounding AMR and AMS among healthcare workers in Kenya.

A qualitative study using in-depth semi-structured interviews

12 private outpatient clinics in Kenya.

Healthcare workers including administrators and clinicians.

A thematic analysis approach was used; the Capability, Opportunity, and Motivation for Behavior model was used to understand the knowledge, attitudes, and practices surrounding AMR and AMS.

Twenty-four participants were interviewed. They had some knowledge regarding AMR but lacked knowledge about AMS and its components. Although participants did not perceive AMR as a problem in their clinics, they reported it was a major problem in the country and globally. There was lack of prioritization of AMS in the clinics.

The lack of knowledge on AMS and its components coupled with failure to recognize AMR as a problem in the facilities led to a lack of prioritization of AMS. There is therefore an urgent need to educate healthcare administrators and clinicians on AMR and AMS to foster a sense of ownership of the problem of AMR and to be pro-active in implementing measures to curb it.

Antibiotics overuse leads to bacterial resistance. The biomarker procalcitonin rises with bacterial pneumonias and remains normal in viral respiratory tract infections. Its use can distinguish between these etiologies and thus guide antibiotics use. We aimed to quantify the effect of procalcitonin use on clinical decision-making.

A retrospective study, spanning a year at a tertiary care center, where 348 patients hospitalized with aspiration pneumonia and 824 with non-aspiration pneumonia were evaluated with regards to procalcitonin use, the length of stay (LOS) and antibiotics prescribing practices. Descriptive statistics and univariate analyses were applied to the ensemble data. Subsets of cases were manually reviewed and analyzed with descriptive statistics. P < 0.05 indicated statistical significance.

21% of both the aspiration and non-aspiration pneumonia cases had procalcitonin checked. In the ensemble analyses, a check of procalcitonin was more likely to happen in prolonged hospitalizations with aspiration pneumonia. The LOS was statistically the same regardless of procalcitonin results (elevated or normal) for both the aspiration and non-aspiration pneumonia cohorts. The overall use of antibiotics was not affected by the procalcitonin results. After excluding two extreme outliers, the per-person antibiotics cost was not affected by the procalcitonin results. Detailed chart reviews of 33 cases revealed that for the vast majority, the procalcitonin results were not used by clinicians to guide the duration of antibiotics use.

Despite its promise as a biomarker for antibiotics stewardship, procalcitonin results appeared to not be utilized by clinicians as a decision-making tool in the management of pneumonia.

To compare clinical failure of intravenous vs intravenous with oral step-down antibiotic treatment for Streptococcus and Enterococcus bloodstream infection.

Multicenter, retrospective, cohort study at one academic medical center and eight community hospitals.

Hospitalized adult patients with blood cultures positive for Streptococcus or Enterococcus were included. Patients were excluded if they had complicated infection, had polymicrobial bacteremia, received less than 5 days of therapy, or died before completing therapy.

Patients who completed intravenous therapy were compared with patients who transitioned to oral therapy after 3 to 7 days. The primary endpoint was clinical failure, defined as 90-day all-cause mortality or recurrent bacteremia. The primary analysis excluded patients with unknown outcomes, and the sensitivity analysis treated them as failures.

429 patients were included (intravenous group: n = 225; oral step-down group; n = 204). The intravenous group had more comorbidities and vasopressor use. The intravenous group had a higher risk of clinical failure in the primary analysis (17.5% vs. 8.8%; adjusted OR 2.14 [95% CI, 1.09–4.2]; p = 0.03) while the sensitivity analysis found no difference in clinical failure (adjusted OR 1.1 [95% CI, 0.69–1.74], p = 0.69). The oral step-down group had a mean length of stay of 9.2 days shorter than the intravenous group ([95% CI, 7.5–11.0]; p<0.001).

Oral step-down therapy was not associated with an increased risk of clinical failure compared to a full course of intravenous therapy for uncomplicated Streptococcus and Enterococcus bloodstream infections. Patients with more comorbidities or who required vasopressors were less likely to be switched to oral therapy.

Overtreatment of asymptomatic bacteriuria (ASB) is a major cause of antibiotic overuse. We facilitated a nationwide implementation of an ASB antimicrobial stewardship intervention in 41 Veterans Affairs facilities. Twenty-one sites participated in a Virtual Learning Collaborative (VLC) with monthly webinars. We assess what VLC teams learned from one another in these webinars.

The bi-monthly VLC webinars featured expert presentations and spotlighted 1–2 site teams, asking them to discuss their barriers and facilitators for the intervention. Data come from analyses of descriptive field notes from the webinars and chat transcripts. Field notes were analyzed using the “sort and sift, think and shift” method. We sorted and labeled common strategies thematically, sifted through illustrative quotes, and iteratively discussed the results to reach consensus.

Across 22 webinars (August 2023–April 2024), sites discussed different resources, team membership, and organizational structures. Sites had to “tailor swiftly” to their site needs and target audiences by adapting educational materials for timing, length, audience, and outreach location. Sites used five tailoring strategies to implement the antimicrobial stewardship program: Organizational and Structural Strategies, Recruitment Strategies, Data- and Information-Based Strategies, Interpersonal Strategies, and Resource Provision.

VLC webinars allowed sites to share tips and strategies for the implementation of a nationwide antimicrobial stewardship program wherein rapid tailoring and local adaptations were effective. Our supportive approach to tailoring allowed implementation sites to adapt antimicrobial stewardship materials and intervention delivery to their different resources and organizational contexts.

It is unknown how providers are utilizing procalcitonin in the real world to make antibiotic prescribing decisions, and whether procalcitonin can limit harms related to antibiotic misuse. We examined how the probability of receiving antibiotics changed just below and above the pre-specified procalcitonin cut-points. We sought to understand whether providers interpret procalcitonin as a dichotomous or continuous diagnostic test.

Retrospective cohort study.

We included adult inpatients who had procalcitonin collected as part of routine care. Patients with procalcitonin collected more than 48 hours after the first antibiotic dose, those discharged from the emergency department, or those on an obstetrics service were excluded.

We used administrative data from the Health Data Compass database (2018-2019) at the University of Colorado Hospital to examine the correlation of pre-specified procalcitonin cut-points (0.1, 0.25, and 0.5 ng/mL) with the antibiotic treatment decisions using a regression discontinuity analysis (RDA), stratified by level of care. We constructed receiver operating characteristic (ROC) curves depicting the relationship between procalcitonin level and antibiotic prescribing. We performed sensitivity analyses by varying bandwidth for RDA.

The study included 4383 patients. A total of 68.9% received a full antibiotic course. RDA did not demonstrate any discontinuity at the pre-specified cut-points. However, sensitivity analyses showed a potential discontinuity at the 0.25 ng/mL cut-point in the ICU subgroup. The ROC curves were consistent with the RDA findings.

This study suggests that most clinicians in real-world settings interpret procalcitonin as a continuous diagnostic test when prescribing antibiotics.