Promoting Antibiotic Stewardship

Antibiotics are not always prescribed optimally in the outpatient setting for common respiratory illnesses. Providers also spend time reiterating the same facts to patients about antibiotics and why their use is not warranted for their common cold symptoms. By providing a visual aid that can capture the attention of patients and present concise, easy to retain facts, we may lessen the amount of time providers spend counseling. At the same time, we are able to get patients to contribute to the fight against antibiotic overuse, antimicrobial resistance, and healthcare associated infections.https://scholarworks.uvm.edu/fmclerk/1280/thumbnail.jp

Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study.

Recently, the Centers for Medicare & Medicaid Services (CMS) final rule required that nursing homes (NHs) develop an infection control program that includes an antibiotic stewardship component and employs a trained infection preventionist (IP). The objectives of this study were to provide a baseline assessment of (1) NH facility and infection control program characteristics associated with having an infection control deficiency citation and (2) associations between IP training and the presence of antibiotic stewardship policies, controlling for NH characteristics. A cross-sectional survey of 2514 randomly sampled US NHs was conducted to assess IP training, staff turnover, and infection control program characteristics (ie, frequency of infection control committee meetings and the presence of 7 antibiotic stewardship policies). Responses were linked to concurrent Certification and Survey Provider Enhanced Reporting data, which contain information about NH facility characteristics and citations. Descriptive statistics and multivariable regression analyses were conducted to account for NH characteristics. Surveys were received from 990 NHs; 922 had complete data. One-third of NHs in this sample received an infection control deficiency citation. The NHs that received deficiency citations were more likely to have committees that met weekly/monthly versus quarterly ( P \u3c .01). The IPs in 39% of facilities had received specialized training. Less than 3% of trained IPs were certified in infection control. The NHs with trained IPs were more likely to have 5 of the 7 components of antibiotic stewardship in place (all P \u3c .05). The IP training, although infrequent, was associated with the presence of antibiotic stewardship policies. Receiving an infection control citation was associated with more frequent infection control committee meetings. Training and support of IPs is needed to ensure infection control and antibiotic stewardship in NHs. As the CMS rule becomes implemented, more research is warranted. There is a need for increase in trained IPs in US NHs. These data can be used to evaluate the effectiveness of the CMS final rule on infection management processes in US NHs

Antibiotic Prescribing Practices of Filipino Dentists

There are reports that dentists overprescribe antibiotics which may contribute to antibiotic resistance. This is an exploratory study on antibiotic prescribing practices of Filipino dentists using an online platform to form a basis for antimicrobial stewardship policy for dentists. A link to an online questionnaire using Survey Monkey was posted in a Closed Group Facebook account of Filipino dentists. Two hundred thirty (230) dentists participated. Data was analyzed by Survey Monkey. Amoxicillin is the first choice of antibiotics(71.18%), andclindamycin is the second (57.27%). Most respondents follow the indications for antibiotic therapy, however, some will prescribe antibiotics for conditions without indications. For dental procedures, 88.99% will prescribe for periodontal surgery, 75.45% for endodontic surgery, 68.3% for extraction of a tooth with chronic infection, 87.17% for third molar surgery, 26.7% for routine endodontics, and 23.56% for periodontal treatment without surgery. Not all of the respondents would prescribe for medical conditions that require antibiotic prophylaxis, while 60.36% will prescribe when in doubt in diagnosis, under time pressure (25.68%), and 48.67% considers patient preference. Only 10.48% of the respondents are very familiar with antimicrobial stewardship, while majority (69.74%) have not attended a lecture for antimicrobial stewardship for dentists.There is inappropriate antibiotic prescribing of participants on certain dental diseases, procedures, and medical conditions. Most respondents are not very familiar and have not attended a lecture on antimicrobial stewardship for specifically for dentists

Antibiotic Stewardship Implementation and Antibiotic Use at Hospitals With and Without On-site Infectious Disease Specialists.

BackgroundMany US hospitals lack infectious disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist.MethodsThis retrospective VHA cohort included all acute-care patient admissions during 2016. A mandatory survey was used to identify hospitals' antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy per days present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient admissions.ResultsEighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525 451 (95.8%) admissions at ID hospitals and 23 007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use (odds ratio, 0.92; 95% confidence interval, .85-.99). Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials (0.61; .54-.70) and higher narrow-spectrum β-lactam use (1.43; 1.22-1.67). Total antibacterial exposure (inpatient plus postdischarge) was lower among patients at ID versus non-ID sites (0.92; .86-.99).ConclusionsPatients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship

Antibiotic stewardship implementation and patient-level antibiotic use at hospitals with and without on-site Infectious Disease specialists.

Many US hospitals lack Infectious Disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist. This retrospective VHA cohort included all acute-care patient-admissions during 2016. A mandatory survey was used to identify hospitals' antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy (DOT) per days-present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient-admissions. Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525,451 (95.8%) admissions at ID hospitals and 23,007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use [OR 0.92, (95% CI, 0.85-0.99)]. Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials [OR 0.61 (95% CI, 0.54-0.70)] and higher narrow-spectrum beta-lactam use [OR 1.43 (95% CI, 1.22-1.67)]. Total antibacterial exposure (inpatient plus post-discharge) was lower among patients at ID versus non-ID sites [OR 0.92 (95% CI, 0.86-0.99)]. Patients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship

Expected Practice as a Novel Antibiotic Stewardship Intervention.

"Expected practice" is a recently described method to alter clinical behavior. We implemented an expected practice around short-course antibiotic therapy, which was associated with decreased antibiotic utilization for multiple bacterial infections. Thus, we describe this expected practice as a novel, simple, and inexpensive tool to enhance antibiotic stewardship

Prioritising research areas for antibiotic stewardship programmes in hospitals: a behavioural perspective consensus paper

SCOPE: Antibiotic stewardship programmes (ASPs) are necessary in hospitals to improve the judicious use of antibiotics. While ASPs require complex change of key behaviours on individual, team, organisation and policy levels, evidence from the behavioural sciences is underutilised in antibiotic stewardship studies across the world, including high-income countries (HICs). A consensus procedure was performed to propose research priority areas for optimising effective implementation of ASPs in hospital settings, using a behavioural perspective. METHODS: A workgroup for behavioural approaches to ASPs was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). Eighteen clinical and academic specialists in antibiotic stewardship, implementation science and behaviour change from four high-income countries with publicly-funded health care systems (that is Canada, Germany, Norway and the UK), met face-to-face to agree on broad research priority areas using a structured consensus method. QUESTION ADDRESSED AND RECOMMENDATIONS: The consensus process on the 10 identified research priority areas resulted in recommendations that need urgent scientific interest and funding to optimise effective implementation of antibiotic stewardship programmes for hospital inpatients in HICs with publicly-funded health care systems. We suggest and detail, behavioural science evidence-guided research efforts in the following areas: 1) Comprehensively identifying barriers and facilitators to implementing antibiotic stewardship programmes and clinical recommendations intended to optimise antibiotic prescribing; 2) Identifying actors ('who') and actions ('what needs to be done') of antibiotic stewardship programmes and clinical teams; 3) Synthesising available evidence to support future research and planning for antibiotic stewardship programmes; 4) Specifying the activities in current antibiotic stewardship programmes with the purpose of defining a 'control group' for comparison with new initiatives; 5) Defining a balanced set of outcomes and measures to evaluate the effects of interventions focused on reducing unnecessary exposure to antibiotics; 6) Conducting robust evaluations of antibiotic stewardship programmes with built-in process evaluations and fidelity assessments; 7) Defining and designing antibiotic stewardship programmes; 8) Establishing the evidence base for impact of antibiotic stewardship programmes on resistance; 9) Investigating the role and impact of government and policy contexts on antibiotic stewardship programmes; and 10) Understanding what matters to patients in antibiotic stewardship programmes in hospitals. Assessment, revisions and updates of our priority-setting exercise should be considered, at intervals of 2 years. To propose research priority areas in low- and medium income countries (LIMCs), the methodology reported here could be applied

An evaluation of antimicrobial stewardship in community pharmacy

This study investigated several aspects of antimicrobial stewardship by gathering information from community pharmacists and members of the public. The aim was to identify how community pharmacists implement antimicrobial stewardship guidelines and influence patients on the use of antibiotics. This study required and received approval from the University of Huddersfield Ethics Committee. Information and opinions of community pharmacists in the Kirklees and Calderdale areas, and surrounding local areas, and of members of the public in Huddersfield town centre, were gathered using two different questionnaires. These focused on initiatives regarding antibiotic resistance, development of the competencies required for medicines optimisation and antimicrobial stewardship, patient education by pharmacists, monitoring of antibiotic prescribing and pharmacy access to records. The results obtained were then analysed. The study consisted of 50 participating pharmacists and 100 participating members of the public. It was identified that eight pharmacists had undertaken recent professional development regarding antimicrobial stewardship, 11 had made an Antibiotic Guardian pledge and eight monitored antibiotic prescribing. It was also discovered that, when handing out a prescription for antibiotics, five pharmacists (all of whom work in an independent pharmacy) always questioned the indication and seven always provided extra self-care information. Finally, 92 members of the public selected that they would be comfortable allowing their indication (the condition that the antibiotic is being used to treat) to be provided on prescriptions for antibiotics, and 83 selected that they would be comfortable with pharmacies having access to medical records. This study suggests that increased awareness is necessary of the resources that are available to pharmacists regarding antibiotic resistance initiatives and monitoring of antimicrobial prescribing. In addition, an improvement is required concerning patient education by community pharmacists. Finally, the public should be appropriately educated regarding patient confidentiality and the benefits of pharmacies having access to patient information

Antibiotic stewardship teams and Clostridioides difficile practices in United States hospitals: A national survey in The Joint Commission antibiotic stewardship standard era

OBJECTIVE: Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship. METHODS: Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression. RESULTS: Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies. CONCLUSIONS: Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship

Evaluation of early implementations of antibiotic stewardship program initiatives in nine Dutch hospitals

Background Antibiotic resistance is a global threat to patient safety and care. In response, hospitals start antibiotic stewardship programs to optimise antibiotic use. Expert-based guidelines recommend strategies to implement such programs, but local implementations may differ per hospital. Earlier published assessments determine maturity of antibiotic stewardship programs based on expert-based structure indicators, but they disregard that there may be valid deviations from these expert-based programs. Aim To analyse the progress and barriers of local implementations of antibiotic stewardship programs with stakeholders in nine Dutch hospitals and to develop a toolkit that guides implementing local antibiotic stewardship programs. Methods An online questionnaire based on published guidelines and recommendations, conducted with seven clinical microbiologists, seven infectious disease physicians and five clinical pharmacists at nine Dutch hospitals. Results Results show local differences in antibiotic stewardship programs and the uptake of interventions in hospitals. Antibiotic guidelines and antibiotic teams are the most extensively implemented interventions. Education, decision support and audit-feedback are deemed important interventions and they are either piloted in implementations at academic hospitals or in preparation for application in non-academic hospitals. Other interventions that are recommended in guidelines - benchmarking, restriction and antibiotic formulary - appear to have a lower priority. Automatic stop-order, pre-authorization, automatic substitution, antibiotic cycling are not deemed to be worthwhile according to respondents. Conclusion There are extensive local differences in the implementation of antibiotic stewardship interventions. These differences suggest a need to further explore the rationale behind the choice of interventions in antibiotic stewardship programs. Rather than reporting this rationale, this study reports where rationale can play a key role in the implementation of antibiotic stewardship programs. A one-size-fits-all solution is unfeasible as there may be barriers or valid reasons for local experts to deviate from expert-based guidelines. Local experts can be supported with a toolkit containing advice based on possible barriers and considerations. These parameters can be used to customise an implementation of antibiotic stewardship programs to local needs (while retaining its expert-based foundation)