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

Abstract 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.

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Development of key quality indicators for appropriate antibiotic use in the Republic of Korea: results of a modified Delphi survey

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-021-00913-y ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Bongyoung Kim ◽

◽

Myung Jin Lee ◽

Se Yoon Park ◽

Song Mi Moon ◽

...

Keyword(s):

Antibiotic Therapy ◽

Quality Indicators ◽

Antibiotic Stewardship ◽

Antibiotic Use ◽

Republic Of Korea ◽

Cochrane Library ◽

Surgical Prophylaxis ◽

Modified Delphi ◽

Stewardship Program ◽

The Republic

Abstract Background An effective antibiotic stewardship program relies on the measurement of appropriate antibiotic use, on which there is a lack of consensus. We aimed to develop a set of key quality indicators (QIs) for nationwide point surveillance in the Republic of Korea. Methods A systematic literature search of PubMed, EMBASE, and Cochrane Library (publications until 20th November 2019) was conducted. Potential key QIs were retrieved from the search and then evaluated by a multidisciplinary expert panel using a RAND-modified Delphi procedure comprising two online surveys and a face-to-face meeting. Results The 23 potential key QIs identified from 21 studies were submitted to 25 multidisciplinary expert panels, and 17 key QIs were retained, with a high level of agreement (13 QIs for inpatients, 7 for outpatients, and 3 for surgical prophylaxis). After adding up the importance score and applicability, six key QIs [6 QIs (Q 1–6) for inpatients and 3 (Q 1, 2, and 5) for outpatients] were selected. (1) Prescribe empirical antibiotic therapy according to guideline, (2) change empirical antibiotics to pathogen-directed therapy, (3) obtain culture samples from suspected infection sites, (4) obtain two blood cultures, (5) adapt antibiotic dosage to renal function, and (6) document antibiotic plan. In surgical prophylaxis, the QIs to prescribe antibiotics according to the guideline and initiate antibiotic therapy 1 h before incision were selected. Conclusions We identified key QIs to measure the appropriateness of antibiotic therapy to identify targets for improvement and to evaluate the effects of antibiotic stewardship intervention.

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Infection Preventionist Run Clostridioides difficile Testing Diagnostic Stewardship Protocol- Experience From a Rural Community Hospital

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1161 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s484-s485

Author(s):

Raghavendra Tirupathi ◽

Ruth Freshman ◽

Norma J Montoy ◽

Melissa Gross

Keyword(s):

Cost Savings ◽

Antibiotic Use ◽

First Year ◽

Multiple Parameters ◽

Clostridioides Difficile ◽

Stewardship Program ◽

Commercial Company ◽

Surgical History ◽

Test Ordering ◽

Infection Preventionists

Background: Distinguishing active Clostridioides difficile infection (CDI) from asymptomatic colonization remains a challenging task in the era of PCR testing. Inappropriate testing leads to overtesting and overdiagnosis, inadvertent treatment, and isolation in addition to laboratory identified (LabID) events, leading to increased incidence to hospital-onset CDI (HO-CDI). The institution has a nurse-driven C. difficile test ordering protocol, and we noted a significant increase in the HO-CDI incidence in 2017 due to inappropriate testing, with rates as high as 0.94 per 1,000 patient days. Methods: In September 2017, a multidisciplinary team reviewed and initiated algorithm-based testing with mandatory audit and review by infection preventionists (IPs) under the guidance of an ID physician of all ordered tests. They reviewed the adequacy and legitimacy of order for multiple parameters, including minimum 3 loose stools in 24 hours, use of laxatives in last 24 hours, consistency of the sample, presence of at least 1 clinical parameters (ie, fever, abdominal pain, leukocytosis, sepsis, or septic shock), recent or concomitant antibiotic use, recent PCR testing in the last 14 days, and chart review for medical and/or surgical history. The IPs served as the gatekeepers to testing and rejected the samples that were deemed inappropriate. Ambiguous cases were discussed with the ID specialist. On the microscope lab side, all specimens sent were batched to be run twice a day at 8:30 a.m. and 2:30 p.m., and testing was performed only on the samples cleared by infection preventionists. Results: The number of PCR tests completed in the comparison quarter of 2016 was 220, which decreased to 157 tests in 2017 with a reduction of 28%. After a full year of implementation of the diagnostic stewardship protocol, the number of completed PCR tests decreased to 626 from 940 PCR tests in 2016, with an overall 34% decrease in testing. In the year following the implementation of diagnostic stewardship, HO-CDI decreased from 60 events in 2017 to 43 events in 2018, with a reduction of 28%. Subsequently, HO-CDI further decreased in 2019 from 43 to 28, with a reduction of 35%. Since the implementation of the project in 2017, HO-CDIs have decreased by 54% overall. The reduction in 314 C. difficile PCR tests in the first year led to a savings of $8,300 in laboratory testing supplies. The reduction of HO CDI by 17 led to cost avoidance of $293,420. Conclusions: Our experience shows that the IP-run diagnostic stewardship program was highly successful in streamlining testing, with cost savings on several fronts.Funding: NoneDisclosures: NoneDisclosures:Commercial Company : If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the funding company.DisagreeRaghavendra Tirupathi

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Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis

Journal of Applied Gerontology ◽

10.1177/07334648211018299 ◽

2021 ◽

pp. 073346482110182

Author(s):

Sainfer Aliyu ◽

Jasmine L. Travers ◽

S. Layla Heimlich ◽

Joanne Ifill ◽

Arlene Smaldone

Keyword(s):

Systematic Review ◽

Nursing Home ◽

Antibiotic Stewardship ◽

Meta Analysis ◽

Nursing Home Residents ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Stewardship Program ◽

Meta Analyses

Effects of antibiotic stewardship program (ASP) interventions to optimize antibiotic use for infections in nursing home (NH) residents remain unclear. The aim of this systematic review and meta-analysis was to assess ASPs in NHs and their effects on antibiotic use, multi-drug-resistant organisms, antibiotic prescribing practices, and resident mortality. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review and meta-analysis using five databases (1988–2020). Nineteen articles were included, 10 met the criteria for quantitative synthesis. Inappropriate antibiotic use decreased following ASP intervention in eight studies with a pooled decrease of 13.8% (95% confidence interval [CI]: [4.7, 23.0]; Cochran’s Q = 166,837.8, p < .001, I2 = 99.9%) across studies. Decrease in inappropriate antibiotic use was highest in studies that examined antibiotic use for urinary tract infection (UTI). Education and antibiotic stewardship algorithms for UTI were the most effective interventions. Evidence surrounding ASPs in NH is weak, with recommendations suited for UTIs.

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Changes in antibiotic use following implementation of a telehealth stewardship pilot program

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.128 ◽

2019 ◽

Vol 40 (7) ◽

pp. 810-814 ◽

Cited By ~ 2

Author(s):

Brigid M. Wilson ◽

Richard E. Banks ◽

Christopher J. Crnich ◽

Emma Ide ◽

Roberto A. Viau ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Long Term Care ◽

Antibiotic Use ◽

Veterans Affairs ◽

Term Care ◽

Medical Centers ◽

Stewardship Program ◽

Days Of Therapy ◽

Veterans Affairs Medical Centers

AbstractStarting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.

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Impact of an Antibiotic Stewardship Program on Antibiotic Prescription for Acute Respiratory Tract Infections in Children: A Prospective Before-After Study

Clinical Pediatrics ◽

10.1177/0009922819870248 ◽

2019 ◽

Vol 58 (11-12) ◽

pp. 1166-1174 ◽

Cited By ~ 1

Author(s):

Nalinee Aoybamroong ◽

Worawit Kantamalee ◽

Kunlawat Thadanipon ◽

Chonnamet Techasaensiri ◽

Kumthorn Malathum ◽

...

Keyword(s):

Respiratory Tract ◽

Antibiotic Stewardship ◽

Respiratory Tract Infections ◽

Instant Messaging ◽

Antibiotic Prescription ◽

Antibiotic Use ◽

Acute Respiratory Tract Infection ◽

Stewardship Program ◽

Tract Infections ◽

E Mail

We assessed the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescriptions for acute respiratory tract infection (ARTI) in a medical school. Our ASP included delivering an antibiotic use guideline via e-mail and LINE (an instant messaging app) to faculty staff, fellows, and residents, and posting of the guideline in examination rooms. Medical records of pediatric patients diagnosed with ARTI were reviewed to assess the appropriateness of antibiotic prescription. ASP could increase the rate of appropriateness from 78% (1979 out of 2553 visits) to 83.4% (2449 out of 2935 visits; P < .001). The baseline of appropriateness was higher in residents (95%) compared with fellows (82%) and faculty staff (75%). The ASP significantly increased the appropriateness only in faculty staff, especially in semiprivate clinics (75% to 83%, P < .001). In conclusion, our ASP increased appropriateness of antibiotic prescriptions for ARTI, with the greatest impact among faculty staff in semiprivate clinics.

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Causal Conditions Supporting Antibiotic Stewardship Information Dashboards

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.771 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S326-S327

Author(s):

Jacob Kean ◽

Jorie Butler ◽

Lisa Bunker ◽

Matthew Goetz ◽

Peter Glassman ◽

...

Keyword(s):

Self Efficacy ◽

Antibiotic Stewardship ◽

Critical Incident ◽

Sufficient Conditions ◽

Population Data ◽

Population Level ◽

Antibiotic Use ◽

User Centered Design ◽

Program Structure ◽

Stewardship Program

Abstract Background Antibiotic stewardship is key to minimizing antibiotic resistance. To assist antibiotic stewards in dissecting population-level antibiotic use patterns, our study group developed a dashboard that displays consolidated patterns, supports data exploration, and compares facility-level antibiotic use to others. We report fuzzy set qualitative comparative analyses (QCA) of interviews designed to elicit user experiences to uncover different combinations of causal conditions supporting dashboard use. Methods Dashboards were iteratively designed based upon longitudinal feedback from stewards. Views include antibiotic use stratified by diagnoses and duration of therapy. Eight VAMCs, each with 0.5 to 2.0 FTE stewards, used the dashboard. One to 2 stewards from each site were interviewed using a structured script that focused on: 1) structure (i.e., program FTE) and functions of the local stewardship program; 2) critical incident or usage story; and 3) perceived knowledge and efficacy. Results Qualitative codes were developed from the interviews and were scaled in a fuzzy logic framework (i.e., between 0 and 1) to reflect the degree to which the qualitative theme was present in the stewardship program at participating clinical sites. The scaling was assigned using prior knowledge external to the data. The most parsimonious QCA solution identified just the absence of program structure (program FTE) a sufficient causal configuration to the frequency of dashboard use (coverage = 0.612, consistency = 0.813). Intermediate solutions added stewardship activities, dashboard self-efficacy, and trust in the data (coverage = 0.502, consistency = 0.952) as sufficient conditions. The coverage for both solutions exceeded 0.75, which was the lower bound of acceptability. Conclusion The dashboard may be successfully integrated into institutions based on the complicated interplay between program structure (e.g., # FTE) and dashboard self-efficacy, experience with data-activities, and trust of population data. Incorporating user-centered design of dashboards supports the development of fully functional teams and has the potential for important population health impact. Disclosures All authors: No reported disclosures.

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Effectiveness and Acceptance of Multimodal Antibiotic Stewardship Program: Considering Progressive Implementation and Complementary Strategies

Antibiotics ◽

10.3390/antibiotics9120848 ◽

2020 ◽

Vol 9 (12) ◽

pp. 848

Author(s):

Flavien Bouchet ◽

Vincent Le Moing ◽

Delphine Dirand ◽

François Cros ◽

Alexi Lienard ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Infectious Diseases ◽

Antibiotic Therapy ◽

Antibiotic Stewardship ◽

Antibiotic Use ◽

Stewardship Program ◽

Microbiological Laboratory ◽

Combined Actions ◽

One Year

Multiple modes of interventions are available when implementing an antibiotic stewardship program (ASP), however, their complementarity has not yet been assessed. In a 938-bed hospital, we sequentially implemented four combined modes of interventions over one year, centralized by one infectious diseases specialist (IDS): (1) on-request infectious diseases specialist consulting service (IDSCS), (2) participation in intensive care unit meetings, (3) IDS intervention triggered by microbiological laboratory meetings, and (4) IDS intervention triggered by pharmacist alert. We assessed the complementarity of the different cumulative actions through quantitative and qualitative analysis of all interventions traced in the electronic medical record. We observed a quantitative and qualitative complementarity between interventions directly correlating to a decrease in antibiotic use. Quantitatively, the number of interventions has doubled after implementation of IDS intervention triggered by pharmacist alert. Qualitatively, these kinds of interventions led mainly to de-escalation or stopping of antibiotic therapy (63%) as opposed to on-request IDSCS (32%). An overall decrease of 14.6% in antibiotic use was observed (p = 0.03). Progressive implementation of the different interventions showed a concrete complementarity of these actions. Combined actions in ASPs could lead to a significant decrease in antibiotic use, especially regarding critical antibiotic prescriptions, while being well accepted by prescribers.

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Trends and Drivers of Inpatient Antibiotic Consumption among 89 China Tertiary General Hospitals from 2011Q1 to 2015Q4

BioMed Research International ◽

10.1155/2018/5968653 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7

Author(s):

Jiangyun Chen ◽

Rui Min ◽

He Wang ◽

Shengwen Zhao ◽

Haomiao Li ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Antibiotic Use ◽

Antibiotic Consumption ◽

Panel Regression ◽

General Hospitals ◽

Policy Interventions ◽

Defined Daily Doses ◽

Stewardship Program ◽

Program Policy ◽

Made In

Antibacterial surveillance is an essential measure for strengthening the management of clinical antibiotic use. This study aimed to determine the trends and drivers of inpatient antibiotic consumption in China. A sample of 89 hospitals with complete data from 2011Q1 to 2015Q4 was included. Accumulative defined daily doses (DDDs), antibiotic use density (AUD), and drug variety were calculated to evaluate antibiotic consumption. From 2011Q1 to 2015Q4, the median values of DDDs, AUD, and drug variety dropped by 10.49%, 39.19%, and 27.96%, respectively. Panel regression results showed, for each additional quarter, DDDs reduced by 6.714 DDDs, AUD reduced by 0.013 DDDs per 100 inpatients per day, and drug variety reduced by 0.012 types (p < 0.001). National hospitals were more likely to use antibiotics, with the highest number of DDDs (106 709 DDDs) and AUD (60 DDDs per 100 inpatients per day) and a large number of drug variety (71 types of drug) all reported from national hospitals. Overall, a downward trend of inpatient antibiotic consumption was observed in competitive tertiary general hospitals in China. However, antibiotic use in China, especially in national hospitals, continues to exceed the guidelines set forth by the nationwide antibiotic stewardship program. China must continue to improve surveillance of antibiotic consumption by constructing a more comprehensive, continuous, and targeted stewardship program. Policy interventions in China should be made in consideration of unbalanced regional development and the consequences this may have on antibiotic consumption.

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1145. Reducing Antibiotic Use In Children With Respiratory Syncitial Virus-related Bronchiolitis: Implementation of TeamSTEPPS® 2.0 to Improve Pharmacy-Physician Communication in a Community Hospital Antibiotic Stewardship Program

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1009 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S408-S408

Author(s):

Ankhi Dutta ◽

Brady Moffett ◽

Samrah Mobeen ◽

Amrita Singh

Keyword(s):

Antibiotic Stewardship ◽

Pediatric Intensive Care ◽

Antibiotic Use ◽

Physician Communication ◽

Communication Tool ◽

Communication Technique ◽

Stewardship Program ◽

Previous Season ◽

Days Of Therapy ◽

Syncytial Virus

Abstract Background Overuse of antibiotics in Respiratory Syncytial virus (RSV) bronchiolitis in children has been reported between 29–80%. Our antibiotic stewardship program (ASP) utilized a validated communication tool using TeamSTEPPS ® 2.0 principles to improve pharmacy-physician communication and improve audit-feedback technique (AFT). Methods We trained pharmacists and physicians in TeamSTEPPS ® 2.0 using simulation-based training. The key component of the training was: closed-loop communication and using a scripted pharmacy communication tool. The scripted pharmacy communication tool was modified from the “DESC” script used in TeamSTEPPS ® 2.0, which includes (1) Describing the situation, (2) Expressing concern, (3) providing Solutions, (4) stating Consequences and coming to an agreement. We incorporated this to improve the audit-feedback technique. We aimed to: (1) Reduce overall percentage of antibiotic (abx) use in RSV bronchiolitis by 25%, (2) reduce use of ceftriaxone, (3) reduce average antibiotic days of therapy (DOT). Results Our baseline data from 2017–18 RSV season showed a 42% (48/113) use of abx, of which 10% were deemed inappropriate. When compared with the 2018–2019 season, no differences were noted in patient demographics. The median length of stay between the two time periods was similar (2.9 days, IQR 1.9–4.8 days vs. 3.1 days, IQR 2.1–5.1 days, P = 0.17). More patients were admitted to the pediatric intensive care unit (PICU) in the 2018–2019 period: 35/96 (36.4%) as compared with 17/113 (15%) in the previous season. Although similar proportions of patients received abx (42% vs. 41%) in the two groups (Figure 1), average abx DOT, significantly decreased in the 2018–2019 period as compared with 2017–2018 (Figure 2). There was also a decrease in the use of ceftriaxone during the 2018–2019 (Figure 3). All physicians and pharmacists were satisfied with the communication technique and thought that it improved their interaction and understanding of the ASP process. Conclusion Though we did not reduce the overall abx use in RSV bronchiolitis, we did reduce the average abx DOT and use of ceftriaxone in our institution. The use of a validated communication tool to improve prospective AFT was crucial to the success of the ASP program. Disclosures All authors: No reported disclosures.

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104. Evaluation of a 2-Step Testing Algorithm for Clostridioides difficile Infection

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.149 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S66-S67

Author(s):

Caitlin C Bettger ◽

Stephanie Giancola ◽

Robert Cybulski ◽

Jason Okulicz ◽

Alice Barsoumian

Keyword(s):

Medical Center ◽

Laboratory Data ◽

Antibiotic Use ◽

Treatment Decisions ◽

High Rate ◽

Clinical Criteria ◽

Treatment Status ◽

Clostridioides Difficile ◽

Stewardship Program ◽

Clostridioides Difficile Infection

Abstract Background A 2-step testing strategy for diagnosis of Clostridioides difficile infection (CDI) is recommended to limit over-diagnosis when clinical criteria requirements for stool sample submission cannot be enforced. Real-world evaluations of this strategy are limited. Methods The Antimicrobial Stewardship Program at Brooke Army Medical Center, San Antonio, TX, implemented a 2-step CDI algorithm: polymerase chain reaction (PCR) testing followed by toxin enzyme immunoassay (EIA). The goal was to improve diagnosis of CDI and reduce unnecessary antibiotic use. Patients with PCR+ tests from August 2018 to September 2019 were included. Charts were reviewed for demographics, laboratory data, treatment, and outcomes. Cases were grouped based on concordant (PCR+/EIA+) or discordant (PCR+/EIA-) results. To determine factors contributing to treatment decisions, an analysis of discordant cases were compared by treatment status. Groups were compared by Chi-squared, Fisher’s exact, or Mann-Whitney U tests. Results A total of 216 PCR+ tests from 215 patients were recorded. Of these, 155 (71.8%) were discordant. Demographics, laboratory data, and risk factors for CDI were similar between groups (Table 1; p >0.05 for all). Compared to discordant cases, concordant cases were more frequently hospitalized (59% vs 43.9%; p=0.05), had a higher median daily stool count (5 [4–7] vs 4 [2–6], p=0.03), met criteria for severe CDI (33.3% vs 18.7%; p=0.05), received treatment (95.1% vs 66.5%; p< 0.01) and were readmitted in 30 days with CDI (8.3% vs 1.3%; p=0.02). Among discordant cases, median daily stool count was higher in treated vs untreated cases (4 [3–7] vs 3 [1–5], p=0.02). Otherwise, there was no difference in variables according to treatment status (Table 2; p >0.05 for all). Discordant cases with infectious disease (ID) or gastroenterology (GI) consultation had a high rate of treatment (73.9% and 61.1%, respectively). Table 1. Characteristics and outcomes of patients with concordant and discordant tests. Table 2. Characteristics and outcomes of treated and untreated patients with discordant tests. Conclusion Implementation of 2-step strategy reduced antibiotic treatment by nearly 30%. However, the majority of discordant cases were deemed clinically significant and received treatment by providers, including ID or GI specialists. Further studies are needed to determine the unmeasured factors that guide treatment decisions in discordant cases. Disclosures All Authors: No reported disclosures

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