Hospitalized neonates are at high risk for hospital-associated bloodstream infections (HA-BSI) and require locally contextualized interventions to prevent HA-BSI.

The Preventing Infections in Neonates (PIN) collaborative aimed to reach a 50% decrease in neonatal HA-BSI rates for a 27-bed Level IV neonatal intensive care unit (NICU). Using quality improvement (QI) methodologies, a multidisciplinary cross-cultural collaborative implemented phased and bundled interventions from July 2017 to September 2019. Descriptive statistics and statistical process control charts were used to analyze infection rates.

There were 916 admissions, 19,812 patient-days, and 4264 central line days in the NICU during the project period. Monthly baseline preintervention HA-BSI median rate was 3.95/1000 patient-days and decreased to 1.73/1000 patient-days (56% change) during the bundled interventions. Quarterly HA-BSI rates also decreased from the preintervention median of 4.5/1000 patient-days to 3.3/1000 patient-days during the intervention period (IRR 0.73; 95%CI 0.39, 1.36). Staff were highly compliant with hand hygiene and environmental cleaning. Through project efforts, compliance with bundle elements increased from 25% at baseline to a peak of 97% for central line (CL) insertion checklists and from 13% to a peak of 56% for CL maintenance checklists.

Unit-based bundled interventions can reduce neonatal HA-BSI in limited resource settings. Future studies can assess similar practices in other units and the impact of the pandemic on interventions to reduce HA-BSIs.

Antimicrobial resistance (AMR) is increasing in tertiary-care hospitals across India, which consumes more antibiotics than any other country. Microorganisms with novel resistance mechanisms, initially isolated in India, are now recognized worldwide. Until now, most efforts to stem AMR in India have focused on the inpatient setting. Ministry of Health data now suggest that rural areas are playing a more significant role in the pathogenesis of AMR than was previously appreciated. Thus, we conducted this pilot study to ascertain whether AMR is common in pathogens causing infections acquired in the wider rural community.

We performed a retrospective prevalence survey of 100 urine, 102 wound, and 102 blood cultures obtained from patients who were admitted to a tertiary-care facility in Karnataka, India, with infections acquired in the community. The study population included patients >18 years of age who (1) were referred to the hospital by primary care doctors, (2) had a positive blood, urine, or wound culture, and (3) were not previously hospitalized. Bacterial identification and antimicrobial susceptibility testing (AST) were carried out on all isolates.

Enterobacteriaceae were the most common pathogens isolated from urine and blood cultures. Significant resistance to quinolones, aminoglycosides, carbapenems, and cephalosporins was noted among pathogens isolated from all cultures. Specifically, high resistance rates (>45%) to quinolones, penicillin, and cephalosporins were evident among all 3 types of culture. Among blood and urinary pathogens, there were high resistance rates (>25%) to both aminoglycosides and carbapenems.

Efforts to stem AMR rates in India need to focus on rural populations. Such efforts will need to characterize antimicrobial overprescribing practices, healthcare-seeking behaviors, and antimicrobial use in agriculture in rural settings.

To determine antibiotic prescribing appropriateness for respiratory tract diagnoses (RTD) by season.

Retrospective cohort study.

Primary care practices in a university health system.

Patients who were seen at an office visit with diagnostic code for RTD.

Office visits for the entire cohort were categorized based on ICD-10 codes by the likelihood that an antibiotic was indicated (tier 1: always indicated; tier 2: sometimes indicated; tier 3: rarely indicated). Medical records were reviewed for 1,200 randomly selected office visits to determine appropriateness. Based on this reference standard, metrics and prescriber characteristics associated with inappropriate antibiotic prescribing were determined. Characteristics of antibiotic prescribing were compared between winter and summer months.

A significantly greater proportion of RTD visits had an antibiotic prescribed in winter [20,558/51,090 (40.2%)] compared to summer months [11,728/38,537 (30.4%)][standardized difference (SD) = 0.21]. A significantly greater proportion of winter compared to summer visits was associated with tier 2 RTDs (29.4% vs 23.4%, SD = 0.14), but less tier 3 RTDs (68.4% vs 74.4%, SD = 0.13). A greater proportion of visits in winter compared to summer months had an antibiotic prescribed for tier 2 RTDs (80.2% vs 74.2%, SD = 0.14) and tier 3 RTDs (22.9% vs 16.2%, SD = 0.17). The proportion of inappropriate antibiotic prescribing was higher in winter compared to summer months (72.4% vs 62.0%, P < .01).

Increases in antibiotic prescribing for RTD visits from summer to winter were likely driven by shifts in diagnoses as well as increases in prescribing for certain diagnoses. At least some of this increased prescribing was inappropriate.

An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist.

In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes.

Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds.

Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing—choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.

This study aimed to assess the impact of clinical decision support (CDS) to improve ordering of multiplex gastrointestinal polymerase chain reaction (PCR) testing panel (“GI panel”).

Single-center, retrospective, before-after study.

Tertiary care Veteran’s Affairs (VA) Medical Center provides inpatient, outpatient, and residential care.

All patients tested with a GI panel between June 22, 2022 and April 20, 2023.

We designed a CDS questionnaire in the electronic medical record (EMR) to guide appropriate ordering of the GI panel. A “soft stop” reminder at the point of ordering prompted providers to confirm five appropriateness criteria: 1) documented diarrhea, 2) no recent receipt of laxatives, 3) C. difficile is not the leading suspected cause of diarrhea, 4) time period since a prior test is >14 days or prior positive test is >4 weeks and 5) duration of hospitalization <72 hours. The CDS was implemented in November 2022.

Compared to the pre-implementation period (n = 136), fewer tests were performed post-implementation (n = 92) with an IRR of 0.61 (p = 0.003). Inappropriate ordering based on laxative use or undocumented diarrhea decreased (IRR 0.37, p = 0.012 and IRR 0.25, p = 0.08, respectively). However, overall inappropriate ordering and outcome measures did not significantly differ before and after the intervention.

Implementation of CDS in the EMR decreased testing and inappropriate ordering based on use of laxatives or undocumented diarrhea. However, inappropriate ordering of tests overall remained high post-intervention, signaling the need for continued diagnostic stewardship efforts.

To describe inpatient fluoroquinolone use and susceptibility data over a 10-year period after the implementation of an antimicrobial stewardship program (ASP) led by an infectious diseases pharmacist starting in 2011.

Retrospective surveillance study.

Large community health system.

Fluoroquinolone use was quantified by days of therapy (DOT) per 1,000 patient days (PD) and reported quarterly. Use data are reported for inpatients from 2016 to 2020. Levofloxacin susceptibility is reported for Pseudomonas aeruginosa and Escherichia coli for inpatients from 2011 to 2020 at a 4 adult-hospital health system.

Inpatient fluoroquinolone use decreased by 74% over a 5-year period, with an average decrease of 3.45 DOT per 1,000 PD per quarter (P < .001). Over a 10-year period, inpatient levofloxacin susceptibility increased by 57% for P. aeruginosa and by 15% for E. coli. P. aeruginosa susceptibility to levofloxacin increased by an average of 2.73% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = −0.99 (P = .002). E. coli susceptibility to levofloxacin increased by an average of 1.33% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = −0.95 (P = .015).

A substantial decrease in fluoroquinolone use and increase in P. aeruginosa and E. coli levofloxacin susceptibility was observed after implementation of an antimicrobial stewardship program. These results demonstrate the value of stewardship services and highlight the effectiveness of an infectious diseases pharmacist led antimicrobial stewardship program.

We surveyed antimicrobials used in Greek pediatric hematology–oncology (PHO) and bone marrow transplant (BMT) units before and after an intervention involving education regarding the 2017 clinical practice guidelines (CPG) for the management of febrile neutropenia in children with cancer and hematopoietic stem-cell transplant recipients.

Antibiotic prescribing practices were prospectively recorded between June 2016 and November 2017.

In December 2017, baseline data feedback was provided, and CPG education was provided. Prescribing practices were followed for one more year. For antibiotic stewardship, days of therapy, and length of therapy were calculated.

Five of the 6 PHO units in Greece and the single pediatric BMT unit participated.

Admitted children in each unit who received the first 15 new antibiotic courses each month.

Administration of ≥4 antibiotics simultaneously and administration of antibiotics with overlapping activity for ≥2 days were significantly more common in PHO units in general hospitals compared to children’s hospitals. Use of at least 1 antifungal was recorded in ∼47% of the patients before and after the intervention. De-escalation and/or discontinuation of antibiotics on day 6 of initial treatment increased significantly from 43% to 53.5% (P = .032). Although the number of patients requiring intensive care support for sepsis did not change, a significant drop was noted in all-cause mortality (P = .008).

We recorded the antibiotic prescribing practices in Greek PHO and BMT units, we achieved improved prescribing with a simple intervention, and we identified areas in need of improvement.

Clinical guidelines or guidance is an important tool for preventing and treating antimicrobial-resistant (AMR) infections. We sought to understand and support the effective use of guidelines and guidance for AMR infections.

Key informant interviews and a stakeholder meeting on the development and use of guidelines and guidance for management of AMR infections; the interview findings and meeting discussion informed a conceptual framework for AMR infection clinical guidelines.

Interview participants included experts with experience in guidelines development and physician and pharmacist hospital leaders and antibiotic stewardship program leaders. Stakeholder meeting participants included federal and nonfederal participants involved in research, policy, and practice related to prevention and management of AMR infections.

Participants described challenges related to timeliness of guidelines, methodologic limitations of the development process, and issues with usability across a range of clinical settings. These findings, and participants’ suggestions for mitigating the challenges identified, informed a conceptual framework for AMR infection clinical guidelines. The framework components include (1) science and evidence, (2) guideline and guidance development and dissemination, and (3) implementation and real-world practice. These components are supported by engaged stakeholders whose leadership and resources help to improve patient and population AMR infection prevention and management.

Use of guidelines and guidance documents for management of AMR infections can be supported through (1) a robust body of scientific evidence to inform guidelines and guidance; (2) approaches and tools to support timely, transparent guidelines that are relevant and actionable for all clinical audiences; and (3) tools to implement guidelines and guidance effectively.

Early administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown.

We used a modified Delphi approach to identify safety criteria for an opt-out protocol to guide de-escalation or discontinuation of antibiotic therapy after 72 hours in non-ICU patients with suspected sepsis. An expert panel with expertise in antimicrobial stewardship and hospital epidemiology rated 48 unique criteria across 3 electronic survey rating tools. Criteria were rated primarily based on their impact on patient safety and feasibility for extraction from electronic health record review. The 48 unique criteria were rated by anonymous electronic survey tools, and the results were fed back to the expert panel participants. Consensus was achieved to either retain or remove each criterion.

After 3 rounds, 22 unique criteria remained as part of the opt-out safety checklist. These criteria included high-risk comorbidities, signs of severe illness, lack of cultures during sepsis work-up or antibiotic use prior to blood cultures, or ongoing signs and symptoms of infection.

The modified Delphi approach is a useful method to achieve expert-level consensus in the absence of evidence suifficient to provide validated guidance. The Delphi approach allowed for flexibility in development of an opt-out trial protocol for sepsis antibiotic de-escalation. The utility of this protocol should be evaluated in a randomized controlled trial.