Outpatient parenteral antimicrobial therapy (OPAT) is now the standard of care for managing patients who no longer need inpatient care but require prolonged intravenous antimicrobial therapy. OPAT increases patient satisfaction, reduces the lengths of hospital stay, lowers emergency department readmission rates, and decreases total healthcare spending.

To investigate Virginia Commonwealth University Health System’s experience with OPAT and to highlight the obstacles patients and clinicians face when navigating and utilizing this program.

We conducted this descriptive study at a large, academic, tertiary-care hospital in Central Virginia.

We performed manual reviews of electronic medical records of 602 patient, and we evaluated the records of those receiving OPAT between 2017 and 2020. Reviews included antimicrobial agents, diagnoses requiring OPAT, adverse effects related to antimicrobials, adverse effects related to peripherally inserted central catheters (PICC), readmission rate, discharge destination, and death. We evaluated our program with descriptive statistics.

Among 602 patients who received OPAT, most were diagnosed with bacteremia or musculoskeletal infections. Patients were either discharged home or to another healthcare facility, with the former comprising most of the rehospitalizations. Ertapenem and vancomycin were associated with the most adverse drug events among our cohort. Elevated transaminase levels were noted in 23% of patients. The rate of PICC-line adverse events in this study population was 0.05%.

Our findings highlight the barriers and challenges that patients and providers face when receiving OPAT, and they can inform efforts to improve patient clinical outcomes.

To determine how pharmacists with formal antimicrobial stewardship program (ASP) responsibilities prioritize their time and pharmacists without formal antimicrobial stewardship program responsibilities contribute to ASP activities.

A nationwide survey.

Members of the American College of Clinical Pharmacy who subscribe to the following practice and research network e-mail listservs: infectious diseases, adult medicine, cardiology, critical care, hematology–oncology, immunology and transplantation, and pediatrics.

A survey was distributed via listservs. Respondents were asked about their personal and institutional demographics and ASP activities.

In total, 245 pharmacists responded: 135 pharmacists with formal antimicrobial stewardship program responsibilities; 110 pharmacists without formal antimicrobial stewardship program responsibilities. Although most respondents had completed a general pharmacy residency (85%), only 20% had completed an infectious diseases (ID) specialty residency. Among pharmacists with formal antimicrobial stewardship program responsibilities, one-third had no formal training or certification in ID or ASP. Pharmacists without formal antimicrobial stewardship program responsibilities spent ∼12.5% of their time per week on ASP activities, whereas pharmacists with formal antimicrobial stewardship program responsibilities spent 28% of their time performing non-ASP activities. Pharmacists with formal antimicrobial stewardship program responsibilities were more likely than pharmacists without formal antimicrobial stewardship program responsibilities to perform antibiotic guideline development (P < .001), antibiotic-related education (P = .002), and direct notification of rapid diagnostic results (P = .018). Pharmacists with formal antimicrobial stewardship program responsibilities without formal ID training or certification spent less time on ASP activities and were more likely to perform lower-level interventions.

Many ASP activities are being performed by pharmacists without formal ID training. To ensure the future success of ASPs, pharmacists with formal antimicrobial stewardship program responsibilities should have adequate training to meet more advanced metrics, and more pharmacists without formal antimicrobial stewardship program responsibilities should be included in basic interventions.

Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone.

We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software.

Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%).

We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.

To re-examine the use of noncarbapenems (NCBPs), specifically piperacillin-tazobactam (PTZ) and cefepime (FEP), for extended-spectrum beta-lactamase–producing Enterobacterales bloodstream infections (ESBL-E BSIs).

Retrospective cohort study.

Tertiary-care, academic medical center.

The study included patients hospitalized between May 2016 and May 2019 with a positive blood culture for ESBL-E. Patients were excluded if they received treatment with antibiotics other than meropenem, ertapenem, PTZ, or FEP. Patients were also excluded if they were aged <18 years, received antibiotics for <24 hours, were treated for polymicrobial BSI, or received concomitant antibiotic therapy for a separate gram-negative infection.

We compared CBPs with FEP or PTZ for the treatment of ESBL-E BSI. The primary outcome was in-hospital mortality. Secondary outcomes included clinical cure, microbiologic cure, infection recurrence, and resistance development.

Data from 114 patients were collected and analyzed; 74 (65%) patients received carbapenem (CBP) therapy and 40 (35%) patients received a NCBP (30 received FEP and 10 received PTZ). The overall in-hospital mortality was 6% (N = 7), with a higher death rate in the CBP arm than in the N-CBP arm, (8% vs 3%; P = .42). No difference in mortality was detected between subgroups with Pitt bacteremia score ≥4, those requiring ICU admission, those whose infections were cause by a nongenitourinary source or causative organism (ie, 76 had Escherichia coli and 38 had Klebsiella spp). We detected no differences in secondary outcomes between the groups.

Compared to CBPs, FEP and PTZ did not result in greater mortality or decreased clinical efficacy for the treatment of ESBL-E BSI caused by susceptible organisms.

Widespread inappropriate antibiotic prescribing is a major driver of resistance. Little is known about antifungal prescribing practices in the United States, which is concerning given emerging resistance in fungi, particularly to azole antifungal agents.

We analyzed outpatient antifungal prescribing data in the United States to inform stewardship efforts.

Descriptive analysis of outpatient antifungal prescriptions dispensed during 2018 in the IQVIA Xponent database.

Prescriptions were summarized by drug, sex, age, geography, and healthcare provider specialty. Census denominators were used to calculate prescribing rates among demographic groups.

Healthcare providers prescribed 22.4 million antifungal courses in 2018 (68 prescriptions per 1,000 persons). Fluconazole was the most commonly prescribed drug (75%), followed by terbinafine (11%) and nystatin (10%). Prescription rates were higher among females versus males (110 vs 25 per 1,000 population) and adults versus children (82 vs 27 per 1,000 population). Prescription rates were highest in the South (81 per 1,000 population) and lowest in the West (48 per 1,000 population). Nurse practitioners and family practitioners prescribed the most antifungals (43% of all prescriptions), but the highest prescribing rates were among obstetrician-gynecologists (84 per provider).

Prescribing antifungal drugs in the outpatient setting is common, with enough courses dispensed for 1 in every 15 US residents in 2018. Fluconazole use patterns suggest vulvovaginal candidiasis as a common indication. Regional prescribing differences could reflect inappropriate use or variations in disease burden. Further study of higher antifungal use in the South could help target antifungal stewardship practices.

Short-term improvements in hospital room cleaning can readily be achieved but are difficult to maintain. This is particularly true for high-risk, “high-touch” surfaces. Therefore, we embarked on a process to sustain improvements in surface cleaning and disinfection to reduce hospital-acquired infection (HAI) rates.

Our environmental services (EVS) and infection prevention departments incorporated a formal education, monitoring, and feedback process for focused cleaning and disinfection of high-touch surfaces into their routine policies and procedures in 2011. Cleaning validation was performed by infection prevention liaison nurses using a fluorescent targeting method to evaluate the thoroughness of cleaning.

Surface cleaning performance on medical-surgical units in 2011 was 74.7%, but this rate incrementally increased in response to the interventions and has been sustained at >90% for the past 6 years. Similar patterns of improvement were observed in the operating room, labor and delivery, endoscopy suite and cardiac catheterization laboratory. Conversely, HAI rates, particularly C. difficile rates, decreased by 75% and surgical site infection rates decreased by 55%.

EVS training, monitoring, and feedback interventions, instituted 10 years ago have enhanced our environmental cleaning and disinfection efforts in multiple areas of the hospital and have been sustained to the present. Although other concurrent initiatives to reduce infection rates also existed, the improvements in environmental cleaning were associated with dramatic reductions in HAI rates over the 10-year period.

To investigate clinically relevant microbiological characteristics of uropathogens and to compare patients with catheter-associated urinary tract infections (CAUTIs) to those with non-CAUTIs.

All urine cultures from the calendar year 2019 of the Swiss Centre for Antibiotic Resistance database were analyzed. Group differences in the proportions of bacterial species and antibiotic-resistant isolates from CAUTI and non-CAUTI samples were investigated.

Data from 27,158 urine cultures met the inclusion criteria. Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus mirabilis together represented 70% and 85% of pathogens identified in CAUTI and non-CAUTI samples, respectively. Pseudomonas aeruginosa was significantly more often detected in CAUTI samples. The overall resistance rate for the empirically often-prescribed antibiotics ciprofloxacin (CIP), norfloxacin (NOR), and trimethoprim-sulfamethoxazole (TMP-SMX) was between 13% and 31%. Except for nitrofurantoin, E. coli from CAUTI samples were more often resistant (P ≤ .048) to all classes of antibiotics analyzed, including third-generation cephalosporines used as surrogate for extended-spectrum β-lactamase (ESBL). Significanty higher resistance proportions in CAUTI samples versus non-CAUTI samples were observed for CIP (P = .001) and NOR (P = .033) in K. pneumoniae, for NOR (P = .011) in P. mirabilis, and for cefepime (P = .015), and piperacillin-tazobactam (P = .043) in P. aeruginosa.

CAUTI pathogens were more often resistant to recommended empirical antibiotics than non-CAUTI pathogens. This finding emphasizes the need for urine sampling for culturing before initiating therapy for CAUTI and the importance of considering therapeutic alternatives.

To understand barriers and facilitators to evidence-based prescribing of antibiotics in the outpatient dental setting.

Semistructured interviews.

Outpatient dental setting.

Dentists from 40 Veterans’ Health Administration (VA) facilities across the United States.

Dentists were identified based on their prescribing patterns and were recruited to participate in a semistructured interview on perceptions toward prescribing. All interviews were recorded, transcribed, and double-coded for analysis, with high reliability between coders. We identified general trends using the theoretical domains framework and mapped overarching themes onto the behavior change wheel to identify prospective interventions that improve evidence-based prescribing.

In total, 90 dentists participated in our study. The following barriers and facilitators to evidence-based prescribing emerged as impacts on a dentist’s decision making on prescribing an antibiotic: access to resources, social influence of peers and other care providers, clinical judgment, beliefs about consequences, local features of the clinic setting, and beliefs about capabilities.

Findings from this work reveal the need to increase awareness of up-to-date antibiotic prescribing behaviors in dentistry and may inform the best antimicrobial stewardship interventions to support dentists’ ongoing professional development and improve evidence-based prescribing.

To evaluate the frequency of antibiotic prescribing for common infections via telemedicine compared to face-to-face visits.

Systematic literature review and meta-analysis.

We searched PubMed, CINAHL, Embase (Elsevier platform) and Cochrane CENTRAL to identify studies comparing frequency of antibiotic prescribing via telemedicine and face-to-face visits without restrictions by publish dates or language used. We conducted meta-analyses of 5 infections: sinusitis, pharyngitis, otitis media, upper respiratory infection (URI) and urinary tract infection (UTI). Random-effect models were used to obtain pooled odds ratios (ORs). Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic test.

Among 3,106 studies screened, 23 studies (1 randomized control study, 22 observational studies) were included in the systematic literature review. Most of the studies (21 of 23) were conducted in the United States. Studies were substantially heterogenous, but stratified analyses revealed that providers prescribed antibiotics more frequently via telemedicine for otitis media (pooled odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04–1.52; I2 = 31%) and pharyngitis (pooled OR, 1.16; 95% CI, 1.01–1.33; I2 = 0%). We detected no significant difference in the frequencies of antibiotic prescribing for sinusitis (pooled OR, 0.86; 95% CI, 0.70–1.06; I2 = 91%), URI (pooled OR, 1.18; 95% CI, 0.59–2.39; I2 = 100%), or UTI (pooled OR, 2.57; 95% CI, 0.88–7.46; I2 = 91%).

Telemedicine visits for otitis media and pharyngitis were associated with higher rates of antibiotic prescribing. The interpretation of these findings requires caution due to substantial heterogeneity among available studies. Large-scale, well-designed studies with comprehensive assessment of antibiotic prescribing for common outpatient infections comparing telemedicine and face-to-face visits are needed to validate our findings.

To describe the characteristics and find out risk factors of COVID-19 patients infected with different categories of bacteria.

Case-control.

We conducted a retrospective study including 129 COVID-19 patients admitted to a tertiary hospital between October 13, 2022 and December 31, 2022. Patients’ data were collected from the hospital information system. Patients were classified as having or not having confirmed secondary bacterial infections, or gram-positive and gram-negative bacterial infections for analysis. Categories and sources of isolated bacteria, characteristics of the patients, and the risk factors for developing secondary bacterial infections were analyzed.

Gram-negative bacteria accounted for the majority of secondary bacterial infections of the included patients. Critical type of COVID-19 (OR = 12.98, 95%CI 3.43∼49.18, p < 0.001), invasive therapy (OR = 9.96, 95%CI 3.01∼32.95, p < 0.001), and previous antibiotics use (OR = 17.23, 95%CI 1.38∼215.69, p = 0.027) were independent risk factors of secondary bacterial infections in COVID-19 patients. Ceftriaxone/cefotaxime use (OR = 15.45, 95%CI 2.72∼87.79, p = 0.002) was associated with gram-positive bacterial infections while age over 70 (OR = 3.30, 95%CI 1.06∼10.26, p = 0.039), invasive therapy (OR = 4.68, 95%CI 1.22∼17.93, p = 0.024), and carbapenems use (OR = 8.48, 95%CI 2.17∼33.15, p = 0.002) were associated with gram-negative bacterial infections.

Critical patients with invasive therapy and previous antibiotics use should be cautious with secondary bacterial infections. Third-generation cephalosporins and carbapenems should be used carefully because both are risk factors for gram-positive or gram-negative bacterial infections.

Penicillin (PCN) allergy labels affect antimicrobial selection for surgical prophylaxis. We aimed to increase the percentage of cefazolin usage in patients with PCN allergy labels undergoing orthopedic surgery from 50% to 80%.

Quality improvement initiative.

Children’s Mercy Kansas City (CMKC), a freestanding children’s hospital.

Children scheduled for an orthopedic surgery (excluding spinal surgery) at CMKC who had a PCN allergy label and received a perioperative antibiotic.

No standardized process existed to identify and clarify PCN-allergic–labeled patients preoperatively. We developed a process for patient identification combined with a pharmacist phone interview for PCN allergy clarification. In plan–do–study–act (PDSA) part 1, we implemented a computer-generated patient list. In PDSA part 2, we combined automated identification with a phone interview. In PDSA part 3, we enhanced the patient list, making it timely and concise. In PDSA part 4, we included a PCN allergy clarification electronic survey to caregivers via the electronic medical record.

Cefazolin use in PCN-allergic surgical patients increased from 50% to 74% following interventions. Patients who had their PCN allergy label clarified were 4 times more likely to receive cefazolin compared to those whose allergy labels were not clarified (OR, 4.21; 95% CI, 1.68–11.61; P = 0.003). Moreover, 90% of patients received cefazolin when their PCN allergy was clarified and cefazolin was recommended. When a PCN allergy label was not clarified, only 59% of patients received cefazolin.

Appropriate clarification and documentation of PCN allergy labels increases the use of cefazolin for surgical prophylaxis.

The Centers for Disease Control and Prevention has called for an interdisciplinary approach to antibiotic stewardship implementation that includes front-line nurses. The literature to date has identified key factors preventing uptake by nurses: lack of education, poor communication among providers, and unit culture. Three e-learning modules were developed to address the nurses’ education regarding the roles nurses play in antibiotic stewardship, antibiotic resistance, allergy assessment, medication side effects and interactions, pharmacokinetics–pharmacodynamics, culture interpretation, specimen collection, and the antibiogram. A survey was used to assess whether nurses felt more prepared to participate after finishing the modules.

Front-line staff nurses in acute care were assigned e-learning modules as part of their pharmacy’s introduction of an antibiotic stewardship program for nurses.

Nurses viewed the modules and completed a survey designed to rank their usefulness and to assess their attitudes.

Overall, 81% of nurses felt that they should be part of the antibiotic stewardship team. After completing the modules, 72% felt more empowered to participate in stewardship discussions and an additional 23% requested more education. Also, 97% felt that the information they learned could be utilized in everyday work regardless of the new program. The most cited barriers to stewardship activities were lack of education (45%) and hospital and/or unit culture (13%).

Education and culture need to be addressed to overcome the barriers to nurses’ involvement in antimicrobial stewardship. E-learning can provide a simple and effective first step to educate nurses, with minimal time investment.

The BioFire FilmArray Respiratory Panel (RFA) has been proposed as a tool that can aid in the timely diagnosis and treatment of respiratory tract infections but its effect on antibiotic prescribing among adult patients has varied. We evaluated the impact of RFA result on antibiotic days of therapy (DOTs) in 2 distinct cohorts: hospitalized patients and patients discharged from the emergency department (ED).

Retrospective cohort study.

The study was conducted in 3 community hospitals in Des Moines, Iowa, from March 3 to March 16, 2019.

Adults aged >18 years.

Potential outcome means and average treatment effects for RFA results on antibiotic DOTs were estimated. Inverse probability of treatment weighting with regression adjustment was used.

We identified 243 patients each in the hospitalized and ED-discharged cohorts. Among hospitalized patients, RFA results did not affect antibiotic DOTs. Among patients discharged from the ED, we found that if all patients had had influenza detected, the average DOTs would have been 2.3 DOTs (−3.2 to −1.4) less than the average observed if all the patients had had a negative RFA (P < .0001); no differences in DOTs were observed when comparing an RFA with a noninfluenza virus detected compared to an RFA with negative results.

The impact of RFA results on antibiotic DOTs varies by clinical setting, and reductions were observed only among patients discharged from the ED who had influenza A or B detected.

Antibiotics are frequently prescribed in nursing homes; national data describing facility-level antibiotic use are lacking. The objective of this analysis was to describe variability in antibiotic use in nursing homes across the United States using electronic health record orders.

A retrospective cohort study of antibiotic orders for 309,884 residents in 1,664 US nursing homes in 2016 were included in the analysis. Antibiotic use rates were calculated as antibiotic days of therapy (DOT) per 1,000 resident days and were compared by type of stay (short stay ≤100 days vs long stay >100 days). Prescribing indications and the duration of nursing home-initiated antibiotic orders were described. Facility-level correlations of antibiotic use, adjusting for resident health and facility characteristics, were assessed using multivariate linear regression models.

In 2016, 54% of residents received at least 1 systemic antibiotic. The overall rate of antibiotic use was 88 DOT per 1,000 resident days. The 3 most common antibiotic classes prescribed were fluoroquinolones (18%), cephalosporins (18%), and urinary anti-infectives (9%). Antibiotics were most frequently prescribed for urinary tract infections, and the median duration of an antibiotic course was 7 days (interquartile range, 5–10). Higher facility antibiotic use rates correlated positively with higher proportions of short-stay residents, for-profit ownership, residents with low cognitive performance, and having at least 1 resident on a ventilator. Available facility-level characteristics only predicted a small proportion of variability observed (Model R2 version 0.24 software).

Using electronic health record orders, variability was found among US nursing-home antibiotic prescribing practices, highlighting potential opportunities for targeted improvement of prescribing practices.