We examined the use of antibiotics for acute respiratory infections in an urgent-care setting.

Retrospective database review.

The study was conducted in 2 urgent-care clinics staffed by academic emergency physicians in San Diego, California.

Visits for acute respiratory infections were identified based on presenting complaints.

The primary outcome was a discharge prescription for an antibiotic. The patient and provider characteristics that predicted this outcome were analyzed using logistic regression. The variation in antibiotic prescriptions between providers was also analyzed.

In total, 15,160 visits were analyzed. The patient characteristics were not predictive of antibiotic treatment. Physicians were more likely than advanced practice practitioners to prescribe antibiotics (1.31; 95% confidence interval [CI], 1.21–1.42). For every year of seniority, a provider was 1.03 (95% CI, 1.02–1.03) more likely to prescribe an antibiotic. Although the providers saw similar patients, we detected significant variation in the antibiotic prescription rate between providers: the mean antibiotic prescription rate within the top quartile was 54.3% and the mean rate in the bottom quartile was 21.7%.

The patient and provider characteristics we examined were either not predictive or were only weakly predictive of receiving an antibiotic prescription for acute respiratory infection. However, we detected a marked variation between providers in the rate of antibiotic prescription. Provider differences, not patient differences, drive variations in antibiotic prescriptions. Stewardship efforts may be more effective if directed at providers rather than patients.

Recognition of sepsis frequently occurs in emergency departments. To evaluate the appropriateness of empiric antibiotic use in the setting of suspected sepsis in emergency department, the percentages of bacterial infection and antibiotic-related adverse drug effects were quantified in an emergency department at an academic medical center.

We retrospectively reviewed electronic medical records of adults who presented to the emergency department between January 2018 and June 2018 with suspected sepsis (defined as having ≥2 systemic inflammatory response syndrome [SIRS] criteria) and received ≥1 dose of intravenous broad-spectrum antibiotic.

In total, 218 patients were included in the final analysis. Moreover, 19.3% of these patients had confirmed bacterial infections; 44.5% had suspected bacterial infections; and 35.9% did not have bacterial infection. Elevated SIRS score (ie, ≥2) and Quick Sequential Organ Failure Assessment (qSOFA) score (ie, ≥2) were not associated with the presence of bacterial infections. We identified 90-day Clostridioides difficile infections in 7 patients and drug-resistant organism infections in 6 patients, regardless of the presence of bacterial infections.

A high number of patients received intravenous broad-spectrum antibiotics in the emergency department without confirmed or suspected bacterial infections that were supported by microbiologic cultures, radiographic imaging, or other symptoms of infections. Most patients who were initially admitted to the emergency department with suspected sepsis were discharged home after receiving 1 dose of intravenous antibiotic. Patients who were initially screened using SIRS score and who received broad-spectrum antibiotics in the emergency department were without confirmed or suspected bacterial infection.

To describe the current landscape of antimicrobial stewardship (AMS) instruction in Canadian entry-to-practice pharmacy programs and the perceived barriers and facilitators to optimizing teaching and learning.

Electronic survey.

Faculty representatives from the 10 Canadian entry-to-practice pharmacy programs, including content experts and faculty leadership.

A review of international literature pertaining to AMS in pharmacy curricula informed a 24-item survey, which was open for completion from March to May of 2021. Curriculum content questions were developed using AMS topics recommended by pharmacy educators in the United States, and professional roles described by the Association of Faculties of Pharmacy of Canada.

All 10 Canadian faculties returned a completed survey. All programs reported teaching AMS principles in their core curricula. Content coverage varied, with programs teaching, on average, 68% of the recommended AMS topics from the United States. Potential gaps were identified within the professional roles of “communicator” and “collaborator.” Didactic methods of content delivery and student assessment, such as lectures and multiple-choice questions, were most frequently used. Three programs offered additional AMS content in their elective curricula. Experiential rotations in AMS were commonly offered, though teaching AMS in formalized interprofessional settings was rare. Curricular time constraints were identified by all programs as a barrier to enhancing AMS instruction. A course to teach AMS, a curriculum framework, and prioritization by the faculty’s curriculum committee were perceived as facilitators.

Our findings highlight potential gaps and areas of opportunity within Canadian pharmacy AMS instruction.

To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital.

Retrospective observational study.

1,278-bed academic hospital.

Adults admitted to non-ICU medicine services.

A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention.

The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality.

The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.

To evaluate the effect of templated microbiology reporting comments on antifungal utilization in patients with candiduria.

In this retrospective, quasi-experimental study, we evaluated a preimplementation cohort (June 2018–January 2019) compared with a postimplementation cohort (June 2019–January 2020).

A multisite health system including 1 academic hospital and 4 community hospitals.

Patients were aged ≥18 years, were hospitalized, and had candiduria documented at least once during their admission. The study included 156 patients in the preimplementation period and 141 patients in the postimplementation period.

In June 2019, Saint Luke’s Health System implemented the use of templated comments for urine cultures with Candida spp growth. When Candida is isolated, the following comment appears in the microbiology result section: “In the absence of symptoms, Candida is generally considered normal flora. No therapy indicated unless high risk (pregnant, neonate, or neutropenic) or undergoing urologic procedure. If Foley catheter present, remove or replace when able.” The primary outcome was rate of antifungal prescribing.

Antifungal administration within 72 hours of a culture identifying a Candida spp occurred in 75 patients in the preimplementation group and 48 patients in the postimplementation group (48.1% vs 34.0%; P = .02). We did not detect a difference between groups in antifungal administration between 73 and 240 hours (1.3% vs 3.5%; P = .26), nor did we detect a difference in median antifungal duration (4 vs 3 days; P = .43).

Using a templated comment with urine cultures reduced antifungal prescription rates in hospitalized patients with candiduria. This strategy is a low-resource technique to improve antimicrobial stewardship.

To describe clinical syndromes, opportunities for antimicrobial optimization, and acceptance of recommendations made by an immunocompromised antimicrobial stewardship program performing in-person prospective audit and feedback (IPPAF) on inpatient oncology services.

Retrospective cohort study.

Three inpatient oncology services including patients with solid tumor malignancies in an academic cancer center.

Hospitalized adults with oncologic malignancies receive antimicrobials for any indication.

We reviewed all patients receiving antimicrobials on inpatient oncology services who were included in IPPAF and prospectively documented clinical syndromes represented, most common recommendations, and acceptance rate. We also examined the standardized antimicrobial administration ratio (SAAR) for oncology units over the study period.

Over 34 weeks, we performed 154 interventions for 138 patients. Metastatic malignancy was common (52%) and 90-day mortality was high (43%). Diagnostic uncertainty was common (33/154, 21%), as were cases of intra-abdominal pathology (30/154, 19%), pneumonia (25/154, 16%), and urinary tract infection (12/154, 8%). The most common recommendations were changes in duration (63/154, 41%) and stopping antimicrobials for syndromes determined to be noninfectious (29/154, 19%). Acceptance of interventions was high (77% overall) and several SAARs on the primary oncology unit significantly decreased after starting IPPAF.

We identified numerous opportunities for antimicrobial optimization among solid tumor malignancy patients. Most clinical syndromes were ones also encountered frequently in non-oncology populations, but several were unique and represented opportunities for targeted education.

To assess the prevalence of antibiotic-resistant gram-negative bacteria (R-GNB) among patients without recent hospitalization and to examine the influence of outpatient antibiotic exposure on the risk of acquiring R-GNB in this population.

2-year retrospective cohort study.

Regional Veterans Affairs healthcare system.

Outpatients at 13 community-based clinics.

We examined the rate of acquisition of R-GNB within 90 days following an outpatient visit from 2018 to 2019. We used clinical and administrative databases to determine and summarize prescriptions for systemic antibiotics, associated infectious diagnoses, and subsequent R-GNB acquisition among patients without recent hospitalizations. We also calculated the odds ratio of R-GNB acquisition following antibiotic exposure.

During the 2-year study period, 7,215 patients had outpatient visits with microbiological cultures obtained within 90 days. Of these patients, 206 (2.9%) acquired an R-GNB. Among patients receiving antibiotics at the visit, 4.6% acquired a R-GNB compared to 2.7% among patients who did not receive antibiotics, yielding an unadjusted odds ratio of 1.75 (95% confidence interval, 1.18–2.52) for a R-GNB following an outpatient visit with versus without an antibiotic exposure. Regardless of R-GNB occurrence, >50% of antibiotic prescriptions were issued at visits without an infectious disease diagnosis or issued without documentation of an in-person or telehealth clinical encounter.

Although the rate of R-GNBs was low (2.9%), the 1.75-fold increased odds of acquiring a R-GNB following an outpatient antibiotic highlights the importance of antimicrobial stewardship efforts in outpatient settings. Specific opportunities include reducing antibiotics prescribed without an infectious diagnosis or a clinical visit.

To review methodologies and outcomes reporting among these studies and to develop a conceptual framework of outcomes to assist in guiding studies and production of clinical metrics.

PubMed and Embase from January 1, 2012, thru December 1, 2021.

Studies evaluating highly multiplex molecular respiratory diagnostics and their impact on either clinical or economic outcomes.

A systematic literature review (SLR) of methodologies and outcomes reporting was performed. A qualitative synthesis of identified SLRs and associated primary studies was conducted to develop conceptual framework for outcomes.

Ultimately, 4 systemic literature reviews and their 12 associated primary studies were selected for review. Most primary studies included patient outcomes focusing on antimicrobial exposure changes such as antibiotic (80%) and antiviral use (50%) or occupancy changes such as hospital length of stay (60%). Economic outcomes were infrequently reported, and societal outcomes, such as antibiotic resistance impact, were absent from the reviewed literature. Qualitative evidence synthesis of reported outcomes yielded a conceptual framework of outcomes to include operational, patient, economic, and societal domains.

Our review highlights the significant heterogeneity in outcomes reporting among clinical impact studies for highly multiplex molecular respiratory diagnostics. Furthermore, we developed a conceptual framework of outcomes domains that may act as a guide to improve considerations in outcomes selection and reporting when evaluating clinical impact of these tests. These improvements may be important in synthesizing the evidence for informing clinical decision making, guidelines, and financial reimbursement.

Feedback on optimal antimicrobial prescribing to clinicians is an important strategy to ensure antimicrobial stewardship (AMS) in the hospital setting.

To explore the perceptions of antimicrobial prescribing feedback among clinicians in acute care.

Prospective qualitative design.

A large inner-city tertiary referral center in Dublin, Ireland.

Clinicians were recruited from the hospital clinician population.

A qualitative study was conducted with a purposive sample of multidisciplinary clinicians. Focus groups and semistructured interviews were used to collect data that were analyzed inductively to identify themes.

In total, 30 clinicians from medical, surgical, nursing and pharmacy professions participated in the study. We identified 5 themes: (1) antimicrobial consumption perceived as a proxy measure for prescribing quality; (2) lack of connection between antimicrobial prescribing and patient outcomes; (3) relevance and impact of antimicrobial prescribing feedback associated with professional role; (4) attitudes regarding feedback as an AMS strategy; and (5) knowledge regarding AMS, including antimicrobial prescribing quality measures.

Focused feedback on antimicrobial prescribing, with clear goals for improvement, could serve as a useful AMS strategy among clinicians in the acute-care setting. The need for further education and training in AMS was also identified.