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 impact of the addition of an indication specification requirement to isolated urine-culture ordering on testing utilization.

Retrospective study utilizing interrupted time series analysis with negative binomial regression. The preintervention period was October 1, 2018–November 11, 2019, and the postintervention period was November 12, 2019–October 31, 2020. The primary outcome was isolated culture rate per 1,000 patient days. Secondary outcomes were the proportion of all urine tests ordered as isolated urine culture and culture positivity. An exploratory analysis assessed the appropriateness of selected testing indications.

A 415-bed, urban, academic medical center.

Adult patients with urine testing performed during hospital admission. In total, 1,494 unique isolated urine-culture orders were included in the analysis.

On November 12, 2019, the laboratory order interface was changed to require the ordering provider to select an indication for isolated urine culture.

Isolated urine-culture rates did not significantly change after the intervention (11.2–7.8 cultures per 1,000 patient days; P = .17) nor did culture positivity (26.9% vs 26.8%). Most ordering providers left the indication for testing blank, and of those charts reviewed, 67% did not have a documented condition for which isolated urine culture was the most appropriate initial test.

The addition of an order-specification requirement for isolated urine-culture testing did not significantly affect ordering practices. The test remains overused as the initial diagnostic evaluation for a suspected urinary tract infection. Further provider education and continued changes in provider workflow are needed to achieve lasting change in practice.

This report describes a cluster of patients infected by Serratia marcescens in a metropolitan neonatal intensive care unit (NICU) and a package of infection control interventions that enabled rapid, effective termination of the outbreak.

Cross-sectional analytical study using whole-genome sequencing (WGS) for phylogenetic cluster analysis and identification of virulence and resistance genes.

NICU in a metropolitan tertiary-care hospital in Sydney, Australia.

All neonates admitted to the level 2 and level 3 neonatal unit.

Active inpatient and environmental screening for Serratia marcescens isolates with WGS analysis for identification of resistance genes as well as cluster relatedness between isolates. Planning and implementation of a targeted, multifaceted infection control intervention.

The cluster of 10 neonates colonized or infected with Serratia marcescens was identified in a metropolitan NICU. Two initial cases involved devastating intracranial infections with brain abscesses, highlighting the virulence of this organism. A targeted and comprehensive infection control intervention guided by WGS findings enabled termination of this outbreak within 15 days of onset. WGS examination demonstrated phylogenetic linkage across the cluster, and genomic unrelatedness of later strains identified in the neonatal unit and elsewhere.

A comprehensive, multipronged, infection control package incorporating close stakeholder engagement, frequent microbiological patient screening, environmental screening, enhanced cleaning, optimization of hand hygiene and healthcare worker education was paramount to the prompt control of Serratia marcescens transmission in this neonatal outbreak. WGS was instrumental in establishing relatedness between isolates and identification of possible transmission pathways in an outbreak setting.

The aim of this study was to characterize the type and extent of virtual care use among infectious disease specialists in Canada, with a focus on the clinical factors that influence the decision to provide virtual versus in-person care.

Infectious disease physicians practicing in Canada were invited to complete a survey regarding their experiences with virtual care. The survey included 14 vignettes depicting new outpatient and post–hospital-discharge referrals. Participants were asked to select which (if any) virtual care modalities they would feel comfortable using and to specify a reason if they did not feel comfortable providing care virtually. Machine learning and natural language processing techniques were used to identify themes.

In total, 57 infectious disease physicians completed the survey. Respondents reported devoting 36.5% (SD, 18.4%) of their infectious disease practice to outpatient care, with 44.2% (SD, 23.2%) of it being delivered virtually. Respondents were more comfortable providing virtual care to post–hospital-discharge referrals who had been seen by an infectious disease physician compared to new outpatient referrals. When respondents were not comfortable with using any virtual care modality, the following common themes emerged: the need for physical examination, the importance of establishing a therapeutic relationship, the need for additional in-person tests or diagnostics, and patient counselling.

This study provides a glimpse into the current state of virtual care use in Canada and some of the major themes that affect decision making for virtual versus in-person care.

Antibiotic overuse is common in outpatient pediatrics and varies across clinical setting and clinician type. We sought to identify social, behavioral, and environmental drivers of outpatient antibiotic prescribing for pediatric patients.

We conducted semistructured interviews with physicians and advanced practice providers (APPs) across diverse outpatient settings including pediatric primary, urgent, and retail care. We used the grounded theory constant comparative method and a thematic approach to analysis. We developed a conceptual model, building on domains of continuity to map common themes and their relationships within the healthcare system.

We interviewed 55 physicians and APPs. Clinicians across all settings prioritized provision of guideline-concordant care but implemented these guidelines with varying degrees of success. The provision of guideline-concordant care was influenced by the patient–clinician relationship and patient or parent expectations (relational continuity); the clinician’s access to patient clinical history (informational continuity); and the consistency of care delivered (management continuity). No difference in described themes was determined by setting or clinician type; however, clinicians in primary care described having more reliable relational and informational continuity.

Clinicians described the absence of long-term relationships (relational continuity) and lack of availability of prior clinical history (informational continuity) as factors that may influence outpatient antibiotic prescribing. Guideline-concordant outpatient antibiotic prescribing was facilitated by consistent practice across settings (management continuity) and the presence of relational and informational continuity, which are common only in primary care. Management continuity may be more modifiable than informational and relational continuity and thus a focus for outpatient stewardship programs.

To evaluate the effectiveness of ultraviolet-C (UV-C) disinfection as an adjunct to standard chlorine-based disinfectant terminal room cleaning in reducing transmission of hospital-acquired multidrug-resistant organisms (MDROs) from a prior room occupant.

A retrospective cohort study was conducted to compare rates of MDRO transmission by UV-C status from January 1, 2016, through December 31, 2018.

Acute-care, single-patient hospital rooms at 6 hospitals within an academic healthcare system in Pennsylvania.

Transmission of hospital-acquired MDRO infection was assessed in patients subsequently assigned to a single-patient room of a source occupant with carriage of 1 or more MDROs on or during admission. Acquisition of 5 pathogens was compared between exposed patients in rooms with standard-of-care chlorine-based disinfectant terminal cleaning with or without adjunct UV-C disinfection. Logistic regression analysis was used to estimate the adjusted risk of pathogen transfer with adjunctive use of UV-C disinfection.

In total, 33,771 exposed patient admissions were evaluated; the source occupants carried 46,688 unique pathogens. Prior to the 33,771 patient admissions, 5,802 rooms (17.2%) were treated with adjunct UV-C disinfection. After adjustment for covariates, exposed patients in rooms treated with adjunct UV-C were at comparable risk of transfer of any pathogen (odds ratio, 1.06; 95% CI, 0.84–1.32; P = .64).

Our analysis does not support the use of UV-C in addition to post-discharge cleaning with chlorine-based disinfectant to lower the risk of prior room occupant pathogen transfer.

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.

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 assess the effectiveness of a targeted intervention using a collaborative approach, added to a comprehensive educational intervention, to facilitate the appropriate use of oral third-generation cephalosporins (3GCs).

Quasi-experimental study.

The University of Tokyo Hospital, a tertiary-care teaching hospital.

Approximately 2,000,000 outpatients and 80,000 inpatients at the hospital between April 2017 and March 2020.

The targeted intervention using the collaborative approach was implemented in the departments with the highest use of oral 3GCs (ophthalmology and dermatology departments). Interrupted time-series analysis was applied to assess the change in days of therapy (DOT) of oral 3GCs between the preintervention period (April 2017–April 2019) and the postintervention period (May 2019–March 2020) for both inpatients and outpatients.

After the introduction of the targeted intervention with oral 3GCs, a significant immediate reduction of 13.48 DOT per 1,000 patient days was detected in inpatients (P < .001). However, no significant change in slope was observed before and after the intervention (−0.02 DOT per 1,000 patient days per month; P = .94). Although a temporary increase was observed after the targeted intervention in outpatients, the slope significantly decreased (−0.69 DOT per 1,000 outpatient visits per month; P = .044). No differences were observed in the use of other oral antibiotics after the intervention.

The targeted intervention contributed to a reduction in DOT of oral 3GCs in both inpatients and outpatients. Targeted interventions using a collaborative approach might be helpful in further decreasing the inappropriate use of antibiotics.

We implemented a preoperative staphylococcal decolonization protocol for colorectal surgeries if efforts to further reduce surgical site infections (SSIs).

Retrospective observational study.

Tertiary-care, academic medical center.

Adult patients who underwent colorectal surgery, as defined by National Healthcare Safety Network (NHSN), between July 2015 and June 2020. Emergent cases were excluded.

Simple and multivariable logistic regression were performed to evaluate the relationship between decolonization and subsequent SSI. Other predictive variables included age, sex, body mass index, procedure duration, American Society of Anesthesiology (ASA) score, diabetes, smoking, and surgical oncology service.

In total, 1,683 patients underwent nonemergent NHSN-defined colorectal surgery, and 33.7% underwent the staphylococcal decolonization protocol. SSI occurred in 92 (5.5%); 53 were organ-space infections and 39 were superficial wound infections. We detected no difference in overall SSIs between those decolonized and not decolonized (P = .17). However, superficial wound infections were reduced in the group that received decolonization versus those that did not: 7 (1.2%) of 568 versus 32 (2.9%) of 1,115 (P = .04).

Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.

To identify important risk factors for carbapenem-resistant Enterobacterales (CRE) infections among hospitalized patients.

We utilized a case–case–control design that compared patients with CRE infections to patients with carbapenem-susceptible Enterobacterales (CSE) infections and randomly selected controls during the period from January 2011 through December 2016.

The study population was selected from patients at a large metropolitan tertiary-care and instructional medical center.

Cases of CRE were defined as initial admission of adults diagnosed with a bacterial infection of an Enterobacterales species resistant clinically or through sensitivity testing to carbapenems 48 hours or more after admission. Cases of CSE were selected from the same patient population as the CRE cases within a 30-day window for admission, with diagnostic pathogens identified as susceptible to carbapenems. Controls were defined as adult patients admitted to any service within a 30-day window from a CRE case for >48 hours who did not meet either of the above case definitions during that admission.

Antibiotic exposure within 90 days prior to admission and length of hospital stay were both associated with increased odds of CRE and CSE infections compared to controls. Patients with CRE infections had >18 times greater odds of prior antibiotic exposure compared to patients with CSE infections.

Antibiotic exposure and increased length of hospital stay may result in increased patient risk of developing an infection resistant to carbapenems and other β-lactams.

Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship.

A discrete choice experiment presented participants with a vignette consisting of the same “stem” plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3–4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute.

The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States.

In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99–1.3), hypotension (utility, 0.88; 95% CI, 0.74–1.03), fever (utility, 0.76; 95% CI, 0.62–0.91) and copious sputum (utility, 0.75; 95% CI, 0.60–0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17–0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05–0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate.

Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.