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COVID-19 therapies were challenging to deploy due to evolving literature and conflicting guidelines. Antimicrobial stewardship can help optimize drug use. We conducted a survey to understand the role of stewardship and formulary restrictions during the pandemic. Restrictions for COVID-19 therapies were common and approval by infectious disease physicians often required.
The coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted Black, indigenous, and people of color (BIPOC). Equitable access to therapeutics is key to addressing health disparities. We established a monoclonal infusion program in the emergency department of a safety-net hospital. Our program successfully reached underserved BIPOC communities and was sustained throughout the pandemic.
Deploying therapeutics for coronavirus disease 2019 (COVID-19) has proved challenging due to evolving evidence, supply shortages, and conflicting guideline recommendations. We conducted a survey on remdesivir use and the role of stewardship. Use differs significantly from guidelines. Hospitals with remdesivir restrictions were more guideline concordant. Formulary restrictions can be important for pandemic response.
We assessed the efficacy of a culturally competent outreach model with promotoras in raising the coronavirus disease 2019 (COVID-19) first-dose vaccination rates in Chicago’s at-risk ZIP codes from February through May 2021. Utilizing community members from within target communities may reduce barriers, increase vaccination rates, and enhance COVID-19 prevention.
To describe antimicrobial resistance before and after the COVID-19 pandemic in the Dominican Republic.
The study included 49 outpatient laboratory sites located in 13 cities nationwide.
Patients seeking ambulatory microbiology testing for urine and bodily fluids
We reviewed antimicrobial susceptibility reports for Escherichia coli isolates from urine and Pseudomonas aeruginosa (PSAR) from bodily fluids between January 1, 2018, to December 31, 2021, from deidentified susceptibility data extracted from final culture results.
In total, 27,718 urine cultures with E. coli and 2,111 bodily fluid cultures with PSAR were included in the analysis. On average, resistance to ceftriaxone was present in 25.19% of E. coli isolated from urine each year. The carbapenem resistance rates were 0.15% for E. coli and 3.08% for PSAR annually. The average rates of E. coli with phenotypic resistance consistent with possible extended-spectrum β-lactamase (ESBL) in urine were 25.63% and 24.75%, respectively, before and after the COVID-19 pandemic. The carbapenem resistance rates in urine were 0.11% and 0.20%, respectively, a 200% increase. The average rates of PSAR with carbapenem resistance in bodily fluid were 2.33% and 3.84% before and after the COVID-19 pandemic, respectively, a 130% percent increase.
Resistance to carbapenems in PSAR and E. coli after the COVID-19 pandemic is rising. These resistance patterns suggest that ESBL is common in the Dominican Republic. Carbapenem resistance was uncommon but increased after the COVID-19 pandemic.
In many developing countries, antimicrobials are available without prescriptions in pharmacies and stores. We performed a survey to describe antimicrobial availability, training, and use recommendations for common symptoms in the Dominican Republic. Pharmacy recommendations varied, whereas aminopenicillins are routinely recommended at bodegas. Frontline staff are gatekeepers and potential targets for stewardship education.
To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks.
HOB preventability rating guide was compared against a reference standard expert panel.
A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison.
The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.
Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic.
Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.
After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64–0.88]) and 87% (κ, 0.79; 95% CI, 0.65–0.94) for the 52 scenarios with expert consensus.
Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.
Strategies for pandemic preparedness and response are urgently needed for all settings. We describe our experience using inverted classroom methodology (ICM) for COVID-19 pandemic preparedness in a small hospital with limited infection prevention staff. ICM for pandemic preparedness was feasible and contributed to an increase in COVID-19 knowledge and comfort.
Background: Hospital-onset bacteremia and fungemia (HOB) may be a preventable hospital-acquired condition and a potential healthcare quality measure. We developed and evaluated a tool to assess the preventability of HOB and compared it to a more traditional consensus panel approach. Methods: A 10-member healthcare epidemiology expert panel independently rated the preventability of 82 hypothetical HOB case scenarios using a 6-point Likert scale (range, 1= “Definitively or Almost Certainly Preventable” to 6= “Definitely or Almost Certainly Not Preventable”). Ratings on the 6-point scale were collapsed into 3 categories: Preventable (1–2), Uncertain (3–4), or Not preventable (5–6). Consensus was defined as concurrence on the same category among ≥70% expert raters. Cases without consensus were deliberated via teleconference, web-based discussion, and a second round of rating. The proportion meeting consensus, overall and by predefined HOB source attribution, was calculated. A structured HOB preventability rating tool was developed to explicitly account for patient intrinsic and extrinsic healthcare-related risks (Fig. 1). Two additional physician reviewers independently applied this tool to adjudicate the same 82 case scenarios. The tool was iteratively revised based on reviewer feedback followed by repeat independent tool-based adjudication. Interrater reliability was evaluated using the Kappa statistic. Proportion of cases where tool-based preventability category matched expert consensus was calculated. Results: After expert panel round 1, consensus criteria were met for 29 cases (35%), which increased to 52 (63%) after round 2. Expert consensus was achieved more frequently for respiratory or surgical site infections than urinary tract and central-line–associated bloodstream infections (Fig. 2a). Most likely to be rated preventable were vascular catheter infections (64%) and contaminants (100%). For tool-based adjudication, following 2 rounds of rating with interim tool revisions, agreement between the 2 reviewers was 84% for cases overall (κ, 0.76; 95% CI, 0.64–0.88]), and 87% for the 52 cases with expert consensus (κ, 0.79; 95% CI, 0.65–0.94). Among cases with expert consensus, tool-based rating matched expert consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewer 1 and reviewer 2, respectively. The proportion of cases rated “uncertain“ was lower among tool-based adjudicated cases with reviewer agreement (15 of 69) than among cases with expert consensus (23 of 52) (Fig. 2b). Conclusions: Healthcare epidemiology experts hold varying perspectives on HOB preventability. Structured tool-based preventability rating had high interreviewer reliability, matched expert consensus in most cases, and rated fewer cases with uncertain preventability compared to expert consensus. This tool is a step toward standardized assessment of preventability in future HOB evaluations.
Background: Antimicrobial use in low- and middle-income countries (LMICs) can play a major role in the development of antimicrobial resistance (AMR). In many LMICs, antimicrobials can be dispensed without prescriptions; they often available in pharmacies and nonpharmacy stores alike. We conducted a nationwide survey to describe the availability and antimicrobial dispensation practices in pharmacies and nonpharmacy stores in the Dominican Republic. Methods: A survey was administered to staff responsible for dispensing antimicrobials at pharmacies and nonpharmacy stores in the Dominican Republic. Stores were randomly selected from March through November 2019 in 7 cities representing all geographic regions of the Dominican Republic. Data on availability of antimicrobials and staff education on antimicrobial use were obtained. Case scenarios with commons symptoms were used to survey staff on antimicrobial use recommendations. Symptoms included dysuria, throat pain, diarrhea, fever, and cough. The availability of antimicrobials ordering by phone and via online delivery was assessed for each store. Results: Staff from 125 stores were invited to participate; 34 pharmacies and 48 nonpharmacy stores participated and 43 refused to participate. Overall, 200 antimicrobial use recommendations were given in pharmacies and 43 in nonpharmacy stores. The most common type of antimicrobial use recommendations were aminopenicillins (Fig. 1). Staff received prior training or education on antimicrobials in 61% of pharmacies and 0% of nonpharmacy stores. Antimicrobial recommendations by case scenario in pharmacies and nonpharmacy stores are shown in Figs. 2 and 3. Antimicrobials are available for phone order in 80% of pharmacies and 90% of nonpharmacy stores. No antimicrobials were available via online delivery apps. Conclusions: Antimicrobials are widely available in the Dominican Republic and can be obtained without a prescription, in person or via delivery. Staff at pharmacy stores recommended different antimicrobials by symptom, whereas staff at nonpharmacy stores commonly recommended aminopenicillins for all symptoms. Training or education on antimicrobial use was common for staff at pharmacy stores but nonexistent for staff at nonpharmacy stores. In LMICs with easy access to antimicrobials, frontline staff in pharmacies and nonpharmacy stores are gatekeepers for antimicrobial use and may represent an important target for outpatient antimicrobial stewardship initiatives.
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