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To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers.
Qualitative semistructured interviews.
The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans’ Health Administration and 4 hospitals in Intermountain Healthcare.
We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders.
Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant’s role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR.
We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff.
Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.
Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization’s urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)–based methodology for disparity and inequity audits in other systems and for other conditions.
To determine the proportion of hospitals that implemented 6 leading practices in their antimicrobial stewardship programs (ASPs). Design: Cross-sectional observational survey.
Advance letters and electronic questionnaires were initiated February 2020. Primary outcomes were percentage of hospitals that (1) implemented facility-specific treatment guidelines (FSTG); (2) performed interactive prospective audit and feedback (PAF) either face-to-face or by telephone; (3) optimized diagnostic testing; (4) measured antibiotic utilization; (5) measured C. difficile infection (CDI); and (6) measured adherence to FSTGs.
Of 948 hospitals invited, 288 (30.4%) completed the questionnaire. Among them, 82 (28.5%) had <99 beds, 162 (56.3%) had 100–399 beds, and 44 (15.2%) had ≥400+ beds. Also, 230 (79.9%) were healthcare system members. Moreover, 161 hospitals (54.8%) reported implementing FSTGs; 214 (72.4%) performed interactive PAF; 105 (34.9%) implemented procedures to optimize diagnostic testing; 235 (79.8%) measured antibiotic utilization; 258 (88.2%) measured CDI; and 110 (37.1%) measured FSTG adherence. Small hospitals performed less interactive PAF (61.0%; P = .0018). Small and nonsystem hospitals were less likely to optimize diagnostic testing: 25.2% (P = .030) and 21.0% (P = .0077), respectively. Small hospitals were less likely to measure antibiotic utilization (67.8%; P = .0010) and CDI (80.3%; P = .0038). Nonsystem hospitals were less likely to implement FSTGs (34.3%; P < .001).
Significant variation exists in the adoption of ASP leading practices. A minority of hospitals have taken action to optimize diagnostic testing and measure adherence to FSTGs. Additional efforts are needed to expand adoption of leading practices across all acute-care hospitals with the greatest need in smaller hospitals.
To examine how individual steward characteristics (eg, steward role, sex, and specialized training) are associated with their views of antimicrobial stewardship program (ASP) implementation at their institution.
Descriptive survey from a mixed-methods study.
Two large national healthcare systems; the Veterans’ Health Administration (VA) (n = 134 hospitals) and Intermountain Healthcare (IHC; n = 20 hospitals).
We sent the survey to 329 antibiotic stewards serving in 154 hospitals; 152 were physicians and 177 were pharmacists. In total, 118 pharmacists and 64 physicians from 126 hospitals responded.
The survey was grounded in constructs of the Consolidated Framework for Implementation Research, and it assessed stewards’ views on the development and implementation of antibiotic stewardship programs (ASPs) at their institutions We then examined differences in stewards’ views by demographic factors.
Regardless of individual factors, stewards agreed that the ASP added value to their institution and was advantageous to patient care. Stewards also reported high levels of collegiality and self-efficacy. Stewards who had specialized training or those volunteered for the role were less likely to think that the ASP was implemented due to a mandate. Similarly volunteers and those with specialized training felt that they had authority in the antibiotic decisions made in their facility.
Given the importance of ASPs, it may be beneficial for healthcare institutions to recruit and train individuals with a true interest in stewardship.
Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.
Efforts to improve antimicrobial prescribing are occurring within a changing healthcare landscape, which includes the expanded use of telehealth technology. The wider adoption of telehealth presents both challenges and opportunities for promoting antimicrobial stewardship. Telehealth provides 2 avenues for remote infectious disease (ID) specialists to improve inpatient antimicrobial prescribing: telehealth-supported antimicrobial stewardship and tele-ID consultations. Those 2 activities can work separately or synergistically. Studies on telehealth-supported antimicrobial stewardship have reported a reduction in inpatient antimicrobial prescribing, cost savings related to less antimicrobial use, a decrease in Clostridioides difficile infections, and improved antimicrobial susceptibility patterns for common organisms. Tele-ID consultation is associated with fewer hospital transfers, a shorter length of hospital stay, and decreased mortality. The implementation of these activities can be flexible depending on local needs and available resources, but several barriers may be encountered. Opportunities also exist to improve antimicrobial use in outpatient settings. Telehealth provides a more rapid mechanism for conducting outpatient ID consultations, and increasing use of telehealth for routine and urgent outpatient visits present new challenges for antimicrobial stewardship. In primary care, urgent care, and emergency care settings, unnecessary antimicrobial use for viral acute respiratory tract infections is common during telehealth encounters, as is the case for fact-to-face encounters. For some diagnoses, such as otitis media and pharyngitis, antimicrobials are further overprescribed via telehealth. Evidence is still lacking on the optimal stewardship strategies to improve antimicrobial prescribing during telehealth encounters in ambulatory care, but conventional outpatient stewardship strategies are likely transferable. Further work is warranted to fill this knowledge gap.
SHEA endorses adhering to the recommendations by the CDC and ACIP for immunizations of all children and adults. All persons providing clinical care should be familiar with these recommendations and should routinely assess immunization compliance of their patients and strongly recommend all routine immunizations to patients. All healthcare personnel (HCP) should be immunized against vaccine-preventable diseases as recommended by the CDC/ACIP (unless immunity is demonstrated by another recommended method). SHEA endorses the policy that immunization should be a condition of employment or functioning (students, contract workers, volunteers, etc) at a healthcare facility. Only recognized medical contraindications should be accepted for not receiving recommended immunizations.
Using the Veterans’ Health Administration MRSA Directive as a platform to collect methicillin-resistant Staphylococcus aureus (MRSA) colonization isolates and an active MRSA infection surveillance program, the genetic relatedness of colonization and infection isolates was evaluated. Infection and colonization strain concordance was found in 85.7% of patients. The USA 500 MRSA strain was identified in 31.8% of patients.
To better understand hospital infection control practices in Ethiopia.
A cross-sectional evaluation of healthcare worker (HCW) knowledge, attitudes, and practices about hand hygiene and tuberculosis (TB) infection control measures.
An anonymous 76-item questionnaire was administered to HCWs at 2 university hospitals in Addis Ababa, Ethiopia. Knowledge items were scored as correct/incorrect. Attitude and practice items were assessed using a Likert scale.
In total, 261 surveys were completed by physicians (51%) and nurses (49%). Fifty-one percent of respondents were male; mean age was 30 years. While hand hygiene knowledge was fair, self-reported practice was suboptimal. Physicians reported performing hand hygiene 7% and 48% before and after patient contact, respectively. Barriers for performing hand hygiene included lack of hand hygiene agents (77%), sinks (30%), and proper training (50%) as well as irritation and dryness (67%) caused by hand sanitizer made in accordance with the World Health Organization formulation. TB infection control knowledge was excellent (more than 90% correct). Most HCWs felt that they were at high risk for occupational acquisition of TB (71%) and that proper TB infection control can prevent nosocomial transmission (92%). Only 12% of HCWs regularly wore a mask when caring for TB patients. Only 8% of HCWs reported that masks were regularly available, and 76% cited a lack of infrastructure to isolate suspected/known TB patients.
Training HCWs about the importance and proper practice of hand hygiene along with improving hand sanitizer options may improve patient safety. Additionally, enhanced infrastructure is needed to improve TB infection control practices and allay HCW concerns about acquiring TB in the hospital.
Describe local changes in the incidence of community-onset and hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) infection and evaluate the impact of MRSA active surveillance on hospital-onset infection.
Observational study using prospectively collected data.
Atlanta Veterans Affairs Medical Center (AVAMC).
All patients seen at the AVAMC over an 8-year period with clinically and microbiologically proven MRSA infection.
All clinical cultures positive for MRSA were prospectively identified, and corresponding clinical data were reviewed. MRSA infections were classified into standard clinical and epidemiologic categories. The Veterans Health Administration implemented the MRSA directive in October 2007, which required active surveillance cultures in acute care settings.
The incidence of community-onset MRSA infection peaked in 2007 at 5.45 MRSA infections per 1,000 veterans and decreased to 3.14 infections per 1,000 veterans in 2011 (P < .001 for trend). Clinical and epidemiologic categories of MRSA infections did not change throughout the study period. The prevalence of nasal MRSA colonization among veterans admitted to AVAMC decreased from 15.8% in 2007 to 11.2% in 2011 (P <.001 for trend). The rate of intensive care unit (ICU)-related hospital-onset MRSA infection decreased from October 2005 through March 2007, before the MRSA directive. Rates of ICU-related hospital-onset MRSA infection remained stable after the implementation of active surveillance cultures. No change was observed in rates of non-ICU-related hospital-onset MRSA infection.
Our study of the AVAMC population over an 8-year period shows a consistent trend of reduction in the incidence of MRSA infection in both the community and healthcare settings. The etiology of this reduction is most likely multifactorial.
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