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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.
Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans’ Health Administration clinics.
We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.
Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.
Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians’ perceptions of antibiotic prescribing practices and should enhance their patient communication skills.
To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program.
The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities.
Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities.
Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection.
The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs.
Antimicrobial stewardship programs (ASPs) are variably implemented.
To characterize variations of antimicrobial stewardship structure and practices across all inpatient Veterans Affairs facilities in 2012 and correlate key characteristics with antimicrobial usage.
A web-based survey regarding stewardship activities was administered to each facility’s designated contact. Bivariate associations between facility characteristics and inpatient antimicrobial use during 2012 were determined.
Total of 130 Veterans Affairs facilities with inpatient services.
Of 130 responding facilities, 29 (22%) had a formal policy establishing an ASP, and 12 (9%) had an approved ASP business plan. Antimicrobial stewardship teams were present in 49 facilities (38%); 34 teams included a clinical pharmacist with formal infectious diseases (ID) training. Stewardship activities varied across facilities, including development of yearly antibiograms (122 [94%]), formulary restrictions (120 [92%]), stop orders for antimicrobial duration (98 [75%]), and written clinical pathways for specific conditions (96 [74%]). Decreased antimicrobial usage was associated with having at least 1 full-time ID physician (P=.03), an ID fellowship program (P=.003), and a clinical pharmacist with formal ID training (P=.006) as well as frequency of systematic patient-level reviews of antimicrobial use (P=.01) and having a policy to address antimicrobial use in the context of Clostridium difficile infection (P=.01). Stop orders for antimicrobial duration were associated with increased use (P=.03).
ASP-related activities varied considerably. Decreased antibiotic use appeared related to ID presence and certain select practices. Further statistical assessments may help optimize antimicrobial practices.
In the early 1950s, Lancefield divided streptococci into groups based on carbohydrates present in the cell wall and designated the groups A through H and K through T. In addition, streptococci may be classified by their characteristics on culture on sheep blood agar. β-Hemolytic streptococci produce zones of clear hemolysis around each colony; α-hemolytic streptococci (Streptococcus viridans) produce a green discoloration characteristic of incomplete hemolysis; absence of hemolysis is characteristic of γ-streptococci.
The sole member of Lancefield group A is Streptococcus pyogenes. Group A streptococcus is ubiquitous in the environment but with rare exceptions is exclusively found in or on the human host. About 5% to 20% of the population harbor group A streptococcus in their pharynx, and some are colonized on their skin. This organism produces a variety of suppurative infections; however, streptococcal pharyngitis, the most common, is characterized by the onset of sore throat, fever, painful swallowing, and chilliness. These symptoms combined with submandibular adenopathy, pharyngeal erythema, and exudates correlate with positive throat cultures in 85% to 90% of cases. Sore throat without fever or any of the other signs and symptoms has a low predictive value for pharyngitis caused by group A streptococcus. Rapid strep tests correlate with positive cultures in 68% to 99% of cases, but results depend greatly on the individual performing the test as well as the bacterial colony count. Colony counts greater than 100 per plate correlated with positive rapid strep tests in 95% of patients, and counts less than 100 per plate correlated with positive rapid strep tests for only 68% of patients.
In the early 1950s, Lancefield divided streptococci into groups based on carbohydrates present in the cell wall and designated the groups A through H and K through T. In addition, streptococci may be classified by their characteristics on culture on sheep blood agar. β-Hemolytic streptococci produce zones of clear hemolysis around each colony; α-hemolytic streptococci (Strepococcus viridans) produce a green discoloration characteristic of incomplete hemolysis; absence of hemolysis is characteristic of γ-streptococci.
The sole member of Lancefield group A is Streptococcus pyogenes. Group A streptococcus is ubiquitous in the environment but with rare exceptions is exclusively found in or on the human host. About 5% to 20% of the population harbor group A streptococcus in their pharynx, and some are colonized on their skin. This organism produces a variety of suppurative infections; however, streptococcal pharyngitis, the most common, is characterized by the onset of sore throat, fever, painful swallowing, and chilliness. These symptoms combined with submandibular adenopathy, pharyngeal erythema, and exudates correlate with positive throat cultures in 85% to 90% of cases. Sore throat without fever or any of the other signs and symptoms has a low predictive value for pharyngitis caused by group A streptococcus. Rapid strep tests correlate with positive cultures in 68% to 99% of cases, but results depend greatly on the individual performing the test as well as the bacterial colony count.
Society for Health Care Epidemiology guidelines recommend decreasing the use of fluoroquinolone antibiotics in institutions where methicillin-resistant Staphylococcus aureus (MRSA) is endemic. We evaluated whether an intervention to limit fluoroquinolone use was associated with a lower rate of nosocomial MRSA infection and summarized changes in antibiotic use, changes in other variables potentially correlated with a lower rate of MRSA infection, and rates of nosocomial infections due to other pathogens.
Single-center quasi-experimental design. A time series of nosocomial MRSA infections was measured at monthly intervals from July 2001 through June of 2004; there were 80 MRSA infections recorded. Segmented regression analysis (ie, quasi-Poisson generalized linear models) was used to evaluate variables possibly associated with the nosocomial MRSA infection rate.
An 87-bed Veterans Affairs teaching hospital with an extended-care facility.
A physician-directed computer-generated intervention designed to limit the use of fluoroquinolone antibiotics was initiated, and institutional changes in antibiotic use and nosocomial MRSA infection rates were tracked.
After the intervention, fluoroquinolone use decreased by approximately 34%, and levofloxacin use decreased by approximately 50%. Decreased fluoroquinolone use was offset by increased cephalosporin, piperacillin-tazobactam, and trimethoprim-sulfamethoxazole use. The nosocomial MRSA infection rate decreased from 1.37 to 0.63 episodes per 1,000 patient-days after the study intervention (P = .02). Coagulase-negative Staphylococcus and Enterococcus infection rates also decreased. However, the rate of infection with gram-negative organisms increased. The rate of MRSA infection was positively correlated with levofloxacin use (P = .01) and azithromycin use (P = .08), whereas it was negatively correlated with summer season (P = .05). In a subsequent model, the rate of MRSA infection was negatively correlated with the study intervention (P = .04).
Reduction in the institutional use of fluoroquinolones may be associated with a lower nosocomial MRSA infection rate.
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