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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 evaluate the effectiveness of Carolinas Healthcare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), a multicomponent outpatient stewardship program to reduce inappropriate antibiotic prescribing for upper respiratory infections by 20% over 2 years.
Before-and-after interrupted time series of antibiotics prescribed between 2 periods: April 2016–October 2017 and May 2018–March 2020.
The study included 162 primary-care practices within a large healthcare system in the greater Charlotte, North Carolina region.
Adult and pediatric patients with encounters for upper respiratory infections for which an antibiotic is inappropriate.
Patient and provider educational materials, along with a web-based provider prescribing dashboard aimed at reducing inappropriate antibiotic prescribing were developed and distributed. Monthly antibiotic prescribing rates were calculated as the number of eligible encounters with an antibiotic prescribed divided by the total number of eligible encounters. A segmented regression analysis compared monthly antibiotic prescribing rates before versus after CHOSEN implementation, while also accounting for practice type and seasonal trends in prescribing.
Overall, 286,580 antibiotics were prescribed during 704,248 preintervention encounters and 277,177 during 832,200 intervention encounters. Significant reductions in inappropriate prescribing rates were observed in all outpatient specialties: family medicine (relative difference before and after the intervention, −20.4%), internal medicine (−19.5%), pediatric medicine (−17.2%), and urgent care (−16.6%).
A robust multimodal intervention that combined a provider prescribing dashboard with a targeted education campaign demonstrated significant decreases in inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated ambulatory network.
To reduce inappropriate antimicrobial prescribing across ambulatory care, understanding the patient-, provider-, and practice-level characteristics associated with antibiotic prescribing is essential. In this study, we aimed to elucidate factors associated with inappropriate antimicrobial prescribing across urgent care, family medicine, and pediatric and internal medicine ambulatory practices.
DESIGN, SETTING, AND PARTICIPANTS
Data for this retrospective cohort study were collected from outpatient visits for common upper respiratory conditions that should not require antibiotics. The cohort included 448,990 visits between January 2014 and May 2016. Carolinas HealthCare System urgent care, family medicine, internal medicine and pediatric practices were included across 898 providers and 246 practices.
Prescribing rates were reported per 1,000 visits. Indications were defined using the International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) criteria. In multivariable models, the risk of receiving an antibiotic prescription was reported with adjustment for practice, provider, and patient characteristics.
The overall prescribing rate in the study cohort was 407 per 1,000 visits (95% confidence interval [CI], 405–408). After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03–1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96–5.97).
Our results suggest that patient, practice, and provider characteristics are associated with inappropriate antimicrobial prescribing. Future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a “one size fits all” approach.
To offer antimicrobial stewardship to a long-term acute care hospital using telemedicine.
We conducted an uninterrupted time-series analysis to measure the impact of antimicrobial stewardship on hospital-acquired Clostridium difficile infection (CDI) rates and antimicrobial use. Simple linear regression was used to analyze changes in antimicrobial use; Poisson regression was used to estimate the incidence rate ratio in CDI rates. The preimplementation period was April 1, 2010–March 31, 2011; the postimplementation period was April 1, 2011–March 31, 2014.
During the preimplementation period, total antimicrobial usage was 266 defined daily doses (DDD)/1,000 patient-days (PD); it rose 4.54 (95% CI, −0.19 to 9.28) per month then significantly decreased from preimplementation to postimplementation (−6.58 DDD/1,000 PD [95% CI, −11.48 to −1.67]; P=.01). The same trend was observed for antibiotics against methicillin-resistant Staphylococcus aureus (−2.97 DDD/1,000 PD per month [95% CI, −5.65 to −0.30]; P=.03). There was a decrease in usage of anti-CDI antibiotics by 50.4 DDD/1,000 PD per month (95% CI, −71.4 to −29.2; P<.001) at program implementation that was maintained afterwards. Anti-Pseudomonas antibiotics increased after implementation (30.6 DDD/1,000 PD per month [95% CI, 4.9–56.3]; P=.02) but with ongoing education this trend reversed. Intervention was associated with a decrease in hospital-acquired CDI (incidence rate ratio, 0.57 [95% CI, 0.35–0.92]; P=.02).
Antimicrobial stewardship using an electronic medical record via remote access led to a significant decrease in antibacterial usage and a decrease in CDI rates.
Infect. Control Hosp. Epidemiol. 2016;37(4):433–439
Antimicrobial stewardship programs (ASPs) are critically important for combating the emergence of antimicrobial resistance. Despite this, there are no regulatory requirements at a national level, which makes initiatives at the state level critical. The objectives of this study were to identify existing antimicrobial stewardship practices, characterize barriers to antimicrobial stewardship implementation in acute care hospitals throughout Massachusetts, and evaluate the impact on these hospitals of a state-sponsored educational conference on antimicrobial stewardship.
In September 2011, a state-sponsored educational program entitled “Building Stewardship: A Team Approach Enhancing Antibiotic Stewardship in Acute Care Hospitals” was offered to interested practitioners from throughout the state. The program consisted of 2 audio conferences, reading materials, and a 1-day conference consisting of lectures focusing on the importance of ASPs, strategies for implementation, improvement strategies for existing programs, and panel discussions highlighting successful practices. Smaller breakout sessions focused on operational issues, including understanding of pharmacodynamics, business models, and electronic surveillance.
We are developing Colossal Magnetoresistive (CMR) manganite thin film bolometric sensors to be employed as total energy detectors for beam diagnostics of the Linear Coherent Light Source (LCLS) Free Electron Laser (FEL) (at the Stanford Linear Accelerator). LCLS is an ultra bright, ultra short coherent x-ray source whose peak brightness will exceed that of third generation x-ray sources by about ten orders of magnitude and average brightness by three orders of magnitudes. It is expected to produce 1012 x-rays per 200 fs pulse with a repeat frequency of 120 Hz through self-amplified stimulated emission. In characterizing the beam, it will be necessary to measure the total energy of the FEL pulse. The Advanced Detector Group at Lawrence Livermore Laboratory has developed a scheme for FEL total energy measurements based on bolometric detection and are collaborating with Towson University to implement such a detector using CMR manganite thin films. Here we discuss the basic scheme, results of simulations of the thermal response and the materials development efforts towards fabricating the thin film detectors.
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