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Antimicrobial stewardship programs (ASPs) optimize antimicrobial use to ensure the best patient outcomes from infections. Since the initial publication of this guidance in 2014, accreditation standards have bolstered antimicrobial stewardship requirements in various healthcare settings, and antibiotic use and resistance data reporting requirements have further increased the scope and resource needs of ASPs. The purpose of this guidance is to outline and update the knowledge and skills necessary to lead ASPs, organized by basic, intermediate, and advanced skills recommended for stewards practicing in acute care, outpatient care, and long-term care settings. This update was developed by a multidisciplinary group of antimicrobial stewardship experts from key organizations and with diverse backgrounds engaged in advancing the practice of antimicrobial stewardship. It does not specifically address healthcare resources, staffing models, reporting structures, or percentage of full-time equivalents needed to conduct this work, which will be addressed by future multi-society publications.
In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) Transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and deimplementation, 6) healthcare outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the "neighbors," 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1-5 are presented in part I of the article and chapters 6-10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the post-pandemic phase) will make healthcare systems more resilient when facing future crises.
In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and de-implementation, 6) health care outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the "neighbors", 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1-5 are presented in part I of the article, and chapters 6-10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the postpandemic phase) will make healthcare systems more resilient when facing future crises.
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To evaluate physician engagement with an antimicrobial stewardship program (ASP) at a tertiary hospital and identify areas for improvement in the delivery of stewardship interventions. Cross-sectional survey study. A 1200-bed tertiary care public hospital in Portugal. Physicians with antibiotic prescribing privileges in inpatient settings. All physicians with active institutional e-mail addresses were invited to participate. An anonymous web-based questionnaire was administered between June and December 2024. The survey addressed six domains: (1) antibiotic knowledge; (2) awareness and use of local prescribing protocols; (3) access to antimicrobial use and resistance reports; (4) awareness of antibiotic restriction policies; (5) use of informal consultations with the stewardship team; and (6) participation in scheduled multidisciplinary case discussions. A total of 154 prescribing physicians responded (response rate: 10%), including specialists (75.3%) and residents (24.0%). Most respondents were aware of institutional protocols (78.6%), but 66.9% reported rarely or never consulting them, citing accessibility and reliance on personal knowledge as key barriers. Participation in case discussions was limited (25.3%) but viewed as highly useful. Awareness of restrictive antibiotic policies was low; however, 69.5% indicated that these policies influenced their prescribing behavior. Respondents expressed strong interest in regular feedback on antimicrobial use and resistance trends. Key areas for improvement in ASP implementation include enhancing access to protocols, expanding case-based discussions, clarifying communication around restrictions, and establishing regular feedback mechanisms. These findings may inform efforts to align ASP strategies with clinical realities in similar hospital settings.
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[This corrects the article DOI: 10.1017/ash.2023.473.].
As Antimicrobial Stewardship and Healthcare Epidemiology (ASHE) concludes its first five years of existence, we reviewed and summarized the career perspectives publications. ASHE Careers publications are structured interviews with luminaries in infection prevention, public health, and antimicrobial stewardship, where leadership and professional development themes are individualized and explored. Across 14 published interviews from experienced infectious disease professionals identified, we synthesized 10 important themes amongst them. Among them emerged a strong emphasis on the central role of mentorship in career development, the importance of maintaining adaptability, and willingness to explore emerging opportunities of an ever-changing field. Together, these lessons offer guidance for those seeking direction or growth in healthcare epidemiology.
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.
Advancement of antimicrobial stewardship (AS) programs requires partnership with clinicians, quality assurance teams, and laboratorians. Inevitably, AS programs also practice diagnostic stewardship (DS), as stewards are aptly placed to connect key stakeholders and help steer processes toward higher value care for pediatric patients. In this review, we illustrate five moments of collaboration between stakeholders in the interplay between AS and DS in pediatrics. These moments include (1) Observation, (2) Reflection, (3) Exploration, (4) Enactment and (5) Evaluation. We offer a targeted narrative of examples in current literature using common relatable scenarios (ie, endotracheal aspirates, blood cultures, gastrointestinal samples, and urine testing) including impact on financial and environmental waste.
We aimed to determine whether automated identification of antibiotic targeting suspected urinary tract infection (UTI) shortened the time to antimicrobial stewardship (AS) intervention. Retrospective before-and-after study. Tertiary and quaternary care academic medical center. Emergency department (ED) or admitted adult patients meeting best practice alert (BPA) criteria during pre- and post-BPA periods. We developed a BPA to alert AS pharmacists of potential ASB triggered by the following criteria: ED or admitted status, antibiotic order with genitourinary indication, and a preceding urinalysis with ≤ 10 WBC/hpf. We evaluated the median time from antibiotic order to AS intervention and overall percent of UTI-related interventions among patients in pre-BPA (01/2020-12/2020) and post-BPA (04/15/2021-04/30/2022) periods. 774 antibiotic orders met inclusion criteria: 355 in the pre- and 419 in the post-BPA group. 43 (35 UTI-related) pre-BPA and 117 (94 UTI-related) post-BPA interventions were documented. The median time to intervention was 28 hours (IQR 18-65) in the pre-BPA group compared to 16 hours (IQR 2-34) in the post-BPA group (P < 0.01). Despite absent pyuria, there were six cases with gram-negative bacteremia presumably from a urinary source. Automated identification of antibiotics targeting UTI without pyuria on urinalysis reduced the time to stewardship intervention and increased the rate of UTI-specific interventions. Clinical decision support aided in the efficiency of AS review and syndrome-targeted impact, but cases still required AS clinical review.
Antimicrobial prescribing and the associated discipline of antimicrobial stewardship have inherent ethical and moral dimensions. We contend that the explicit, formal application of ethical principles and frameworks can strengthen and further justify the value of antimicrobial stewardship programs and their work. To illustrate the value of this process, we highlight 3 ethical scenarios that antimicrobial stewardship programs regularly encounter at the prescriber, institutional, and societal levels, and we analyze these scenarios using the Beauchamp and Childress biomedical ethics framework.
Diagnostic stewardship is increasingly recognized as a powerful tool to improve patient safety. Given the close relationship between diagnostic testing and antimicrobial misuse, antimicrobial stewardship (AMS) pharmacists should be key members of the diagnostic team. Pharmacists practicing in AMS already frequently engage with clinicians to improve the diagnostic process and have many skills needed for the implementation of diagnostic stewardship initiatives. As diagnostic stewardship becomes more broadly used, all infectious disease clinicians, including pharmacists, must collaborate to optimize patient care.
Days of antibiotic spectrum coverage (DASC) is a novel metric that incorporates the antibiotic spectrum into consumption metrics, addressing the limitations of traditional metrics such as days of therapy (DOT). This study aimed to evaluate the feasibility of integrating DASC into the Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system. Retrospective observational study. Hospitals voluntarily participating in J-SIPHE. Inpatients from 1,833 hospitals between January 2019 and December 2022. Antibiotic use was assessed using DOT, DASC, and DASC/DOT. Antibiotic spectrum coverage scores were assigned based on published data or expert consensus. Annual trends were assessed using median values, and hospital-level variation was explored by hospital size. Proportional use of antibiotic classes by DOT and DASC was compared using 2022 data. As the number of hospitals participating in J-SIPHE increased over time-particularly small and medium-sized hospitals-median DOT and DASC per 1,000 patient-days declined by 21.2% and 19.1%, respectively, from 2019 to 2022, while DASC/DOT remained stable. In 2022, proportional use of antibiotic classes varied by hospital size, and rankings differed when comparing DOT- and DASC-based measures. Broad-spectrum agents such as carbapenems and fluoroquinolones ranked higher by DASC than DOT. Hospital-level distributions of DOT and DASC/DOT showed substantial variation across hospital sizes. Integration of DASC metrics into national surveillance is feasible. DASC and DASC/DOT complement DOT by incorporating spectrum breadth, providing more comprehensive insight into antimicrobial use patterns and supporting stewardship benchmarking and intervention planning.
Clinical pharmacist-driven antimicrobial stewardship programs (ASPs) have been successfully implemented. Although relevant guidance and several studies suggest that clinical pharmacists be integrated into the current ASP team model, barriers still exist in Asia, primarily due to lack of dedicated personnel and lack of career advancement. We review the effectiveness and the ideal role of clinical pharmacist among ASPs in Asia. Several studies conducted in Asia have shown the effectiveness of pharmacist-led ASP interventions in hospitals and other healthcare settings. However, opportunities to expand the role of clinical pharmacists in ASPs in Asia exist in the implementation of rapid diagnostic test and drug allergies.
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.
Factors influencing excessive antimicrobial utilization in hospitalized patients remain poorly understood, particularly with the COVID-19 pandemic. In this retrospective cohort, we compared administrative data regarding antimicrobial prescriptions in hospitalized patients in South Carolina from March 2020 through September 2022. The study examined variables associated with antimicrobial use across demographics, COVID status, and length of stay, among other variables. Significant relationships were seen with antimicrobial use in COVID-19 positive patients (OR 2.00, 95% Confidence Interval (CI): 1.9-2.1), young adults (OR 1.08, 95% CI: 0.99-1.12, COVID-19 positive Blacks and Hispanics (OR 1.06, 95% CI: 1.01-1.11, OR 1.05, 95% CI: 0.89-1.23), and COVID-19 positive patients with ≥2 comorbid conditions (OR 1.55, 95% CI: 1.43-1.68). Further analysis in more than one healthcare system should explore these ecologic relationships further to understand if these are common trends to inform ongoing stewardship interventions.
Candida auris (also referred to as Candidozyma auris) is an emerging multidrug-resistant fungal pathogen associated with high morbidity and mortality. Existing infection prevention and control (IPC) guidance has largely focused on adult populations, with limited recommendations for pediatric healthcare and non-healthcare settings. The Society for Healthcare Epidemiology of America (SHEA) convened a multidisciplinary expert panel to develop IPC recommendations for C. auris. The panel developed recommendations using a structured, iterative Delphi consensus process with rounds of discussion, refinement, and anonymous electronic voting with predefined consensus thresholds. Panelists reviewed relevant peer-reviewed and gray literature integrated with expert judgment and practical considerations. Preambles and remarks provide additional context and guidance. This consensus statement provides recommendations for prevention of C. auris in pediatric acute care settings, non-acute healthcare settings, and non-healthcare congregate settings. Recommendations incorporate pediatric risk factors and care and address screening practices, isolation precautions, caregiver-infant/child dyad considerations, room placement and rooming in, breastfeeding and skin-to-skin practices, visitation, use of shared spaces, environmental cleaning and disinfection, and management of medical and non-medical equipment, including toys. Recommendations emphasize coordination with local infection prevention and public health partners. This SHEA consensus statement addresses gaps in pediatric-specific IPC guidance for C. auris. The recommendations provide a practical framework to support prevention of transmission within the context of pediatric clinical, developmental, and family-centered care.