More than 80% of antibiotics are prescribed in the outpatient setting, of which 30% are inappropriate. The National Action Plan for Combating Antimicrobial Resistance called for a 50% decrease in outpatient antibiotic use by 2020. Inappropriate antibiotics are associated with adverse reactions and Clostridioides difficile infection, especially among older adults.

Before and after study.

We performed a quality improvement initiative at the University of Colorado Seniors Clinic. Providers received education on antibiotic guidelines, electronic antibiotic order sets were introduced with standardized stop dates. Antibiotic use data were collected for 6 months before and 6 months after the intervention, from December to May to avoid seasonal variation. Descriptive statistics and linear mixed-effects regression models were used for this comparison.

Total antibiotic prescriptions for acute respiratory conditions decreased from 137 prescriptions before the intervention (December 1, 2017, to May 31, 2018) to 112 prescriptions after the intervention (December 1, 2018, to May 31, 2019), driven primarily by decreases in antibiotic prescriptions for pneumonia, sinusitis, and bronchitis. Prescriptions for broad-spectrum antibiotics declined following the intervention including decreases in levofloxacin from 12 (9%) to 3 (3%) and amoxicillin-clavulanate from 15 (12%) to 7 (7%). We detected significant reductions in prescribed antibiotic durations (days) after the intervention for sinusitis (estimate, −2.0; 95% CI, −3.1 to −1.0; P = .0003), pharyngitis (estimate, −2.5; 95% CI, −4.6 to −0.5; P = .018), and otitis (−3.2; 95% CI, −5.2 to −1.3; P = .008).

Low-cost interventions were initially successful in changing patterns of antibiotic use and decreasing overall antibiotic prescribing among older patients in the outpatient setting. Long-term follow-up studies are needed to determine the sustainability and clinical impact of these interventions.

We developed an implementation plan to integrate diagnostic testing for coronavirus disease 2019 (COVID-19) into a public school system. Implementation barriers were identified and strategies were mapped to overcome them.

A COVID-19 diagnostic testing program leveraging a public–private partnership was developed for a public school system.

A suburban school district and a local hospital during the 2020–2021 academic year.

Using Consolidated Framework for Implementation Research (CFIR) constructs and evidenced-based implementation strategies, the program was designed as a “closed system” and was adapted based on stakeholder feedback. Implementation barriers and facilitators were identified and mapped to CFIR constructs to provide insights into factors influencing program adoption.

Preimplementation stages of engagement, feasibility, and readiness planning were completed. The program did not progress to implementation due to multiple factors, including changes in school leadership (inner setting and process-level constructs), improved access to outside testing, and lack of an existing paradigm for in-school testing (external constructs). Limited support from key stakeholders and opinion leaders was also a barrier (process-level construct).

Although this locally initiated program did not progress beyond the preimplementation stage, the processes developed and barriers identified may be useful to inform planning efforts in other testing programs within public school systems. Future programs may consider incorporating multiplex diagnostic testing for influenza in addition to COVID-19. With relaxation of infection control measures, the prevalence of other respiratory viruses will increase. Actionable results will be needed to inform decisions about closures and quarantines.

To assess the prevalence of antibiotic-resistant gram-negative bacteria (R-GNB) among patients without recent hospitalization and to examine the influence of outpatient antibiotic exposure on the risk of acquiring R-GNB in this population.

2-year retrospective cohort study.

Regional Veterans Affairs healthcare system.

Outpatients at 13 community-based clinics.

We examined the rate of acquisition of R-GNB within 90 days following an outpatient visit from 2018 to 2019. We used clinical and administrative databases to determine and summarize prescriptions for systemic antibiotics, associated infectious diagnoses, and subsequent R-GNB acquisition among patients without recent hospitalizations. We also calculated the odds ratio of R-GNB acquisition following antibiotic exposure.

During the 2-year study period, 7,215 patients had outpatient visits with microbiological cultures obtained within 90 days. Of these patients, 206 (2.9%) acquired an R-GNB. Among patients receiving antibiotics at the visit, 4.6% acquired a R-GNB compared to 2.7% among patients who did not receive antibiotics, yielding an unadjusted odds ratio of 1.75 (95% confidence interval, 1.18–2.52) for a R-GNB following an outpatient visit with versus without an antibiotic exposure. Regardless of R-GNB occurrence, >50% of antibiotic prescriptions were issued at visits without an infectious disease diagnosis or issued without documentation of an in-person or telehealth clinical encounter.

Although the rate of R-GNBs was low (2.9%), the 1.75-fold increased odds of acquiring a R-GNB following an outpatient antibiotic highlights the importance of antimicrobial stewardship efforts in outpatient settings. Specific opportunities include reducing antibiotics prescribed without an infectious diagnosis or a clinical visit.

We aimed to decrease the use of outpatient parenteral antimicrobial therapy (OPAT) for patients admitted for bone and joint infections (BJIs) by applying a consensus protocol to suggest oral antibiotics for BJI.

A quasi-experimental before-and-after study.

Inpatient setting at a single medical center.

All inpatients admitted with a BJI.

We developed a consensus table of oral antibiotics for BJI among infectious diseases (ID) specialists. Using the consensus table, we implemented a protocol consisting of a weekly reminder e-mail and case-based discussion with the consulting ID physician. Outcomes of patients during the implementation period (November 1, 2020, to May 31, 2021) were compared with those during the preimplementation period (January 1, 2019, to October 31, 2020). Our primary outcome was the proportion of patients treated with OPAT. Secondary outcomes included length of hospital stay (LOS) and recurrence or death within 6 months.

In total, 77 patients during the preimplementation period and 22 patients during the implementation period were identified to have a BJI. During the preimplementation period, 70.1% of patients received OPAT, whereas only 31.8% of patients had OPAT during the implementation period (P = .003). The median LOS after final ID recommendation was significantly shorter during the implementation period (median 3 days versus 1 day; P < .001). We detected no significant difference in the 6-month rate of recurrence (24.7% vs 31.8%; P = .46) or mortality (9.1% vs 9.1%; P = 1.00).

More patients admitted with BJIs were treated with oral antibiotics during the implementation phase of our quality improvement initiative.

The Centers for Disease Control and Prevention has called for an interdisciplinary approach to antibiotic stewardship implementation that includes front-line nurses. The literature to date has identified key factors preventing uptake by nurses: lack of education, poor communication among providers, and unit culture. Three e-learning modules were developed to address the nurses’ education regarding the roles nurses play in antibiotic stewardship, antibiotic resistance, allergy assessment, medication side effects and interactions, pharmacokinetics–pharmacodynamics, culture interpretation, specimen collection, and the antibiogram. A survey was used to assess whether nurses felt more prepared to participate after finishing the modules.

Front-line staff nurses in acute care were assigned e-learning modules as part of their pharmacy’s introduction of an antibiotic stewardship program for nurses.

Nurses viewed the modules and completed a survey designed to rank their usefulness and to assess their attitudes.

Overall, 81% of nurses felt that they should be part of the antibiotic stewardship team. After completing the modules, 72% felt more empowered to participate in stewardship discussions and an additional 23% requested more education. Also, 97% felt that the information they learned could be utilized in everyday work regardless of the new program. The most cited barriers to stewardship activities were lack of education (45%) and hospital and/or unit culture (13%).

Education and culture need to be addressed to overcome the barriers to nurses’ involvement in antimicrobial stewardship. E-learning can provide a simple and effective first step to educate nurses, with minimal time investment.

We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim–sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or β-lactam prescribing, or longer duration of therapy.

This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis.

Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and β-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a β-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58–15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07–4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15–1.44) were associated with longer antibiotic duration.

We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.

To establish an antimicrobial stewardship program in the outpatient setting.

Prescribers of antimicrobials were asked to complete a survey regarding antimicrobial stewardship. We also monitored their compliance with appropriate prescribing practices, which were shared in monthly quality improvement reports.

The study was performed at Loyola University Health System, an academic teaching healthcare system in a metropolitan suburban environment.

Prescribers of antimicrobials across 19 primary care and 3 immediate- and urgent-care clinics.

The voluntary survey was developed using SurveyMonkeyand was distributed via e-mail. Data were collected anonymously. Rates of compliance with appropriate prescribing practices were abstracted from electronic health records and assessed by 3 metrics: (1) avoidance of antibiotics in adult acute bronchitis and appropriate antibiotic treatment in (2) patients tested for pharyngitis and (3) children with upper respiratory tract infections.

Prescribers were highly knowledgeable about what constitutes appropriate prescribing; verified compliance rates were highly concordant with self-reported rates. Nearly all prescribers were concerned about resistance, but fewer than half believed antibiotics were overprescribed in their office. Among respondents, 74% reported intense pressure from patients to prescribe antimicrobials inappropriately. Immediate- and urgent-care prescribers had higher rates of compliance than primary-care prescribers, and the latter group responded well to monthly reports and online educational resources.

Intense pressure from patients to prescribe antimicrobials when they are not indicated leads to overprescribing, an effect compounded by the importance of patient satisfaction scores. Compliance reporting improved the number of appropriate antibiotics prescribed in the primary care setting.

To evaluate whether rates of healthcare-associated infections (HAIs) changed during the coronavirus disease 2019 (COVID-19) pandemic in malignant hematology and stem cell transplant patients.

A retrospective, cohort study.

The study included malignant hematology and stem cell transplant patients admitted between March 1, 2019, through July 31, 2019, and March 1, 2020, through July 31, 2020.

Rates of catheter-associated urinary tract infections (CAUTIs), central-line–associated bloodstream infections (CLABSIs), central-line–associated mucosal barrier injury infections (CLAMBIs), and Clostridioides difficile infections (CDIs) during the pandemic were compared to those in a control cohort. Secondary outcomes included the rate of non–COVID-19 respiratory viruses.

The rate of CAUTIs per 1,000 hospital days was 0.435 before the pandemic and 0.532 during the pandemic (incidence rate ratio [IRR], 1.224; 95% confidence interval [CI], 0.0314–47.72; P = .899). The rate of CLABSIs was 0.435 before the pandemic and 1.064 during the pandemic (IRR, 2.447; 95% CI, 0.186–72.18; P = .516). The rate of CLAMBIs was 2.61 before the pandemic and 1.064 during the pandemic (IRR 0.408, 95% CI 0.057–1.927; P = .284). The rate of CDIs was 2.61 before the pandemic and 1.579 during the pandemic (IRR, 0.612; 95% CI, 0.125–2.457; P = .512). Non–COVID-19 respiratory virus cases decreased significantly from 12 (30.8%) to 2 cases (8.3%) (P = 0.014).

There was no significant difference in HAIs among inpatient malignant hematology and stem cell transplant patients during the COVID-19 pandemic compared to those of a control cohort. Rates of infection were low among both cohorts. Rates of community-acquired respiratory viruses decreased significantly during the pandemic among this population.

The purpose of this retrospective study was to evaluate safety and efficacy end points of a postoperative antibiotic prophylaxis protocol in liver transplant (LT) patients, which was revised to limit antibiotic use.

In the routine antibiotics group (RA), patients routinely received prophylactic antibiotics for around 3 days postoperatively for a variety of rationales, versus the limited antibiotics group (LA), in which patients received antibiotics for the treatment of secondary peritonitis. Patients were included if they were 18 or older and underwent liver transplant between January 2016 and September 2019. In total, 216 patients remained after exclusion: 118 patients in the RA group and 98 patients in the LA group.

We detected a significant difference in the primary end point of postoperative antibiotic days of therapy. The median days of therapy was 2 for the RA group and 0 for the LA group (P < 0.005). Significantly fewer patients received only intraoperative antibiotics in the RA group versus the LA group: 42 (35.6%) versus 76 (73.5%) respectively (P < .005). There was no significant difference in secondary or safety outcomes, including surgical site infections.

This study provides evidence that limiting the duration of prophylactic antibiotics postoperatively and treating most patients with only intraoperative antibiotics is safe.

Despite evidence favoring perioperative antibiotic prophylaxis (ABP) use in patients undergoing craniotomy to reduce rates of surgical site infections (SSIs), standardized protocols are lacking. We describe demographic characteristics, risk factors, and ABP choice in patients with craniotomy complicated with SSI.

Retrospective case series from January 1, 2017, through December 31, 2020.

Tertiary-care referral center.

Adults who underwent craniotomy and were diagnosed with an SSI.

Logistic regression to estimate odds ratios and 95% confidence intervals to identify factors associated with SSIs.

In total, 5,328 patients undergoing craniotomy were identified during the study period; 59 (1.1%) suffered an SSI. Compared with non-SSI cases, patients with SSI had a significantly higher frequency of emergency procedures: 13.5% versus 5.8% (P = .02; odds ratio [OR], 2.52; 95% confidene interval [CI], 1.10–5.06; P = .031). Patients with SSI had a higher rate of a dirty (5.1% vs 0.9%) and lower rate of clean-contaminated (3.3% vs 14.5%) wound class than those without infection (P = .002). Nearly all patients received ABP before craniotomy (98.3% in the SSI group vs 99.6% in the non-SSI group; P = .10). Combination of vancomycin and cefazolin as dual therapy was more prevalent in the group of patients without infection (n = 1,761, 34.1%) than those with SSI (n = 4, 6.8%) (P < .001), associated with decreased odds for SSI (OR, 0.17; 95% CI, 0.005–0.42; P ≤ .001).

SSI are frequently seen after an emergent neurosurgical procedure and a dirty wound classification. Combination of prophylactic cefazolin and vancomycin is associated with decreased risk for SSI.

To perform a review of the literature on the role of simulation-based training (SBT) in healthcare-associated infection (HAI) prevention and to highlight the importance of SBT as an educational tool in infection prevention.

We reviewed English language publications from PubMed to select original articles that utilized SBT as the primary mode of education for infection prevention efforts in acute-care hospitals.

Overall, 27 publications utilized SBT as primary mode of education for HAI prevention in acute-care hospitals. Training included the following: hand hygiene in 3 studies (11%), standard precaution in 1 study (4%), disaster preparedness in 4 studies (15%), central-line–associated blood stream infection (CLABSI) prevention in 14 studies (52%), catheter-associated urinary tract infection (CAUTI) prevention in 2 studies (7%), surgical site infection prevention in 2 studies (7%), and ventilatory associated pneumonia prevention in 1 study (4%). SBT improved learner’s sense of competence and confidence, increased knowledge and compliance in infection prevention measures, decreased HAI rates, and reduced healthcare costs.

SBT can function as a teaching tool in day-to-day infection prevention efforts as well as in disaster preparedness. SBT is underutilized in infection prevention but can serve as a crucial educational tool.