To assess the effectiveness of a 3-question decision-support tool to guide the diagnosis and treatment of urinary tract infections (UTIs) in acute care hospitalized patients as an antibiotic and diagnostic stewardship initiative.

Retrospective cohort study.

Four acute care hospitals within the same health system in Miami, FL.

124, admitted from the emergency department and hospitalized adult patients, treated with antibiotics for the indication of a UTI between March and April 2023.

We developed a 3-step clinical decision-support tool (CDST) to evaluate the appropriateness of urine cultures and antibiotic treatment. The tool’s recommendations when deciding to prescribe antibiotics were compared with the actual need for treatment throughout the hospitalization, up to the time of patient discharge.

Overall, 31% of antibiotics prescribed for UTIs were inappropriate and met the criteria for asymptomatic bacteriuria (ASB) based on the CDST. Prospective implementation of the decision-support tool could potentially reduce antibiotic use by 33.6%, corresponding to 265 days of unnecessary therapy. The sensitivity and specificity of the tool were calculated to be 98.6% and 100%, respectively, indicating high accuracy in identifying the need for antibiotic treatment. Urinalysis alone was insufficient to differentiate between symptomatic UTIs and ASB, with leukocyturia present in 95.3% of UTI cases and 94.6% of ASB cases (P = 0.87).

Implementing a 3-question CDST may reduce unnecessary laboratory work-up and treatment for ASB improving the diagnostic and antimicrobial stewardship of UTIs.

To describe the use of plasma next-generation sequencing (NGS) and determine if it provided additional information from routine tests or lead to change in antimicrobial management.

This retrospective cohort study evaluated patients with a NGS test performed who were admitted to a hospital health system in the greater Houston area between May 2022 and May 2023.

In total, 143 NGS tests were ordered in the span of one year for 135 unique patients. Most patients were ≥ 18 years (74.1%), White/Caucasian (43.7%), male (61.5%), and immunocompetent (54.1%). Eight patients had repeat tests during the study period, four being after an initial rejected test, and the rest being greater than 7 days from the initial test.

Of the 139 NGS tests performed, 56 (40%) were positive. When compared to routine testing, 49 (35%) were negative when routine testing was negative, 15 (11%) positive were concordant with routine testing, 29 (21%) positive were discordant from routine testing, 17 (12%) negative while routine testing was positive, and 29 (21%) were positive while routine testing was negative. Documented changes in antimicrobial due to NGS occurred after 16 (13.6%) tests, with the majority of these changes occurring in immunocompromised patients (14/16 [88%]).

NGS provided additional data when compared to routine testing but rarely resulted in antimicrobial changes. The majority of changes occurred in immunocompromised patients. Diagnostic stewardship is a vital component for this type of NGS testing and others in which guidelines do not exist.

To develop a symptom assessment tool to assist health care providers with discussing bowel habits in a sensitive and accurate method.

Pre and Post education survey.

180 bed academically affiliated Veterans Affairs Hospital.

Nurses, nursing assistants and physicians who participated in a brief educational session.

A Bowel Habits Assessment Tool (BHAT) was developed to assist health care providers in learning skills to assess patient bowel habits accurately. The BHAT was introduced at educational sessions. An anonymous pre and post survey employing a 5-point Likert scale was administered to participants.

Pre-educational session survey results for Question 1 (Q1) “I am comfortable discussing patient’s bowel habits included: 4.6% strongly disagreed or somewhat disagreed, 3% neither agreed nor disagreed, 20% somewhat agreed and 72.3% strongly agreed. After the BHAT education, 100% (n=65) of participants strongly agreed or somewhat agreed that they were comfortable discussing patient’s bowel habits. Q1 pre/post mean difference 0.25 (CI 0.06539 - 0.4269, p = 0.0084). On the pre-survey, only 34% of participants strongly agreed that they were aware of tools to help discuss patients’ bowel habits. This increased to 77% after the BHAT educational session. (Q2). Q2 pre/post mean difference 1.02 (CI 0.7366 - 1.294, p <0.0001).

The BHAT improved clinicians’ comfort level discussing patient’s bowel habits. Health care providers found the BHAT useful and related to their work. This tool shows promise in improving providers’ comfort discussing bowel habits and diagnosing Clostridioides difficile in a timely manner.

During the past several decades, enterococci are emerging as an important cause of healthcare-associated infections. They have developed resistance to various antimicrobials previously used for the treatment of urinary tract infections (UTIs). This study was aimed to determine the prevalence of Enterococcus species among urinary tract-infected patients in a tertiary care hospital, in Karnataka, India.

We have analyzed 4341 culture-positive urine samples received by microbiology laboratory during the year 2021. The bacterial identification was done by matrix-assisted laser desorption ionization-time of flight mass spectrometry. The antibiotic sensitivity was tested by automated VITEK-2® COMPACT (bioMérieux) system.

Among 4341 culture-positive samples, Enterococcal species were isolated from 159 samples. A total of 64.7% of the isolates were identified as Enterococcus faecalis and 28.3% of the strains as Enterococcus faecium. All the enterococci were sensitive to linezolid, teicoplanin, and vancomycin, whereas 59.1%, 30.9%, and 23.3% of the strains exhibited resistance to high-level gentamicin, benzylpenicillin, and nitrofurantoin, respectively. 33.67 % of the isolates were identified as multidrug-resistant (MDR) strains as they exhibited resistance to high-level gentamicin, benzylpenicillin, and nitrofurantoin.

Our study shows the prevalence of Enterococcus faecalis and high-level gentamicin-resistant enterococcal strains. The MDR pattern of enterococci requires careful consideration of antimicrobial therapy to treat UTIs. The reserved drugs such as linezolid, vancomycin, and teicoplanin should be cautiously used for the treatment of enterococcal UTI.

Computerized clinical decision support (CDS) assists healthcare professionals in making decisions to improve patient care. In the realms of antimicrobial stewardship (ASP) and infection prevention (IP) programs, CDS interventions can play a crucial role in optimizing antibiotic prescribing practices, reducing healthcare-associated infections, and promoting diagnostic stewardship when optimally designed. This primer article aims to provide ASP and IP professionals with a practical framework for the development, design, and evaluation of CDS interventions.

Large academic medical center design: Established frameworks of CDS evaluation, “Five Rights” of CDS and the “Ten Commandments of Effective Clinical Decision Support”, were applied to two real-world examples of CDS tools, a Vancomycin Best Practice Advisory and a Clostridioides Difficile order panel, to demonstrate a structured approach to developing and enhancing the functionality of ASP/IP CDS interventions to promote efficacy and reduce unintended consequences of CDS.

By outlining a structured approach for the development and evaluation of CDS interventions, with focus on end user engagement, efficiency and feasibility, ASP and IP professionals can leverage CDS to enhance IP/ASP quality improvement initiatives aimed to improve antibiotic utilization, diagnostic stewardship, and adherence to IP protocols.

We performed a systematic literature review to identify and describe pharmacist-led antimicrobial stewardship programs (ASPs) interventions in low- and middle-income countries (LMICs).

Systematic literature review.

We searched PubMed for studies evaluating pharmacist-led ASP interventions in LMICs from January 1, 2012, to November 4, 2023. We evaluated the article’s country of origin, described ASP interventions, and analyzed their reported outcomes.

Twenty-four studies were included; ten were conducted in China, two in India, two in Thailand, five in Africa, three in Latin America, and two in the Middle East. The predominant interventions in the studies were education and training followed by audit and feedback. The outcomes reported included reduction in antimicrobial consumption, cost reduction, shortening of the duration of antimicrobial therapy, and de-escalation.

Our findings reinforce the importance of clinical pharmacists leading interventions related to antimicrobial stewardship in LMCIs and the global importance of investing in Infectious Disease training.

To examine practices of providers and nursing staff in evaluating febrile patients and identify drivers of excessive diagnostic testing.

Prospective multiple-choice surveys.

Inpatient areas and the Emergency Department at Rhode Island Hospital (RIH) in Providence, RI.

We conducted two surveys focused on the evaluation of febrile inpatients at RIH. One survey was of providers trained in internal medicine, surgery, pediatrics, emergency medicine, and neurology; the other survey was of nursing staff (registered nurses and certified nursing assistants), in inpatient areas and the emergency department.

70 providers (9%) and 178 nursing staff (12%) completed the surveys. 64% of providers (n = 43) reported “always” or “often” ordering full fever workups and 67% of providers (n = 47) reported “always” or “often” physically evaluating febrile patients. Nurses were less likely than providers to report that providers “always” or “often” physically evaluate febrile patients (n = 80, 45%; P < 0.01) and more likely to report providers “always” or “often” order full fever workups (n = 135, 76%; P = 0.04). 71% of providers (n = 50) reported “always” or “often” receiving written handoffs. 86% of providers (n = 60) reported handoffs are “always” or “often” accurate; however, only 17% of providers responded these were “always” accurate. 77% of providers (n = 54) reported “always” or “often” following handoff instructions to obtain a full fever workup for febrile patients, regardless of clinical status. Responses differed significantly by unit type and provider specialty and position.

This study elucidates drivers of inefficient and excessive utilization of diagnostic studies and identifies targets for diagnostic stewardship interventions.

We aim to highlight the risks of acquiring carbapenemase-producing Enterobacterales (CPE) resistance genes in patients with severe coronavirus disease 2019 (COVID-19) in intensive care.

Outbreak analysis to assess for a transmission risk area (TRA) conducted after identification of potential CPE outbreak within shared room spaces in intensive care.

Analysis conducted within a 24-bed single-room model intensive-care department within a level-3 tertiary center public hospital in regional Victoria, Australia.

3 patients, with severe COVID-19 admitted to intensive care over a 3-month period with shared room spaces requiring prolonged mechanical ventilation and broad-spectrum antimicrobials, identified and were managed for CPE isolated from sputum. Overlap carbapenemase genes were identified among different organisms raising suspicion of transmitted resistance genes. A subsequent case managed for severe community-acquired pneumonia isolated CPE 3 months beyond these cases.

Outbreak analysis via weekly cross-sectional point prevalence screening of fecal samples or rectal swabs for CPE from patients admitted to the intensive-care department over a 4-week period.

34 patients were included in the analysis with 51 tests for CPE screening conducted. No further cases of CPE were identified. Statewide Infection Surveillance team and the Department of Health and Human Services did not find the cases to derive from a TRA. No further action including environmental screening was indicated.

These cases highlight the independent acquisition of CPE genes in patients with severe COVID-19 and antimicrobial selective pressures resulting in significant morbidity and mortality. Increasing awareness, robust antimicrobial stewardship, and infection prevention measures could reduce pressures driving CPE resistance mutations and the risk of CPE transmission.

To describe antimicrobial usage (AMU) trends before and during the coronavirus disease 2019 (COVID-19) pandemic, between COVID-19 and non-COVID-19 wards, and if there was any association with a COVID-19 order set.

Quasi-experimental retrospective interrupted time series analysis of AMU rates with a contemporaneous comparison of COVID-19 versus non-COVID-19 control wards. Analysis using incidence rate ratios (IRR) was conducted using a Poisson regression generalized linear model.

Five COVID-19 and 4 comparable non-COVID-19 wards and 6 intensive care units (ICUs) at 4 hospitals during pandemic waves 1–4.

All inpatients receiving systemic antimicrobials.

The COVID-19 checkbox antimicrobial order set was implemented in March 2020, to be used only if considered clinically indicated with modification in August 2021.

The primary outcome was a change in AMU rates (defined daily dose per 100 patient days per month) comparing pre- versus peri-pandemic periods and COVID-19 versus control non-COVID-19 wards. Secondary outcomes included antifungal usage rate in ICUs and assessing AMUs following implementation and modification of a COVID-19 order set.

Significantly greater rates of AMU (IRR[95%CI]) were observed on COVID-19 wards versus non-COVID-19 wards during waves 1–4 for all systemic antimicrobials (1.76[1.71–1.81], 1.10[1.07–1.13], 1.48[1.43–1.53], and 1.06[1.03–1.09]); for azithromycin (11.76[9.80–14.23], 10.96[9.49–12.74], 12.41[10.73–14.45], and 4.88[4.31–5.55]); and for ceftriaxone (2.39[2.16–2.65], 3.64[3.29–4.03], 2.94[2.67–3.23], and 1.62[1.49–1.76]).

We observed significantly increased AMU rates of all systemic agents during the first 4 waves of the pandemic and on COVID-19 wards compared with control wards for azithromycin and ceftriaxone. These agents saw a twofold reduction following order-set removal, suggesting that the clinical decision-support tool order set, as utilized, had influenced prescribing behavior.