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Antimicrobial Stewardship across the Continuum of Care

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A special issue of Pharmacy (ISSN 2226-4787).

Deadline for manuscript submissions: closed (30 June 2020) | Viewed by 34787

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Dr. P. Brandon Bookstaver

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Guest Editor

College of Pharmacy, University of South Carolina, Columbia, SC 29208, USA
Interests: antimicrobial stewardship; penicillin allergy management; Clostridioides difficile infection; expanding the pharmacy services and scholarship
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Majdi N. Al-Hasan

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Guest Editor

School of Medicine, University of South Carolina, Columbia, SC 29208, USA
Interests: antimicrobial stewardship; antimicrobial resistance; bloodstream infections; sepsis; Gram-negative bacteria; antibiotics; antibacterial agents; urinary tract infections
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Sparked by heightened concerns over developing resistance and surge in Clostridioides difficile infection cases, antimicrobial stewardship programs (ASPs) have been established to optimize appropriate antibiotic use. Behind the support of many regulatory agencies and national organizations, ASPs are required in many practice areas in the United States. Stewardship programs continue to expand globally, including to low- and middle income countries, and across the continuum of care.

Successful ASPs exemplify many common traits, including strong interdisciplinary leadership by pharmacists and physicians. These programs not only demonstrate sustainable patient impact but also drive best practices through research and scholarship. Increased interest in scholarly deliverables by ASPs is evident across the peer-reviewed literature landscape.

We invite you and your colleagues to submit articles for this special edition on Antimicrobial Stewardship. We welcome manuscripts from across the globe on all aspects of antimicrobial stewardship including but not limited to original research on stewardship interventions or best practices, special commentaries on important areas for ASPs, reviews or meta-analyses on related topics, and stewardship education of trainees or healthcare workers. We look forward to your submission!

Prof. Dr. Brandon Bookstaver
Prof. Dr. Majdi N. Al-Hasan
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Pharmacy is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

Antimicrobial stewardship
Antimicrobial resistance
Clostridioides difficile infection
Education
Antibiotic utilization
Stewardship interventions
Infection control
Syndrome-specific interventions
Multidrug resistant bacteria
Rapid diagnostics

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Published Papers (9 papers)

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Research

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19 pages, 2340 KiB

Open AccessArticle

Assessing Pharmacy Students’ and Preceptors’ Understanding of and Exposure to Antimicrobial Stewardship Practices on Introductory Pharmacy Practice Experiences

by Sara Revolinski, Jacqueline Pawlak and Ciara Beckers

Pharmacy 2020, 8(3), 149; https://doi.org/10.3390/pharmacy8030149 - 20 Aug 2020

Cited by 6 | Viewed by 3093

Abstract

Antimicrobial stewardship (AMS) is commonly employed, and may be required, in multiple healthcare settings, with pharmacists playing an integral role in developing and conducting AMS techniques. Despite its prevalence, AMS is minimally taught in pharmacy school curricula. In order to increase student and preceptor understanding and application of AMS techniques, the Medical College of Wisconsin School of Pharmacy required introductory pharmacy practice students to complete three checklists and reflections of AMS techniques observed at three different practice settings: inpatient, ambulatory, and community (retail) pharmacy. Student and preceptor understanding and application of AMS techniques were then assessed via voluntary survey. Survey response rates were 43% for pharmacy students, while preceptor response rates were 27%. Student understanding and application of AMS techniques increased after completion of the AMS checklist, with the largest magnitude of change seen with antibiotic selection recommendations and guideline and policy development. Preceptor understanding was minimally impacted by the activity; however, an increase in understanding was seen for allergy assessments, antibiotic time-outs, and vaccine assessments and recommendations. AMS is an important component of pharmacy practice today. Implementation of a checklist and reflection activity within experiential education increases perceived student understanding and application of relevant AMS techniques. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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11 pages, 1235 KiB

Open AccessArticle

Implementation of a Urinary Tract Infection Treatment Protocol to Improve Prescribing Practices in the Long-Term Care Facility of a Veteran’s Healthcare System

by Spencer H. Durham, Natalie S. Hohmann and Addison H. Ragan

Pharmacy 2020, 8(3), 129; https://doi.org/10.3390/pharmacy8030129 - 24 Jul 2020

Cited by 3 | Viewed by 5075

Abstract

Urinary tract infections (UTIs) are a commonly diagnosed problem in long-term care facilities (LTCFs), but antimicrobial treatment is often incorrectly prescribed. Although bacterial resistance to antimicrobials commonly used for UTIs, such as trimethoprim/sulfamethoxazole and fluoroquinolones, has been dramatically increasing, they are still commonly prescribed. The purpose of this project was to determine if implementation of a standard treatment protocol for UTIs, which emphasized correct UTI diagnosis and use of nitrofurantoin and cefpodoxime/ceftriaxone as empiric therapy per the institutional antibiogram, changed clinician prescribing practices. This quasi-experimental model utilized two years of pre-intervention and two years of post-intervention data. Three hundred patient encounters were included. Antibiotics prescribed in the pre-intervention period included: trimethoprim/sulfamethoxazole (32%), ciprofloxacin (14%), amoxicillin (13%), levofloxacin (9%), cefpodoxime (9%), ceftriaxone (8%), amoxicillin/clavulanate (5%), nitrofurantoin (4%), and other (6%). By contrast, antibiotics prescribed in the post-intervention period included: cefpodoxime (46%), nitrofurantoin (30%), ceftriaxone (10%), trimethoprim/sulfamethoxazole (8%), amoxicillin/clavulanate (1%), and other (5%). These differences in prescribed drug between the pre-intervention and post-intervention encounters were statistically significant (p < 0.001). Overall, appropriate empiric treatment was prescribed in only 48/217 encounters (22%) during the pre-intervention period, but this increased to 73/83 encounters (88%) in the post-intervention period (p < 0.001). The results indicate that the treatment protocol was successful in changing prescribing practices and decreasing the use of inappropriate antimicrobials at the LTCF. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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13 pages, 1602 KiB

Open AccessArticle

The Mbeya Antimicrobial Stewardship Team: Implementing Antimicrobial Stewardship at a Zonal-Level Hospital in Southern Tanzania

by Jeffrey W. Hall, Jeannette Bouchard, P. Brandon Bookstaver, Matthew S. Haldeman, Peter Kishimbo, Godlove Mbwanji, Issakwisa Mwakyula, Davance Mwasomola, Megan Seddon, Mark Shaffer, Stephanie C. Shealy and Anthony Nsojo

Pharmacy 2020, 8(2), 107; https://doi.org/10.3390/pharmacy8020107 - 24 Jun 2020

Cited by 17 | Viewed by 4218

Abstract

Background: In 2017, Mbeya Zonal Referral Hospital (MZRH) and the University of South Carolina (UofSC) agreed to collaboratively strengthen antimicrobial prescribing in the southern highlands of Tanzania and train a new generation of clinicians in responsible antimicrobial use. Methods: Key stakeholders and participants were identified and the Mbeya Antimicrobial Stewardship Team (MAST) was created. The team identified assets brought by the collaborators, and four investigations of baseline needs were developed. These investigations included (a) a baseline clinician survey regarding antimicrobial resistance and stewardship, (b) a serial chart review of inpatient antimicrobial prescribing practices, (c) an investigation of antimicrobial resistance rates using existing isolates at the MZRH laboratory, and (d) a survey of antimicrobial availability at community pharmacies in the city. Results: 91% of physicians believe antimicrobial resistance is problem in Tanzania, although only 29% of physicians were familiar with the term “antimicrobial stewardship”. Escherichia coli isolates had resistance rates of over 60% to the commonly used agents ciprofloxacin, trimethoprim-sulfamethoxazole, and ceftriaxone. Thirteen out of 14 community pharmacies offered over-the-counter antibiotics for upper respiratory symptoms. Conclusions: International antimicrobial stewardship collaborations can successfully identify opportunities and needs. Evaluating the team’s efforts to improve patient outcomes will be essential. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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13 pages, 2152 KiB

Open AccessArticle

Impact of Nasal Swabs on Empiric Treatment of Respiratory Tract Infections (INSERT-RTI)

by Vanessa Huffman, Diana Carolina Andrade, Jared Ham, Kyle Brown, Leonid Melnitsky, Alejandro Lopez Cohen and Jayesh Parmar

Pharmacy 2020, 8(2), 101; https://doi.org/10.3390/pharmacy8020101 - 11 Jun 2020

Cited by 3 | Viewed by 3326

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) polymerase-chain-reaction nasal swabs (PCRNS) are a rapid diagnostic tool with a high negative predictive value. A PCRNS plus education “bundle” was implemented to inform clinicians on the utility of PCRNS for anti-MRSA therapy de-escalation in respiratory tract infections (RTI). The study included patients started on vancomycin with a PCRNS order three months before and after bundle implementation. The primary objective was the difference in duration of anti-MRSA therapy (DOT) for RTI. Secondary objectives included hospital length of stay (LOS), anti-MRSA therapy reinitiation, 30-day readmission, in-hospital mortality, and cost. We analyzed 62 of 110 patients screened, 20 in the preintervention and 42 in the postintervention arms. Mean DOT decreased after bundle implementation by 30.3 h (p = 0.039); mean DOT for patients with a negative PCRNS decreased by 39.7 h (p = 0.014). Median cost was lower after intervention [USD$51.69 versus USD$75.30 (p < 0.01)]. No significant difference in LOS, mortality, or readmission existed. The bundle implementation decreased vancomycin therapy and cost without negatively impacting patient outcomes. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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9 pages, 1184 KiB

Open AccessArticle

Pharmacist-Driven Culture and Sexually Transmitted Infection Testing Follow-Up Program in the Emergency Department

by Stephanie C. Shealy, Christine Alexander, Tina Grof Hardison, Joseph Magagnoli, Julie Ann Justo, Caroline Derrick, Joseph Kohn, Hana Rac Winders, Troy Privette, Majdi N. Al-Hasan and P. Brandon Bookstaver

Pharmacy 2020, 8(2), 72; https://doi.org/10.3390/pharmacy8020072 - 23 Apr 2020

Cited by 9 | Viewed by 3778

Abstract

Expanding pharmacist-driven antimicrobial stewardship efforts in the emergency department (ED) can improve antibiotic management for both admitted and discharged patients. We piloted a pharmacist-driven culture and rapid diagnostic technology (RDT) follow-up program in patients discharged from the ED. This was a single-center, pre- and post-implementation, cohort study examining the impact of a pharmacist-driven culture/RDT follow-up program in the ED. Adult patients discharged from the ED with subsequent positive cultures and/or RDT during the pre- (21 August 2018–18 November 2018) and post-implementation (19 November 2018–15 February 2019) periods were screened for inclusion. The primary endpoints were time from ED discharge to culture/RDT review and completion of follow-up. Secondary endpoints included antimicrobial agent prescribed during outpatient follow-up, repeat ED encounters within 30 days, and hospital admissions within 30 days. Baseline characteristics were analyzed using descriptive statistics. Time-to-event data were analyzed using the Wilcoxon signed-rank test. One-hundred-and-twenty-seven patients were included, 64 in the pre-implementation group and 63 in the post-implementation group. There was a 36.3% reduction in the meantime to culture/RDT data review in the post-implementation group (75.2 h vs. 47.9 h, p < 0.001). There was a significant reduction in fluoroquinolone prescribing in the post-implementation group (18.1% vs. 5.4%, p = 0.036). The proportion of patients who had a repeat ED encounter or hospital admission within 30 days was not significantly different between the pre- and post-implementation groups (15.6 vs. 19.1%, p = 0.78 and 9.4% vs. 7.9%, p = 1.0, respectively). Introduction of a pharmacist culture and RDT follow-up program in the ED reduced time to data review, time to outpatient intervention and outpatient follow-up of fluoroquinolone prescribing. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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9 pages, 636 KiB

Open AccessArticle

Effects of a Remote Antimicrobial Stewardship Program on Antimicrobial Use in a Regional Hospital System

by Joshua Knight, Jessica Michal, Stephanie Milliken and Jenna Swindler

Pharmacy 2020, 8(1), 41; https://doi.org/10.3390/pharmacy8010041 - 16 Mar 2020

Cited by 8 | Viewed by 3047

Abstract

While antimicrobial stewardship programs (ASPs) are well established at most large medical centers, small or rural facilities often do not have the same resources; therefore, different methods must be developed to start or expand ASPs for these hospitals. The purpose of this quality improvement study was to describe the implementation of a pharmacist-led remote ASP and assess the effect on antimicrobial use. Antimicrobial use in days of therapy per 1000 patient days (DOT/1000 PD) was compared between the six months before and after remote ASP implementation. Changes in system-wide, facility-specific, and target antimicrobial use were evaluated. Pharmacist interventions, acceptance rates, and number of times infectious disease (ID) physician assistance was sought were also tracked. System-wide antimicrobial use was 4.6% less in the post-implementation time period than in the pre-implementation time period, with vancomycin, piperacillin/tazobactam, and fluoroquinolones having the greatest reductions in use. Ninety-one percent of interventions made during the post-implementation period were accepted. ID physician review was requested 38 times, and direct ID physician intervention was required six times. Remote ASPs delivered from a central facility to serve a larger system may reduce antimicrobial use, especially against targeted agents, with minimal increase in ID physician workload. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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9 pages, 2075 KiB

Open AccessArticle

Implementation of an Extended-Infusion Piperacillin-Tazobactam Dosing Protocol: Unexpected Findings when Monitoring Safety and Compliance with Smart Pump Technology

by Nathaniel J. Rhodes, Jenna Lopez, Cecilia K. Pham, Helga Brake, Michael Fotis, Spencer E. Harpe, Sean Avedissian and Marc H. Scheetz

Pharmacy 2019, 7(4), 169; https://doi.org/10.3390/pharmacy7040169 - 11 Dec 2019

Viewed by 3414

Abstract

Compliance with recommended infusion rates was evaluated before, during, and after the implementation of extended-infusion (EI) piperacillin-tazobactam at an academic medical center. Software-controlled infusion-pump alert data were studied for piperacillin-tazobactam administrations before and after implementation of a four-hour EI protocol. Compliance was analyzed 16 weeks before (pre-EI), two weeks after (peri-EI), and an additional 16 weeks after (post-EI) protocol implementation. We defined potential harm as a programmed infusion rate exceeding the recommended rate, possible harm as a programmed infusion aborted by the user, and compliance as reversion to recommended rates. Potential and possible harm were standardized to 1000 patient days. Overall, 3110 alerts were identified during the period. Potential harm per 1000 patient days for pre-, peri-, and post-EI were 0, 6.12, and 1.05 (p < 0.001). Possible harm per 1000 patient days for the pre-, peri-, and post-EI were 0.33, 21.9, and 5.02 (p < 0.001). Compliance after an initial potential harm alert occurred more often post-EI (0.4 per 1000 patient days vs. 0 per 1000 patient days for pre- and peri-EI; p < 0.001), while alerts remaining in non-compliance were more prevalent if they initially occurred during the peri- and post-EI vs. pre-EI (6.1 and 0.6 per 1000 patient days vs. 0 per 1000 patient days; p < 0.001) period. Piperacillin-tazobactam infusions were administered faster than recommended during implementation (i.e., peri-EI) despite standardized orders. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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10 pages, 1516 KiB

Open AccessArticle

Implementation of a Health-System Wide Antimicrobial Stewardship Program in Omaha, NE

by Jennifer Anthone, Dayla Boldt, Bryan Alexander, Cassara Carroll, Sumaya Ased, David Schmidt, Renuga Vivekanandan and Christopher J. Destache

Pharmacy 2019, 7(4), 156; https://doi.org/10.3390/pharmacy7040156 - 25 Nov 2019

Cited by 4 | Viewed by 4501

Abstract

The Centers for Medicare and Medicaid Services (CMS) have mandated that acute care and critical access hospitals implement an Antimicrobial Stewardship (AMS) Program. This manuscript describes the process that was implemented to ensure CMS compliance for AMS, across a 14-member health system (eight community hospitals, five critical access hospitals, and an academic medical center) in the Omaha metro area, and surrounding cities. The addition of the AMS program to the 14-member health system increased personnel, with a 0.5 full-time equivalent (FTE) infectious diseases (ID) physician, and 2.5 FTE infectious diseases trained clinical pharmacists to support daily AMS activities. Clinical decision support software had previously been implemented across the health system, which was also key to the success of the program. Overall, in its first year, the AMS program demonstrated a $1.2 million normalized reduction (21% total reduction in antimicrobial purchases) in antimicrobial expenses. The ability to review charts daily for antimicrobial optimization with ID pharmacist and physician support, identify facility specific needs and opportunities, and to collect available data endpoints to determine program effectiveness helped to ensure the success of the program. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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Review

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13 pages, 237 KiB

Open AccessReview

BundlED Up: A Narrative Review of Antimicrobial Stewardship Initiatives and Bundles in the Emergency Department

by Maressa Santarossa, Emily N. Kilber, Eric Wenzler, Fritzie S. Albarillo and Ethan J. Sterk

Pharmacy 2019, 7(4), 145; https://doi.org/10.3390/pharmacy7040145 - 1 Nov 2019

Cited by 8 | Viewed by 3391

Abstract

Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED. Full article

(This article belongs to the Special Issue Antimicrobial Stewardship across the Continuum of Care)

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