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Background There is a pervasive view among some nurses and health care disciplines that antibiotic stewardship (AS) is solely a physician or pharmacist responsibility. There is an urgent need to alter this view so that nurses can seize every opportunity to prevent patient harm from antibiotics and optimize antibiotic use. One challenge to achieving full nurse engagement as equal members of the AS team is lack of an organizing framework to illustrate relationships of phenomena and concepts inherent to adoption of AS nursing practices. Methods We sought to create a framework derived from the peer-reviewed literature, systematic and scoping reviews, and professional standards, consensus statements and white papers. The emerging framework went through multiple iterations as it was vetted with nurse clinicians, scholars and educators, physicians, pharmacists, infection preventionists and AS subject matter experts. Results Our evidence-based Antibiotic Stewardship Nursing Practice SCAN-P Framework provides the much-needed context and clarity to help guide local-level nurses to participate in and lead AS nursing practice. Conclusions Nurses worldwide are ideally situated to provide holistic person-centered care, advocate for judicious use of antibiotics to minimize antibiotic resistance, and be AS educators of their patients, communities and the general public. The Antibiotic Stewardship Nursing Practice SCAN-P Framework provides a tool to do so.

Over diagnosis of catheter-associated urinary tract infection (CAUTI) contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridiodes difficile infections, as well as a false elevation in CAUTI rates. Utilizing agile implementation to implement a urine culture algorithm achieved statistically significant reduction in CAUTI rates in a critical care unit resulting in sustainment and spread throughout the system.

The prescription of prophylactic antibiotics prior to dental procedures is common, although factors influencing prescribing are poorly understood. We surveyed general and specialist medical providers and dentists on beliefs and attitudes regarding prophylactic antibiotic prescribing prior to dental procedures. There were significant differences in factors influencing decisions and perceived responsibility regarding prophylactic antibiotic prescribing between groups, although interest in additional education on the subject was high across both groups.

It is encouraging that most acute care centers have formal antimicrobial stewardship (AS) programs; though, most antibiotic use occurs in outpatient settings where access to infectious diseases specialists are limited. Stewardship programs often target dichotomous populations (adult or pediatric), but most children receive care in nonacademic, community outpatient settings. We propose 3 considerations for adult providers and infection preventionists seeking to incorporate outpatient AS elements and implement quality improvement initiatives that optimize pediatric care.

Reduction of health care-associated infections is trending in the right direction after decades of work by those involved in infection prevention and control and antibiotic stewardship. With institutional priorities currently pivoting to meet the needs of COVID-19 patients, this may be an advantageous time to promote integration of facility-level antibiotic stewardship and infection prevention and control programs. We propose a team science framework as a tool to leverage the complementary expertise of stewardship and infection prevention and control professionals. This framework considers stages of team development and fluidity needed when working with shifting priorities and can be used by leaders and team members throughout all phases of team building-from developing and launching the team, through evaluating and modifying team activities to best suit local needs.

Background Antimicrobial resistance is a continued global threat to public health. In recognition of this threat, the executive branch of the United States government consolidated guidelines through the President's Council of Advisors on Science and Technology and Executive Order 13676. Methods An analysis was conducted to assess the US government's response to this growing threat. Human and animal health legislation from 2011 to 2019 was reviewed using the congressional legislative database where 28 pieces of antimicrobial distinct legislation was identified. Results The majority of the bills identified were human health related and common themes found were incentivizing the development of new products, biodefense, expanded scope of use, and stewardship. Much fewer were identified pertaining to animal health; of those identified, common themes included stricter veterinary oversight, barriers to approval pathways for new products, and stewardship. Conclusions The public health impact of these legislative efforts is in part related to a broader political tension of the role of government vs local authorities in managing regulatory enforcement and guidelines.

Objective To evaluate antimicrobial stewards’ experiences of using a dashboard display integrating local and national antibiotic use data implemented in the U.S. Department of Veterans Affairs (VA). This paper reports early formative evaluation. Design Qualitative interviewing. Setting Eight VA hospitals participated with established antimicrobial stewardship (AS) programs participated in the pilot. Participants Six infectious disease physicians and eight clinical pharmacists agreed to be interviewed (n = 14). Methods A 3-part qualitative interview script was used involving a description of local stewardship activities, a Critical Incident description of dashboard use, and general questions regarding attitudes towards the tool. An inductive open coding approach was used for analysis. Results We found 4 themes showing the complexities of using stewardship tools: (1) Data validity is socially negotiated; (2) Performance feedback motivates and persuades social goals when situated in an empirical distribution; (3) Shared problem awareness is aided by authoritative data; and (4) The AS dashboard encourages connections with local quality improvement culture. Conclusions Social dimensions of AS tool use emerged as distinct from, and equally important as decision support provided by the dashboard. Successful stewardship tools should be designed to support both the social and cognitive needs of users.

Background Nursing has been called for greater participation in antibiotic stewardship. Although many of the functions that are integral to successful stewardship are within the scope of bedside nurses, data evaluating nursing engagement in stewardship are limited. The objective of this study was to identify nurses' roles and confidence in engaging in stewardship practices by conducting a survey of pediatric staff nurses employed at a 354-bed freestanding children's hospital with a well-established prospective audit and feedback stewardship program. Methods An investigator-developed online survey was used to assess 10 identified practices that fall within the responsibility of inpatient nurses and contribute to the stewardship process. Results One hundred and eighty nurses participated in the study. Nurses were highly confident assessing for an adverse drug reaction history, obtaining cultures prior to antibiotics, and participating in patient education. They were less confident in reviewing microbiology results to determine antibiotic appropriateness. Clinical practice and hospital culture influenced perceptions of the nursing role in stewardship. Reported barriers to stewarding included nurses not included in rounds, interdisciplinary power differentials, and nursing input not actively sought. Conclusions Barriers to nurse engagement were identified and could be addressed by improving education in microbiology and principles of antibiotic use along with more consistent inclusion of nurses in bedside rounds while also cultivating an environment where nurse contribution is actively sought.

Background There is a growing recognition of the need to partner with nurses to promote effective antibiotic stewardship. In this study, we explored the attitudes of nurses and infection preventionists toward 5 nurse-driven antibiotic stewardship practices: 1) questioning the need for urine cultures; 2) ensuring proper culturing technique; 3) recording an accurate penicillin drug allergy history; 4) encouraging the prompt transition from intravenous (IV) to oral (PO) antibiotics; and 5) initiating an antibiotic timeout. Methods Nine focus groups and 4 interviews with 49 clinical nurses, 5 nurse managers, and 7 infection preventionists were conducted across 2 academic pediatric and adult hospitals. Results Nurse-driven antibiotic stewardship was perceived as an extension of the nurses' role as patient advocate. Three practices were perceived most favorably: questioning the necessity of urinary cultures, ensuring proper culturing techniques, and encouraging the prompt transition from IV to PO antibiotics. Remaining recommendations were perceived to lack relevance or to challenge traditionally held nursing responsibilities. Prescriber and family engagement were noted to assist the implementation of select recommendations. Infection preventionists welcomed the opportunity to assist in providing nurse stewardship education. Conclusions Nurses appeared to be enthusiastic about participating in antibiotic stewardship. Efforts to engage nurses should address knowledge needs and consider the contexts in which nurse-driven antibiotic stewardship occurs.

Highlights • Fungal superinfection is a concern in patients who are hospitalized with COVID-19. • There is concern that the COVID-19 pandemic will lead to the overuse of antifungals. • Antifungal use was not increased early in the COVID-19 pandemic at an academic medical center.

Background Guidelines on antimicrobial stewardship emphasize the importance of an interdisciplinary team, but current practice focuses primarily on defining the role of infectious disease physicians and pharmacists; the role of inpatient staff nurses as antimicrobial stewards is largely unexplored. Methods An updated integrative review method guided a systematic appraisal of 13 articles spanning January 2007-June 2016. Quantitative and qualitative peer-reviewed publications including staff nurses and antimicrobial knowledge or stewardship were incorporated into the analysis. Results Two predominant themes emerged from this review: (1) nursing knowledge, education, and information needs; and (2) patient safety and organizational factors influencing antibiotic management. Discussion Focused consideration to empower and educate staff nurses in antimicrobial management is needed to strengthen collaboration and build an interprofessional stewardship workforce. Conclusions Further exploration on the integration and measurement of nursing participation is needed to accelerate this important patient safety initiative.

Antibiotic resistance is one of the top infectious disease threats facing the world today. The escalating resistance to antibiotics has been named by the Centers for Disease Control and Prevention as one of the top 5 threats to health in the United States and has led to the development of the National Action Plan for Combating Antibiotic-Resistant Bacteria. The plan, released by the White House in March 2015, calls for the establishment of antibiotic stewardship programs in all acute care hospitals by 2020. For antibiotic stewardship programs to achieve optimal success they must include nursing's perspectives and the active participation of nurses and the nursing profession. Although clearly any successful efforts to address this complex problem must be comprehensive, sustained, and involve all sectors of the health care community and public, the aim of this article is to convey the immediate need for nurses and the nursing profession to actively engage in initiatives, strategies, and solutions to combat antibiotic resistance, and to recommend what stakeholders within the nursing profession might contribute to antibiotic stewardship.

Providers in pediatric post-acute care facilities were surveyed about knowledge of and resources for antimicrobial stewardship. All agreed that antibiotics were overused in such pediatric facilities, but 60% had not implemented stewardship strategies. Lack of treatment guidelines (47%) was identified as the most common barrier to antimicrobial stewardship.

We describe the proportion of health care facility-onset Clostridium difficile infection (HO-CDI) National Healthcare Safety Network laboratory-identified events at our facility that were deemed nontrue HO-CDIs. Reasons included testing in a patient without significant diarrhea or with recent laxative use, or delayed testing. Standardized infection ratios using only true HO-CDI in the numerator were improved compared with publically reported standardized infection ratios. A prioritization matrix identifies which clinical services could benefit most from directed diagnostic stewardship interventions.

We implemented an electronic medical record (EMR) decision support tool for ordering urine cultures per evidence-based guidelines. Following the EMR change, we found a significant increase in proportion of cultures ordered for catheterized intensive care unit (ICU) patients meeting guidelines. We surveyed providers and found poor understanding of urine culture guidelines for catheterized ICU patients. EMR-based interventions and educational opportunities have potential to improve urine culture guideline adherence and reduce unnecessary testing and antibiotic use.

Background Globally, the health and economic burden posed by health care–associated infections (HAIs) remains wide and severe. To curb the burden associated with HAIs, countries, including Iran, aim at HAI prevention and control. This study explores the challenges faced by the Iranian health system in addressing the issues associated with the prevention and control of HAIs. Methods A qualitative research method was adopted in exploring the phenomenon. We used the purposive sampling approach in reaching 24 key informants at the national and subnational levels. The thematic framework analysis was conducted for analyzing the interviews. Results Five main themes emerged from our study demonstrating the obstacles toward the prevention and control of HAIs. They include governance and stewardship, resources, safety culture, monitoring and surveillance systems, and inappropriate prescription of antibiotics. Conclusions Strengthening of reporting and surveillance systems for HAIs coupled with proper governance and stewardship are crucial in order to improve the health and safety of patients. However, the availability of resources, through an intersectoral approach, is essential to achieve sustained output.

Background: The CDC and The Joint Commission have called for an interdisciplinary approach to antibiotic stewardship implementation. The healthcare team should consist of infectious disease physicians, pharmacists, infectious disease pharmacists, infection preventionists, microbiologists, and nurses. The scant literature to date has looked at nurses’ attitudes and beliefs toward participating in antibiotic stewardship and have identified several factors that contribute to the lack of uptake by nurses: lack of education around stewardship, poor communication among healthcare providers, and hospital or unit culture, among others. Additionally, nurses’ lack of interest in what would be more work or not within their scope of work was put forth as an additional factor by infection preventionists and pharmacists as a barrier to implementation. Method: An investigator-developed online survey was used to assess the usefulness of 3 investigator-developed educational e-learning modules that encompassed the role of nurses in antibiotic stewardship, pharmacy and laboratory topics related to antimicrobial stewardship, as well as the nurses’ attitudes toward their participation in such activities. Results: Participants took the survey after review of the 3 e-learning modules. The results indicate that, contrary to what pharmacists and infection preventionists thought, 82% of nurses felt they should contribute to and be part of the antimicrobial stewardship team. Additionally, after completing the modules, 73% felt more empowered to participate in stewardship discussions with an additional 23% wanting more education. 100% felt that they learned information that they could utilize in their everyday work. Barriers to implementation of stewardship activities on their unit included lack of education (41%), hospital or unit culture (27%), with only 4% citing they did not feel it was their job or that they had anything to contribute to a discussion. Also, 24% felt that there were no obstacles to participation. Conclusions: Surprisingly, most nurses who took this educational series and survey felt that they should be part of the antibiotic stewardship team. As cited previously from the literature, education and culture need to be addressed to overcome the nurses’ barriers to stewardship involvement. E-learning can provide an easy first step to educating nurses when time permits and can provide a good springboard for discussion on the units and with physicians and pharmacists. For a copy of the modules, please contact the author.Funding: NoneDisclosures: None

Background Nursing homes (NHs) are implementing antibiotic stewardship programs due to recent federal regulations. We sought to evaluate if NH antibiotic stewardship policies change antibiotic use in NH residents. Methods Antibiotic stewardship policy data were collected from nationally-representative samples of NHs in 2013 and 2017. An aggregate antibiotic stewardship intensity index, ranging from 0-100, was calculated from five antibiotic stewardship policy measures. Survey data were merged with concurrent MDS 3.0 data and antibiotic use was defined as a one-day prevalence from annual and quarterly assessments. Multivariable models, overall and stratified by infection type, were used to estimate antibiotic use as a function of antibiotic stewardship intensity, NH and resident characteristics, and time. The total adjusted change in antibiotic use was calculated as the difference in predicted use after setting time and stewardship intensity to 2013 values and then to 2017 values, adjusting for 2017 characteristics. The isolated contribution of antibiotic stewardship intensity was calculated as the predicted antibiotic use when time is set to 2013 and policy intensity to 2017 divided by the total adjusted change in antibiotic use. Results Data from 584,540 resident assessments from 1,825 NHs were analyzed. On average, antibiotic stewardship intensity in NHs increased significantly from 2013 to 2017 (µ=33.08 to µ=67.94, p Conclusions Improved antibiotic stewardship programs have resulted in a modest decline in antibiotic use, suggesting that the full extent of the translation from antibiotic stewardship policy to practice remains to be seen.

Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile.We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care-associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis.The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days -15.3, P.01). The health care-associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P.01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile.Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.

Background Antimicrobial stewardship is recommended as a crucial mechanism to reduce the emergence of antimicrobial resistance. The purpose of this article was to describe implementation of antimicrobial management programs (AMPs) across a large health system of community hospitals. Methods The initiative was structured in 4 phases. Although each phase was implemented sequentially, facilities could progress at their own pace. Phase goals needed to be met before moving to the next phase. The 4 phases included preparatory, foundational, clinical care optimization, and refinement. A survey was administered prior to the initiative in 2010, and modified surveys were administered in 2015 and 2017. Results Stewardship activities improved in most areas of the AMP initiative in 2015, with substantial improvement by 2017. Important changes included an increase in established programs, from 82% in 2010 to 88% and 96% in 2015 and 2017, respectively. Physician Champions increased from 73% in 2010 to 94% in 2017. Advances were made in the use of evidence-based treatment recommendations, antibiogram development, prospective audit and feedback for antimicrobials, tracking of antibiotic usage metrics, and a cost reduction of 40% from baseline. Conclusion A well-designed, phased approach to implementing AMP can help community hospitals and hospital systems recognize substantial clinical and financial benefits.

Background The availability of effective antibiotics is considered one of the most important developments in medicine. However, many organisms that were once susceptible to common antibiotics are becoming resistant. Antimicrobial stewardship programs (ASPs) are considered to be vital for combating the emergence of resistance. To understand current antimicrobial stewardship practices in Kansas, the authors designed a 36-question survey. Results of this survey will be used to develop a coordinated, public health strategy for improving current practices. Methods To assess the number of ASPs and general antimicrobial stewardship practices in Kansas, a 36-question survey was developed and sent out to infection preventionists at all 154 acute care facilities in Kansas via e-mail. Results Of the 154 eligible facilities, 129 (83.7%) responded to this survey, and 61 of 127 (48%) had a formal committee devoted to antimicrobial stewardship. Acute care facilities were more likely than critical access facilities to have formal committees and were also more likely to engage in core stewardship strategies. Conclusions In a world with increasing microbial resistance, the role of public health in antimicrobial stewardship is becoming more important. After surveying all hospitals in Kansas about antimicrobial stewardship practices, we realize that critical access hospitals have the greatest need for support and may see the greatest opportunities for development and improvements.

ObjectiveTo measure the impact of an antimicrobial stewardship (AMS) program on the use of antibiotics for surgical prophylaxis at acute care hospitals in Egypt.MethodsThis was a before-and-after intervention study conducted in 5 tertiary, acute-care surgical hospitals. The baseline, intervention, and follow-up periods were 3, 6, and 3 months, respectively. The impact of the intervention was measured by preintervention and postintervention surveys for surgical patients with clean and clean-contaminated wounds. Information was collected on demographic characteristics and antibiotic use. The intervention focused mainly on educating surgical staff on the optimal timing and duration of antibiotics used for surgical prophylaxis. Only 3 hospitals identified a surgeon to audit antibiotic surgical prescriptions. The primary outcome measures were the percentages of surgical patients receiving optimal timing and duration of surgical prophylaxis.ResultsData were collected for 745 patients before the intervention and for 558 patients after the intervention. The optimal timing of the first dose improved significantly in 3 hospitals, increasing from 6.7% to 38.7% (P < .01), from 2.6% to 15.2% (P < .01), and from 0% to 11% (P < .01). All hospitals showed a significant rise in the optimal duration of surgical prophylaxis, with an overall increase of 3%-28% (P < .01). Days of therapy per 1000 patient-days were decreased significantly in hospitals A, B, C, and D, with no change in hospital E.ConclusionsAn AMS program focusing on education supported by auditing and feedback can have a significant impact on optimizing antibiotic use in surgical prophylaxis practices.