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Background: Antimicrobial stewardship (AMS) initiatives are imperative to safeguard antimicrobials and reduce resistance. Across the UK, AMS relies in part on the self-regulation of the veterinary profession, particularly in farm animal practice, alongside voluntary schemes and quality assurance systems. In Europe, AMS initiatives are often statutory and require responsibility from several sectors. Consideration of broader AMS initiatives, potentially unfamiliar to the Welsh veterinary profession, could optimise future policy and align it with the requirements of Welsh veterinarians., Methods: AMS initiatives were collated from nations with long-standing low antimicrobial use. A survey was constructed permitting veterinarians' evaluation of initiative feasibility and effectiveness (collectively, 'acceptability') within Welsh farm animal practice., Results: Veterinarian-directed AMS initiatives, particularly those implemented within individual practices, were considered most acceptable. Initiatives that demanded cooperation from entities outside practices, or those regarded as punitive, were less acceptable., Limitations: The findings of this voluntary survey may be biased towards particularly motivated respondents in the veterinary sector. Additionally, the cause or effect of the recorded professional behaviour is not known in this study., Conclusion: Future antimicrobial policy should consider AMS acceptability by veterinarians, alongside farmers and other stakeholders, to promote compliance and attainment. The study data suggest that veterinarians may perceive continuous professional development/knowledge exchange as being most acceptable, alongside activities allied to a strong veterinarian‒client prescribing relationship. Continued support should focus on expanding these areas. Decoupling (ie, abolishing the professional licence for veterinarians to both prescribe and dispense medicines) was viewed as least acceptable by veterinarians in this study., (© 2024 The Author(s). Veterinary Record published by John Wiley & Sons Ltd on behalf of British Veterinary Association.)

Quality is central to value-based care, and measurement is essential for assessing performance and understanding improvement over time. Both value-based care and methods for quality measurement are evolving. Infectious diseases (ID) has been less engaged than other specialties in quality measure development, and ID providers must seize the opportunity to engage with quality measure development and research. Antimicrobial stewardship programs are an ideal starting point for ID-related quality measure development; antimicrobial stewardship program interventions and best practices are ID specific, measurable, and effective, yet they are grossly undercompensated. Herein, we provide a scheme for prioritizing research focused on development of ID-specific quality measures. Maturation of quality measurement research in ID, beginning with an initial focus on stewardship-related conditions and then expanding to non-stewardship topics, will allow ID to take control of its future in value-based care and promote the growth of ID through greater recognition of its value., Competing Interests: Potential conflicts of interest. All authors served on the IDSA Quality Improvement Committee (now the Practice and Quality Committee). Dr. Eby received an honorarium for work on UTI measure research with IDSA; this measure was not included in the manuscript and no funding from the honorarium was used as support for this manuscript. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Antimicrobial stewardship programs (ASPs) refer to a set of coordinated actions that improve the quality of care and combat antimicrobial resistance. Currently, information regarding the status of ASPs in Mexico is scarce. We aimed to describe the status of ASPs in 12 hospitals from Christus Muguerza Healthcare System., Methods: A cross-sectional study was conducted in 12 hospitals, with a previously developed self-assessment tool to calculate each hospital's ASP development score. The self-assessment tool includes 7 standards with 23 items. Score categories were defined as; high, medium, low, or none. The overall ASP development score was calculated using the proportional weight of each standard. Participating hospitals were divided into 2 groups according to their bed count. Statistical analysis was conducted in Excel program (Microsoft, Redmont, Washington)., Results: 12 hospitals completed the self-assessment survey. The median overall ASP development score was 32.3%. The highest overall development scores were observed for hospitals with > 40 beds. The core elements with the lowest development scores were Education and training, and Reporting and feedback. Unlike hospitals with over 40 beds, those with 40 beds or less had a low development score for Hospital leadership support. The core element with the highest development score was Infection prevention and control., Conclusions: This is the first multicenter assessment of ASPs in Mexico, revealing a high proportion of low-score hospitals. National implementation of ASPs is required to combat antimicrobial resistance., (© 2024. The Author(s).)

BackgroundAntibiotic resistance poses a considerable public health threat, with data-driven stewardship a main prevention measure. While quantifying antibiotic consumption is a key component of antibiotic stewardship programmes, the choice of denominator for calculating this metric can impact comparative analyses and trend evaluations substantially, influencing targeted stewardship interventions.AimWe aim to evaluate how using hospital sector-specific antibiotic consumption rate denominators at country level impacts country rankings and trends, addressing the limitations of the commonly used 'defined daily doses (DDD) per 1,000 inhabitants per day' metric.MethodsHospital antibiotic consumption data from ESAC-Net and denominator data from Eurostat ('inhabitants,' 'bed-days' and 'discharges') for 2017-2021 were used to calculate hospital antibiotic consumption rates for 24 reporting European Union/ European Economic Area (EU/EEA) countries. Countries were ranked by their consumption rates and trends were analysed to assess the effects of using different denominators.ResultsCountry rankings and 5-year trend analyses varied depending on the denominator used. Antibiotic consumption rates were more similar when using hospital activity-based denominators 'bed-days' and 'discharges' compared with the population-based 'inhabitants' denominator. Differences in country rankings and trends were also seen among rates derived using 'bed-days' and 'discharges'.ConclusionThe study underscores the importance of using hospital activity-based denominators such as 'bed-days' and 'discharges' when evaluating hospital antibiotic consumption. ESAC-Net's historical reliance on only 'DDD per 1,000 inhabitants per day' is challenged, advocating for the use of multiple hospital activity-based denominators. Corresponding hospital activity denominators for ESAC-Net data will more effectively inform national hospital antibiotic stewardship interventions.

Objectives: We examined local prescribing patterns across the entire treatment course for children treated for uncomplicated urinary tract infection (UTI) to determine opportunities for antibiotic stewardship initiatives., Methods: We conducted a retrospective review of emergency department and inpatient encounters for febrile and afebrile UTI in a children's hospital from 2021 to 2022. An antibiotic spectrum ranking was established, and providers' choices were assessed for appropriateness on the basis of the individuals' urine culture (UCx). Groups were stratified by fever presence and compared using χ2, Fisher's exact, and Mann-Whitney U tests., Results: Of 172 encounters (83% emergency department), 99 (58%) had a positive UCx. Eighty (80%) grew Escherichia coli, with 67 (84%) being susceptible to cefazolin (minimum inhibitory concentration ≤16 mg/L). There were 229 antibiotic regimens and 39 (17%) were appropriate. Inappropriate antibiotic choices included unnecessary use of broad-spectrum antibiotics and misdiagnosed UTI. Grouping by encounter, at least 1 dose of a third cephalosporin was given in 51% of encounters, and 80% of these received it unnecessarily because of UTI misdiagnosis or suitability of a narrower-spectrum antibiotic. The median prescribed antibiotic duration was 7 days (interquartile range 7-10). Of 73 encounters with UCx growing mixed flora or a nonuropathogen, only 29 (40%) had antibiotics discontinued. Confirmed UTI was associated with fever and nitrite positivity., Conclusions: Our study revealed high prevalence of inappropriate antibiotics, particularly unnecessary prescribing of third cephalosporin, prescriptions not supported by laboratory data, and prolonged treatment courses. Our results identify factors that can be used to support UTI treatment pathways and ensure antibiotic stewardship., (Copyright © 2024 by the American Academy of Pediatrics.)

Purpose: To describe the long-term effects of an ASP among febrile neutropenia (FN) patients., Methods: A quasi-experimental study was conducted between 2015 and 2023 at a tertiary care hospital in Istanbul, Türkiye. The ASP was implemented for FN patients, and the effects were assessed before and after the ASP interventions, which included FN clinical pathways and regular multi-disciplinary meetings with relevant healthcare workers., Results: A total of 489 FN episodes of 290 patients were included, 42% were female, and the mean age was 56 years (SD: 15, range: 18-89 years). After the intervention, the rate of appropriate antimicrobial therapy at the levels of starting (p = 0.005), switching (p < 0.001), and de-escalation/discontinuation, (p < 0.001) significantly increased. Another positive impact of the ASP was a significant reduction in candidemia (from 4.88 to 0.74, p = 0.004), as well as a significant reduction in the 90-day mortality rate (from 19 to 5%, p < 0.001). In multivariate analysis, having a gram-negative bloodstream infection, prolonged days with fever, and a high risk for neutropenia were found to be significant predictors of 90-day mortality, while follow-up with ASP significantly reduced mortality., Conclusion: Implementation of ASP led to reduced candidemia and LOS without increasing mortality, even in a country with a high rate of antimicrobial resistance. Implementation of sustainable ASP for FN patients is critical in combating antimicrobial resistance., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Scope: This European Society of Clinical Microbiology and Infectious Diseases guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are (a) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? (b) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? (c) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? (d) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing?, Methods: An expert panel was convened by European Society of Clinical Microbiology and Infectious Diseases and the guideline chair. The panel selected in consensus the four most relevant antimicrobial stewardship topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes and stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively., Recommendations: The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e. withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very low and low certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Optimization of antibiotic stewardship requires determining appropriate antibiotic treatment and duration of use. Our current method of identifying infectious complications alone does not attempt to measure the resources actually utilized to treat infections in patients. We sought to develop a method accounting for treatment of infections and length of antibiotic administration to allow benchmarking of trauma hospitals with regard to days of antibiotic use., Methods: Using trauma quality collaborative data from 35 American College of Surgeons (ACS)-verified level I and level II trauma centers between November 1, 2020, and January 31, 2023, a two-part model was created to account for (1) the odds of any antibiotic use, using logistic regression; and (2) the duration of usage, using negative binomial distribution. We adjusted for injury severity, presence/type of infection (eg, ventilator-acquired pneumonia), infectious complications, and comorbid conditions. We performed observed-to-expected adjustments to calculate each center's risk-adjusted antibiotic days, bootstrapped Observed/Expected (O/E) ratios to create confidence intervals, and flagged potential high or low outliers as hospitals whose confidence intervals lay above or below the overall mean., Results: The mean antibiotic treatment days was 1.98°days with a total of 88,403 treatment days. A wide variation existed in risk-adjusted antibiotic treatment days (.76°days to 2.69°days). Several hospitals were identified as low (9 centers) or high (6 centers) outliers., Conclusion: There exists a wide variation in the duration of risk-adjusted antibiotic use amongst trauma centers. Further study is needed to address the underlying cause of variation and for improved antibiotic stewardship., Competing Interests: Competing InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Anne H. Cain-Nielsen and Mark R. Hemmila receive salary support from Blue Cross Blue Shield of Michigan and Blue Care Network (a nonprofit mutual company) through grant funding of the Michigan Trauma Quality Improvement Program and from the Michigan Department of Health and Human Services through grant funding of the Michigan Trauma Quality Improvement Program. The remaining authors have no conflicts to disclose.

Background: Early initiation of targeted antibiotic therapy is important to achieve the best patient outcomes in intubated patients with pneumonia in the intensive care unit (ICU). This study aimed to investigate the applicability of multiplex polymerase chain reaction (PCR) in an ICU by comparing the test results to the results of conventional microbiological methods to assess the possible impact on antibiotic therapy., Method: This retrospective study investigated adult patients with pneumonia on mechanical ventilation in the ICU. Tracheal aspirates were collected within 24h after intubation and the initiation of mechanical ventilation. Samples were initially tested by conventional microbiological methods and subsequently re-evaluated with rapid multiplex PCR on stored samples. Concordance between the two methods was assessed. An intensivist and a microbiologist retrospectively reviewed the patients' electronic health records for relevant clinical details to evaluate the potential impact of multiplex PCR results on antibiotic therapy., Results: In this study, 76 patients were enrolled and 55 (72.4%) tested positive for 95 pathogens using multiplex PCR, while conventional microbiological methods identified 40 pathogens in 32 (42.2%) patients. Concordance between the two methods was observed in 42 (55.3%) patients. Multiplex PCR detected 39 additional pathogens in 31 (40.7%) patients. Retrospective analysis indicated potential antibiotic de-escalation in 35 (46.1%) patients and escalation in 4 (5.3%) patients. Multiplex PCR significantly reduced the turnaround time for test results., Conclusion: In ICU patients with suspected pneumonia, multiplex PCR identified a higher number of pathogens compared to CMM. A retrospective assessment indicates that the use of multiplex PCR could potentially have prompted the de-escalation of antibiotic therapy in nearly half of the patients. Therefore, multiplex PCR may serve as a supplement to CMM in guiding antibiotic stewardship., (© 2024 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Objective: We sought to characterize and evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use and subsequent surgical site infections (SSI) in perioperative settings., Methods: A systematic review and meta-analysis was conducted by searching PubMed, Embase and CINAHL. Two independent reviewers extracted the data using the Descriptive Elements of Pharmacist Intervention Characterization Tool and undertook quality assessment using the Crowe Critical Appraisal. A meta-analysis was conducted using a random-effect model., Results: Eleven studies were included in this review. Pharmacists were found to have various roles in AMS, including educational sessions, ward rounds, audits and feedback, and guidelines development. The discussion of interventions lacked details on the development. A meta-analysis revealed that pharmacist-led AMS programs in perioperative settings was associated with a significant improvement in antibiotic selection (OR 4.29; 95 % CI 2.52-7.30), administration time (OR 4.93; 95 % CI 2.05-11.84), duration (OR 5.27; 95 % CI 1.58-17.55), and SSI (OR 0.51; 95 % CI 0.34-0.77)., Conclusion: Pharmacist-led AMS programs were effective in improving antimicrobial prescribing while reducing SSI; however most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions, therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. High-quality, multicomponent, theory-derived, interventional studies using appropriate methodology and standardized data collection, are needed., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Evaluation of hospital-specific antimicrobial use is necessary for successful national antimicrobial stewardship. This study aimed to identify antimicrobial use in long-term care hospitals (LCHs) in Korea., Methods: A multi-centre retrospective study was conducted to evaluate the prescription patterns and appropriateness of antimicrobials in 20 LCHs in Korea. The medical record data of hospitalized patients who were newly prescribed antimicrobials at each hospital were collected manually between 10 th July and 31 st October 2023 to evaluate the appropriateness of antimicrobial use., Results: The prevalence of antimicrobial prescriptions was 8.9% (365/4086) and 10.3% (402/3892) on 12 th July 2023 and 18 th October 2023, respectively. In total, 885 antimicrobials were prescribed to 740 patients. Among the antimicrobials, third- or fourth-generation cephalosporins (31.9%) represented the most prescribed antimicrobial class. A large majority of antimicrobials (96.6%, 855/885) were prescribed for the treatment of infectious diseases; however, only 37.7% (322/855) of antimicrobials were prescribed appropriately for infections. The route of administration, dosage and prescribed antimicrobial were appropriate in 99.6% (852/855), 56.1% (480/855) and 62.0% (530/855) of cases, respectively. In total, 35.2% (252/715) of patients were prescribed antimicrobials appropriately. The diagnosis of infectious disease was appropriate for 52.9% (472/892) of cases. Of the five, 15 and 10 antimicrobials used for surgical site infection prophylaxis, medical prophylaxis and other purposes, respectively, none were used appropriately., Conclusion: The proportion of antimicrobials used appropriately is low in Korean LCHs. These data highlight the importance of establishing antimicrobial stewardship in LCHs., (Copyright © 2024 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Inappropriate use of antimicrobials can push the environment out of balance, and cause unnecessary waste that can contaminate our soil, animals and waterways. Health professional education is committed to preparing students for antimicrobial stewardship (AMS) and supporting planetary health, but a more multidisciplinary action is needed to curb the expansion of antimicrobial resistance (AMR). The aim of this scoping review is to showcase the current antimicrobial knowledge of undergraduate students across the disciplines of medicine, pharmacy, nursing, dentistry and veterinary. This will consequently showcase the gaps and trends across the different disciplines and countries to help inform planetary health multidisciplinary undergraduate curriculums., Methods: A search of the existing literature published prior to December 2023 was conducted using CINAHL, EMBASE, MEDLINE, SCOPUS, and ERIC databases. Studies were excluded if they included postgraduate students or discussed the knowledge, attitude and practice (KAP) of students towards antimicrobial prescribing, AMR and AMS related to a specific learning activity., Results: A total of 144 articles were included. The most represented countries were India and Pakistan accounting for 17% and 8% of the studies, respectively. Single-disciplinary research accounted for approximately 80% of the studies. Medicine was the most represented discipline in both single-disciplinary and multidisciplinary research, appearing in approximately 62% of the studies, followed by pharmacy appearing in approximately 30% of the studies and dentistry appearing in approximately 18% of the studies. Three major priority themes were identified: students are more familiar with the term AMR compared to AMS; inappropriate use of antimicrobials is seen as the main driver of AMR; and the need for more training and education in the field of appropriate antimicrobial prescribing, AMR and AMS., Conclusion: This review has highlighted that there is a need for more AMS interprofessional education (IPE) activities in all five disciplines, and especially within the disciplines of nursing, veterinary and dentistry, as shown by a lack of multidisciplinary research in this area. Most of the knowledge assessments have just touched the surface of AMS and focused on inappropriate antimicrobial use alone. Interdisciplinary planetary health education needs to go beyond these skills and broaden the understanding of other factors that can contribute to AMR such as inappropriate disposal, environmental contamination, monitoring and surveillance, one health, false allergies, and more importantly, how each health professional can contribute to a team., (© 2024. The Author(s).)

Purpose: An advisory panel of experts was convened by the ASHP Foundation as a part of its Medication-Use Evaluation Resources initiative to provide commentary on an approach to antibiotic stewardship in the treatment of skin and soft tissue infections (SSTIs), with a focus on oral antibiotics in the emergency department (ED) setting for patients who will be treated as outpatients. Considerations include a need to update existing guidelines to reflect new antibiotics and susceptibility patterns, patient-specific criteria impacting antibiotic selection, and logistics unique to the ED setting., Summary: While national guidelines serve as the gold standard on which to base SSTI treatment decisions, our advisory panel stressed that institutional guidelines must be regularly updated and grounded in local antimicrobial resistance patterns, patient-specific factors, and logistical considerations. Convening a team of experts locally to establish institution-specific guidelines as part of a comprehensive antibiotic stewardship program can ensure patients receive the most appropriate oral therapy for the outpatient treatment of SSTIs in patients visiting the ED., Conclusion: SSTI treatment considerations for antibiotic selection in the ED supported by current, evidence-based guidelines, including guidance on optimal oral antibiotic selection for patients discharged for outpatient treatment, are a useful tool to improve the quality and efficiency of care, enhance patient-centric outcomes and satisfaction, decrease healthcare costs, and reduce overuse of antibiotics., (© American Society of Health-System Pharmacists 2024.)

Background: Antimicrobial stewardship programs (ASP) often function naturally as facilitators within clinical hospital settings, by working with individuals and teams to reduce unnecessary antibiotics. Within implementation science, facilitation has been studied and evaluated as an implementation strategy that can accelerate and improve fidelity to implementation efforts. This study describes a novel, virtual facilitation strategy developed and served as an intervention within the optimizing perioperative antibiotics for children trial (OPERATIC trial). This paper: (1) describes ASP team's preferences for and use of a facilitation workshop and (2) describes sustained use of facilitation skills throughout the study period., Methods: Study participants included antimicrobial stewardship team members from the nine children's hospitals that participated in this study and completed facilitation training. All individuals who completed facilitation training were asked to evaluate the training through an online survey. Additionally, site leads were interviewed by the site coordinator every other month and asked about their team's use of facilitation skills throughout the rest of the study period. Survey data were managed and coded in R, and qualitative interview data were analyzed using rapid methodology., Results: 30 individuals, including both physicians and pharmacists, completed the evaluation. Individuals largely rated themselves as novice facilitators (53%). Individuals reported satisfaction with virtual facilitation and identified different components of the workshops as valuable. An additional 108 interviews were performed throughout the study period. These interviews found that facilitators reported using all skills throughout the study period and described varied use of skills over time. All nine sites applied facilitation strategies, team building techniques, and communication/conflict skills at some point during the intervention phase., Conclusion: We describe the use of virtual facilitation as an acceptable and appropriate strategy to enhance facilitation skills for ASP teams working to reduce unnecessary postoperative antibiotics. Participants reported different useful components of facilitation training and described using differing facilitation skills throughout the trial. Overall, the use of facilitation skills continued throughout the duration of the study period. This paper outlines how facilitation training can be conducted virtually in a way that is feasible and acceptable to clinicians., Trial Registration: NCT04366440, April 24, 2020., (© 2024. The Author(s).)

Background: Overuse and misuse of antibiotics is one of the driving factors of antimicrobial resistance, a growing global health threat. The use of antibiotics is particularly high in children. Even though the implementation of antibiotic stewardship programs (ASP) in pediatrics has been shown to reduce antibiotic use, this implementation has been limited to large university hospitals in Germany. Telemedicine applications might be an effective approach to implement ASP in non-university settings., Methods: This protocol details the TeleKasper study (Telemedical Competence Network "Antibiotic Stewardship in Pediatrics"). Tele-Kasper is a stepped-wedge cluster-randomized trial that will be conducted across non-university children's hospitals in Germany. The intervention consists of a telemedical consultation service in the form of a network in different German areas, using an app as a communication tool. The primary outcome will be a 20% reduction in overall antibiotic consumption measured using defined daily doses per 100 patient days., Discussion: The TeleKasper study aims to implement and evaluate a prototype for a nationwide antibiotic stewardship program by telemedical means in pediatric departments in non-university hospitals in Germany to promote rational antibiotic use and improve medical care for infections., Trial Registration: German Clinical Trials Register (DRKS) DRKS00028534. Registered on 22nd of April 2022., (© 2024. The Author(s).)

Background: Antibiotic resistant infections cause over 700,000 deaths worldwide annually. As antimicrobial stewardship (AMS) helps minimise the emergence of antibiotic resistance resulting from inappropriate use of antibiotics in healthcare, we developed ePAMS+ (ePrescribing-based Anti-Microbial Stewardship), an ePrescribing and Medicines Administration (EPMA) system decision-support tool complemented by educational, behavioural and organisational elements., Methods: We conducted a non-randomised before-and-after feasibility trial, implementing ePAMS+ in two English hospitals using the Cerner Millennium EPMA system. Wards of several specialties were included. Patient participants were blinded to whether ePAMS+ was in use; prescribers were not. A mixed-methods evaluation aimed to establish: acceptability and usability of ePAMS+ and trial processes; feasibility of ePAMS+ implementation and quantitative outcome recording; and a Fidelity Index measuring the extent to which ePAMS+ was delivered as intended. Longitudinal semi-structured interviews of doctors, nurses and pharmacists, alongside non-participant observations, gathered qualitative data; we extracted quantitative prescribing data from the EPMA system. Normal linear modelling of the defined daily dose (DDD) of antibiotic per admission quantified its variability, to inform sample size calculations for a future trial of ePAMS+ effectiveness., Results: The research took place during the SARS-CoV-2 pandemic, from April 2021 to November 2022. 60 qualitative interviews were conducted (33 before ePAMS+ implementation, 27 after). 1,958 admissions (1,358 before ePAMS+ implementation; 600 after) included 24,884 antibiotic orders. Qualitative interviews confirmed that some aspects of ePAMS+ , its implementation and training were acceptable, while other features (e.g. enabling combinations of antibiotics to be prescribed) required further development. ePAMS+ uptake was low (28 antibiotic review records from 600 admissions; 0.047 records per admission), preventing full development of a Fidelity Index. Normal linear modelling of antibiotic DDD per admission showed a residual variance of 1.086 (log-transformed scale). Unavailability of indication data prevented measurement of some outcomes (e.g. number of antibiotic courses per indication)., Conclusions: This feasibility trial encountered unforeseen circumstances due to contextual factors and a global pandemic, highlighting the need for careful adaptation of complex intervention implementations to the local setting. We identified key refinements to ePAMS+ to support its wider adoption in clinical practice, requiring further piloting before a confirmatory effectiveness trial., Trial Registration: ISRCTN Registry ISRCTN13429325, 24 March 2022., (© 2024. The Author(s).)

Errors in antibiotic prescriptions are frequent, often resulting from the inadequate coverage of the infection-causative microorganism. The efficacy of iAST, a machine-learning-based software offering empirical and organism-targeted antibiotic recommendations, was assessed. The study was conducted in a 12-hospital Spanish institution. After model fine-tuning with 27,531 historical antibiograms, 325 consecutive patients with acute infections were selected for retrospective validation. The primary endpoint was comparing each of the top three of iAST's antibiotic recommendations' success rates (confirmed by antibiogram results) with the antibiotic prescribed by the physicians. Secondary endpoints included examining the same hypothesis within specific study population subgroups and assessing antibiotic stewardship by comparing the percentage of antibiotics recommended that belonged to different World Health Organization AWaRe groups within each arm of the study. All of iAST first three recommendations were non-inferior to doctor prescription in the primary endpoint analysis population as well as the secondary endpoint. The overall success rate of doctors' empirical treatment was 68.93%, while that of the first three iAST options was 91.06% ( P < 0.001), 90.63% ( P < 0.001), and 91.06% ( P < 001), respectively. For organism-targeted therapy, the doctor's overall success rate was 84.16%, and that of the first three ranked iAST options was 97.83% ( P < 0.001), 94.09% ( P < 0.001), and 91.30% ( P < 0.001), respectively. In empirical therapy, compared to physician prescriptions, iAST demonstrated a greater propensity to recommend access antibiotics, fewer watch antibiotics, and higher reserve antibiotics. In organism-targeted therapy, iAST advised a higher utilization of access antibiotics. The present study demonstrates iAST accuracy in predicting antibiotic susceptibility, showcasing its potential to promote effective antibiotic stewardship., Clinical Trials: This study is registered with ClinicalTrials.gov as NCT06174519., Competing Interests: J.B. has received fees for speaking engagements and scientific consulting from Pfizer, Wyeth, Merck, Angelini, Menarini, Meiji Pharma Spain, Shionogi, and Gilead. J.F., P.V., and S.R.-B. hold shares of Pragmatech AI Solutions, the company that developed and owns the iAST software.

The antibiotic stewardship round (ASR) is a way to use the knowledge of the infectious disease (ID) specialist to audit and assess the treatment with antibiotics and promote rational use. We implemented ASRs twice a week in two geriatric hospitals and weekly in advanced home care facilities during 9 weeks. All patients treated with antibiotics were discussed and advice regarding the antibiotic treatment was given. In 25 percent of the cases the ID specialist found that the ASR made a difference to the treatment plan, and in 10,8 percent of cases the antibiotic treatment could be discontinued. Other common advice was to switch from intravenous to oral administration and shorten the number of treatment days. Thus, ASRs were found to be an intervention associated with lower and more rational antibiotic use and should be considered an important tool for antimicrobial stewardship in geriatric hospitals.

Objectives: To investigate whether using the BioFire® FilmArray® Blood Culture Identification 2 panel (BCID2) leads to timely antimicrobial therapy and improves patient outcomes in critically ill patients with bloodstream infections (BSIs)., Methods: This retrospective observational study included patients with BSIs admitted to the intensive care unit from July 1, 2021, to August 31, 2023. Patients were divided into groups receiving appropriate or inappropriate antimicrobial therapy. Those receiving inappropriate therapy underwent adjustments using standard-of-care (SOC) testing or BCID2. Propensity score matching (PSM) was performed on the original cohort (Model 1) and a time-window bias-adjusted cohort (Model 2). Clinical impact of BCID2-guided antimicrobial adjustment was analysed in both models., Results: A total of 181 patients received inappropriate antimicrobial therapy, with 33 undergoing BCID2 testing and 148 undergoing SOC testing. Following PSM and time-window bias adjustment, 66 patients were analysed in Model 1 and 46 patients in Model 2. BCID2 significantly reduced the median time to appropriate antimicrobial therapy (40.8 vs. 74.0 h in Model 1; 42.8 vs. 68.9 h in Model 2) and the day-28 mortality rate (27.8% vs. 77.1%, P < 0.001 in Model 1; 23.5% vs. 58.6%, P = 0.021 in Model 2). In multivariate regression analysis, BCID2-guided antimicrobial adjustment was an independent prognostic factor for day-28 mortality (adjusted odds ratio [aOR] 0.07 in Model 1 and aOR 0.12 in Model 2)., Conclusion: BCID2-guided antimicrobial stewardship was associated with a shorter time to appropriate antimicrobial therapy and reduced day-28 mortality in critically ill patients with BSIs receiving inappropriate antimicrobial therapy., (Copyright © 2024 Elsevier Ltd and International Society of Antimicrobial Chemotherapy. All rights reserved.)

Background: To formulate effective strategies for antimicrobial stewardship (AMS) in primary care, it is crucial to gain a thorough understanding of factors influencing prescribers' behavior within the context. This qualitative study utilizes the Theoretical Domains Framework (TDF) to uncover these influential factors., Methods: We conducted a qualitative study using in-depth interviews and focus group discussions with primary care workers in two provinces in rural Vietnam. Data analysis employed a combined inductive and deductive approach, with the deductive aspect grounded in the TDF., Results: Thirty-eight doctors, doctor associates, and pharmacists participated in twenty-two interviews and two focus group discussions. We identified sixteen themes, directly mapping onto seven TDF domains: knowledge, skills, behavioral regulation, environmental context and resources, social influences, social/professional role and identity, and optimism. Factors driving unnecessary prescription of antibiotics include low awareness of antimicrobial resistance (AMR), diagnostic uncertainty, prescription-based reimbursement policy, inadequate medication supplies, insufficient financing, patients' perception of health insurance medication as an entitlement, and maintaining doctor-patient relationships. Potential factors facilitating AMS activities include time availability for in-person patient consultation, experience in health communication, and willingness to take action against AMR., Conclusion: Utilizing the TDF to systematically analyze and present behavioral determinants offers a structured foundation for designing impactful AMS interventions in primary care. The findings underscore the importance of not only enhancing knowledge and skills but also implementing environmental restructuring, regulation, and enablement measures to effectively tackle unnecessary antibiotic prescribing in this context., (© 2024. The Author(s).)

Background: Antimicrobial stewardship (AMS) programs are critical in combating antimicrobial resistance (AMR). In Zambia, there is little information regarding the capacity of hospitals to establish and implement AMS programs. The objective of this study was to conduct a baseline assessment of WHO core elements for an AMS program implementation in eight hospitals in Zambia., Materials and Methods: We conducted an exploratory cross-sectional study from September 2023 to December 2023 using a self-scoring Periodic National and Healthcare Facility Assessment Tool from the World Health Organization (WHO) policy guidance on integrated AMS activities in human health. Eight public hospitals were surveyed across the five provinces of Zambia. Data was analyzed using the WHO self-scoring tool and thematic analysis., Results: Overall, 62.5% (6/8) of the facilities scored low (below 60%) in implementing AMS programs. Most facilities had challenges with reporting AMS feedback within the hospital (average score = 46%), Drugs and Therapeutics Committee (DTC) functionality (average score = 49%), AMS actions (average score = 50%), education and training (average score = 54%), and leadership commitment to AMS activities (average score = 56%). The overall score for all AMS core elements was average (56%). All the hospitals (100%) did not have an allocated budget for AMS programs. Finally, there were neither antibiograms to guide antimicrobial utilization nor AMS-trained staff in more than 50% of the hospitals surveyed., Conclusion: This study found low AMS implementation in these public hospitals, especially where DTCs were non-functional. The identified challenges and gaps require urgent attention for sustainable multidisciplinary AMS programs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Chizimu, Mudenda, Yamba, Lukwesa, Chanda, Nakazwe, Simunyola, Shawa, Kalungia, Chanda, Chola, Mateele, Thapa, Kapolowe, Mazaba, Mpundu, Masaninga, Azam, Nakajima, Suzuki, Bakyaita, Wesangula, Matu and Chilengi.)

Background: Academic detailing, audit and feedback, and peer comparison have been advocated as effective ways to promote appropriateness of prescribing and antimicrobial stewardship (AMS). This study explored the effectiveness of a multifaceted intervention aimed at supporting the appropriateness of antibiotic prescribing in paediatrics., Methods: Over the course of 7 years, all 89 paediatricians of the Local Health Authority (LHA) of Reggio Emilia (530 000 residents) were provided with scientific literature focused on antimicrobial resistance and the appropriateness of use of specific antibiotics, together with local data on antimicrobial resistance and prescribing reports comparing each paediatrician with colleagues in the same district and with local averages. Prescribing rates of specific target antibiotics/classes of antibiotics were evaluated by comparing Reggio-Emilia with the other seven LHAs of the Emilia-Romagna Region (control area), adjusting for prescriptions during a 2-year baseline period., Results: A significant increase in the rate of amoxicillin prescriptions (91 more per 1000 children/year) was observed in the intervention area compared with the control area along with a significant reduction in the rate of amoxicillin+clavulanate prescriptions (70 fewer per 1000 children/year) and a significant increase in the ratio of their prescription rates. No differences were observed in cephalosporin and macrolide prescription rates and overall antibiotic prescriptions., Conclusions: Improvements in prescribing appropriateness were observed. This study confirms the importance of an audit and feedback approach through small group meetings supported by scientific literature, local resistance data and prescribing reports. Such approach should always be considered as part of multifaceted interventions to promote AMS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Antimicrobials are frequently used in critically ill children admitted to the Paediatric Intensive Care Unit (PICU). The antimicrobial use data from Indian PICUs is limited using standard metrics such as Days of therapy (DOT). This study aimed to determine the baseline trend of antimicrobial use in PICU of a tertiary care teaching hospital of Raipur district of Chhattisgarh, India using standard metrics with the goal of developing facility-wide antibiotic policy and strengthening the antimicrobial stewardship activities. This active surveillance was conducted over a period of 18 months, from November 1, 2019, to March 21, 2021, in patients aged one month to 14 years who were admitted for ≥ 48 hours to the PICU at a tertiary care teaching hospital of Raipur District. Data on patient characteristics, antimicrobial indications, antimicrobial prescription information, and clinical outcomes were collected using pre-designed data abstraction forms. The descriptive statistic was used to represent the results. The antimicrobial consumption was analyzed according to the WHO AWaRe Class (Access, Watch, and Reserve groups) of antibiotics. The antimicrobial consumption was expressed as DOT/1000 patient-days (PD). A total of 216 patients were surveyed during the study period. The average number of antimicrobials prescribed per hospitalisation was 2.60 (range: 1-12), with 97.22% administered via parenteral route. Overall, DOT/1000-PD was 1318. The consumption of Watch Group antimicrobials was highest with 949 DOT/1000-PD, followed by Access (215) and Reserve Group (154), respectively. Ceftriaxone (208 DOT/1000 PD) was the most commonly prescribed antimicrobial agent, followed by Vancomycin (201), Meropenem (175), Piperacillin-Tazobactam (122) and Colistin (91). The patients who were escalated (28.24%) from empirical antimicrobial therapy had longer median PICU stay (8 days) compared those who were de-escalated (23.6%). Targeted therapy was given in 10.2% patients. The overall mortality rate was 14.35% and was higher (29.3%) in patients in whom empirical therapy was escalated compared to those who were de-escalated or continued. The study established a benchmark for antimicrobials use in the PICU and highlighted priority areas for antimicrobial stewardship intervention to enhance de-escalation rates, enhance targeted therapy, and reduce the overuse of antimicrobials especially belonging to the reserve group., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Singh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs)., Objective: This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes., Methods: A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements., Results: A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025., Conclusions: This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention., International Registered Report Identifier (irrid): DERR1-10.2196/60099., (©Ana García-Sangenís, Daniela Modena, Jette Nygaard Jensen, Athina Chalkidou, Valeria S Antsupova, Tina Marloth, Anna Marie Theut, Beatriz González López-Valcárcel, Fabiana Raynal, Laura Vallejo-Torres, Jesper Lykkegaard, Malene Plejdrup Hansen, Jens Søndergaard, Jonas Kanstrup Olsen, Anders Munck, András Balint, Ria Benko, Davorina Petek, Nina Sodja, Anna Kowalczyk, Maciej Godycki-Cwirko, Helena Glasová, Jozef Glasa, Ruta Radzeviciene Jurgute, Lina Jaruseviciene, Christos Lionis, Marilena Anastasaki, Agapi Angelaki, Elena Petelos, Laura Alvarez, Marta Ricart, Sergi Briones, Georg Ruppe, Ramon Monfà, Anders Bjerrum, Carl Llor. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 16.09.2024.)

Objective: To understand antimicrobial stewardship (AS) and infection prevention and control (IPC) activities in veterinary schools., Methods: An online survey was completed by representatives from American Association of Veterinary Medical Colleges-accredited veterinary schools in the US and Caribbean prior to attending the Inaugural Small Animal Antimicrobial Stewardship Workshop for US Veterinary Schools. Responses were examined to identify patterns among AS and IPC activities and adherence to the AVMA core principles., Results: Half (12 of 24) of the surveyed schools had an AS committee and most (79% [19 of 24]) had an IPC committee. Lack of dedicated staff time was a common barrier to AS (88% [21 of 24]) and IPC (75% [18 of 24]) reported by schools both with and without AS and IPC committees. Eleven of 24 schools (46%) reported performing at least 1 activity focused on each of the AVMA's 5 core principles of AS. Although 79% (19 of 24) of schools incorporate AS into preclinical curricula, training of clinical faculty (17% [4 of 24]), veterinary technicians and support staff (21% [5 of 24]), and house officers (42% [10 of 24]) is less common, despite these individuals engaging in teaching clinical-year veterinary students., Conclusions: Veterinary schools varied in established AS education and AS and IPC practices, though financial and human resources were a common barrier., Clinical Relevance: A collaborative and cohesive approach to AS and IPC among schools to create sustainable frameworks for practice improvement will help combat the global threat of antimicrobial resistance. This is a critical action for settings where future veterinarians are trained.

Importance: Point prevalence surveys (PPSs) are used globally to collect data on antibiotic prescriptions. However, the optimal frequency for data collection to ensure comprehensive understanding of antibiotic use and to target and monitor stewardship interventions remains unknown., Objective: To identify the optimal frequency for collecting data on antibiotic use among the pediatric population through PPSs leveraging administrative data., Design, Setting, and Participants: This prognostic study used a cross-sectional validation approach and was conducted in pediatric outpatient and inpatient settings in the Veneto region of Italy. Antibiotics were classified according to the World Health Organization Access, Watch and Reserve criteria. Prescribing rates of access antibiotics were analyzed for pediatric inpatients with records dated between October 1, 2014, and December 31, 2022, and outpatients with records dated between January 1, 2010, and December 31, 2022. The study included children younger than 15 years with an antibiotic prescription who were admitted to the pediatric acute care unit or evaluated by a primary care pediatrician. Data analysis was performed from October 2023 to January 2024., Main Outcomes and Measures: An algorithm was developed to identify optimal time frames for conducting PPSs. This approach sought to minimize the discrepancy between quarterly and yearly PPS results, aiming to accurately estimate annual antibiotic prescribing rates in both inpatient and outpatient settings (primary outcome). External validity of the optimal PPS time frames derived from outpatient data when applied to the inpatient setting was also investigated. Validation involved assessing the effectiveness of administrative data in identifying strategic PPS periods for capturing inpatient antibiotic use patterns (secondary outcome)., Results: This analysis included 106 309 children: 3124 were inpatients (1773 males [56.8%]) and 103 185 were outpatients (53 651 males [52.0%]). A total of 5099 and 474 867 antibiotic prescriptions from inpatients and outpatients were analyzed, respectively. Outpatients tended to be older than inpatients, with a median age of 3.2 (IQR, 1.3-6.3) years vs 2.6 (IQR, 0.6-6.6) years, respectively, and with a lower burden of clinical comorbidities (≥1 comorbidity: 6618 [6.4%] vs 1141 [36.5%], respectively). The algorithm successfully identified distinct time frames within the calendar year from inpatient and outpatient records optimized for PPS data collection. Rates obtained from the quarterly PPS during these identified periods exhibited greater agreement with annual antibiotic prescribing rates (inpatient: r = 0.17, P < .001; and outpatient: r = 0.42, P < .001) than those derived from the yearly PPS (inpatient: r = 0.04, P = .58; and outpatient: r = 0.05, P = .34), with a Δ reduction of up to 89.8% (where Δ represents the percentage point change in antibiotic prescribing rates). Furthermore, the optimal PPS time frames gleaned from the outpatient data demonstrated robust applicability to the inpatient setting, yielding comparable results in both scenarios., Conclusions and Relevance: This study evaluated the potential of administrative data in determining the optimal timing of PPS implementation. The quarterly PPS balanced precision and sustainability, especially when implemented during strategically selected periods across different seasons. Further studies are needed to validate the algorithm used in this study, especially in post-COVID-19 pandemic years and different settings.

Background: Antimicrobial resistance is driven by inappropriate antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is an Australian-developed auditing platform to assist in the assessments of antimicrobial quality by antimicrobial stewardship programmes using consensus-based definitions. The NAPS has demonstrated to be transferable to other countries. Its adaptation to Portugal could improve knowledge about the quality of antimicrobial prescribing in the country., Objectives: To translate, culturally adapt, and validate the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing for Portugal., Methods: International recommendations on translation and adaptation of instruments were followed. Two panels of experts participated in the process, using Zoom® for discussions and interviews, and Google Forms® for assessing vignettes. A native English-speaking person proficient in Portuguese conducted the back-translation. SPSS v.28 and Excel® were used for validity calculation., Results: The Portuguese version was well accepted, its implementation being perceived as desirable and feasible by the experts. Validation process showed a Fleiss' κ score of 0.483 (95% CI, 0.415-0.551, P < 0.005) for appropriateness, and an average agreement with the Australian NAPS team of 0.8 and 0.9, respectively, for appropriateness and reasons for inappropriateness., Conclusions: The Portuguese version of the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing, the first to be translated from English, was deemed non-inferior to the original, was well accepted, considered to be desirable and feasible, and could inspire other countries, particularly other Portuguese-speaking countries, to adapt and validate them in their own contexts, reinforcing the possibility of transferring NAPS use beyond Australia., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: Antimicrobial stewardship (AMS) aims to improve antibiotic use while reducing resistance and its consequences. There is a paucity of data on the availability of AMS programmes in southern Nigeria. Further, there is no data on Nigerian healthcare professionals' knowledge of the WHO 'Access, Watch and Reserve' (AWaRe) classification of antibiotics. This study sought to assess knowledge of AMS and the AWaRe classification of antibiotics among frontline healthcare professionals in Akwa Ibom State, Nigeria., Methods: This was a cross-sectional survey of 417 healthcare professionals, comprising medical doctors, pharmacists and nurses, across 17 public hospitals in Akwa Ibom State, Nigeria. A paper-based self-completion questionnaire was used to collect data from the participants during working hours between September and November 2023. Statistical analysis was done using SPSS version 25.0, with p < 0.05 indicating statistical significance., Results: Four hundred and seventeen out of the 500 healthcare professionals approached agreed to participate, giving an 83.4% response rate. Most of the participants were female (62.1%) and nurses (46.3%). Approximately 57% of participants were familiar with the term antibiotic/antimicrobial stewardship, however, only 46.5% selected the correct description of AMS. Majority (53.0%) did not know if AMS programme was available in their hospitals. 79% of participants did not know about AWaRe classification of antibiotics. Among the 87 (20.9%) who knew, 28.7% correctly identified antibiotics into the AWaRe groups from a given list. Only profession significantly predicted knowledge of AMS and awareness of the AWaRe classification of antibiotics (p < 0.001). Pharmacists were more likely to define AMS correctly than medical doctors (odds ratio [OR] = 2.02, 95% confidence interval [CI] = 1.16-3.52, p = 0.012), whereas nurses were less likely to be aware of the WHO AWaRe classification of antibiotics than medical doctors (OR = 0.36, 95% CI = 0.18-0.72, p = 0.004)., Conclusions: There was a notable knowledge deficit in both AMS and the AWaRe classification of antibiotics among participants in this study. This highlights the need for educational interventions targeted at the different cadres of healthcare professionals on the role of AMS programmes in reducing antimicrobial resistance and its consequences., (© 2024. The Author(s).)

Background: Penicillin allergy delabelling (PAD), the process of evaluating penicillin allergy labels, is a key target in antibiotic stewardship, but uptake of the procedure outside clinical studies is limited. We aimed to explore factors that need to be addressed to sustainably implement a clinical pathway for PAD., Methods: We conducted a qualitative study based on semi-structured interviews with focus groups consisting of a purposive sample of twenty-five nurses and physicians working in four different hospitals in Western Norway. Systematic text condensation was applied for analysis., Results: Psychological safety was reported as crucial for clinicians to perform PAD. A narrative of uncertainty and anticipated negative outcomes were negatively associated with PAD performance. Education, guidelines, and colleague- and leadership support could together create psychological safety and empower health personnel to perform PAD. Key factors for sustainable implementation of PAD were facilitating the informant's profound motivation for providing optimal health care and for reducing antimicrobial resistance. Informants were motivated by the prospect of a simplified PAD procedure. We identified three main needs for implementation of PAD: (1) creating psychological safety; (2) utilising clinicians' inherent motivation and (3) optimal organisational structures., Conclusion: A planned implementation of PAD must acknowledge clinicians' need for psychological safety and aid reassurance through training, leadership, and guidelines. To implement PAD as an everyday practice it must be minimally disruptive and provide a contextually adaptive logistic chain. Also, the clinician's motivation for providing the best possible healthcare should be utilised to aid implementation. The results of this study will aid sustainable implementation of PAD in Norway., Ethics: The study was approved by the Western Norway Regional Committee for Medical Research Ethics (Study No:199210)., (© 2024. The Author(s).)

BackgroundIn Europe and other high-income countries, antibiotics are mainly prescribed in the outpatient setting, which consists of primary, specialist and hospital-affiliated outpatient care. Established surveillance platforms report antimicrobial consumption (AMC) on aggregated levels and the contribution of the different prescriber groups is unknown.AimTo determine the contribution of different prescribers to the overall outpatient AMC in Switzerland.MethodsWe conducted a retrospective observational study using claims data from one large Swiss health insurance company, covering the period from 2015 to 2022. We analysed antibiotic prescriptions (ATC code J01) prescribed in the Swiss outpatient setting. Results were reported as defined daily doses per 1,000 inhabitants per day (DID) and weighted according to the total population of Switzerland based on census data.ResultsWe analysed 3,663,590 antibiotic prescriptions from 49 prescriber groups. Overall, AMC ranged from 9.12 DID (2015) to 7.99 DID (2022). General internal medicine (40.1% of all prescribed DID in 2022), hospital-affiliated outpatient care (20.6%), group practices (17.3%), paediatrics (5.4%) and gynaecology (3.7%) were the largest prescriber groups. Primary care accounted for two-thirds of the prescribed DID. Quantity and type of antibiotics prescribed varied between the prescriber groups. Broad-spectrum penicillins, tetracyclines and macrolides were the most prescribed antibiotic classes.ConclusionPrimary care contributed considerably less to AMC than anticipated, and hospital-affiliated outpatient care emerged as an important prescriber. Surveillance at the prescriber level enables the identification of prescribing patterns within all prescriber groups, offering unprecedented visibility and allowing a more targeted antibiotic stewardship according to prescriber groups.

Objectives: Factors that affect the change of first-line antimicrobial agents were investigated to further promote their appropriate use., Methods: This descriptive study used an electronic medical records database. Total 16,353 of the 199,896 patients enrolled between 1996 and 2019 met the inclusion criteria and formed the overall pediatric acute otitis media (AOM) cohort. The factors leading to the change in first-line antimicrobial agents within 14 days were analyzed using classification and regression trees (CART) analysis., Results: This antimicrobial treatment cohort, involved 4860 cases of AOM alone and 9567 cases of AOM with other diseases. The size of the medical facility based on number of beds and historical duration of patient registration impacted on antimicrobial changes., Conclusions: The current results show that hospital-wide or nation-wide antimicrobial stewardship promotion could be the most influencing factor for antimicrobial changes. Particularly in cases of AOM where other diseases coexist, a more accurate diagnosis and definition of treatment failure of first-line drug are suggested to be important while establishing future treatment strategies. The current study is important to promote appropriate antimicrobial use for AOM treatment., (Copyright © 2024 Japanese Society of Chemotherapy, Japanese Association for Infectious Diseases, and Japanese Society for Infection Prevention and Control. Published by Elsevier Ltd. All rights reserved.)

Background: Research on the effectiveness of pharmacist-led antimicrobial stewardship programmes (ASPs) in the urology department is limited., Aim: To evaluate the impact of pharmacist-led multi-faceted ASPs on antibiotic use and clinical outcomes., Methods: A prescription review of inpatients receiving one or more antibiotics in the urology department of a large teaching hospital in Guangzhou, China, was conducted from April 2019 to March 2023. The pharmacist-led multi-faceted ASP intervention included guideline development, training, medication consultation, review of medical orders, indicator monitoring, and consultation. The primary outcome was antibiotic consumption. The data were analysed using interrupted time-series (ITS) analysis., Findings: Following the implementation of ASPs, an immediate decrease was observed in total antibiotic consumption, antibiotic use rate, second-generation cephalosporins, third-generation cephalosporins, fluoroquinolones, and WHO Watch category antibiotics. No differences were observed in mortality rate before and after the intervention, and no significant short- or long-term effects were found on length of hospital stay (LOS) using ITS. However, there was a significant short-term effect on average antibiotic cost., Conclusion: The implementation of pharmacist-led multi-faceted ASPs had positive impacts on reducing antimicrobial consumption without increasing LOS, antibiotic cost, or mortality rate., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

With increased focus on antimicrobial stewardship in post-acute, long-term care (PALTC) settings, optimization of diagnostic testing is essential. Molecular diagnostics are currently being offered and used for the diagnosis of urinary tract infections (UTIs) in community and PALTC settings. Yet, no studies to date explore the role of rapid diagnostics such as polymerase chain reaction and other molecular methods in the stewardship efforts of PALTC settings, specifically compared with standard testing with urinalysis and culture with antimicrobial susceptibility testing. This article outlines a framework of diagnostic stewardship to critically evaluate the use of molecular diagnostics for the diagnosis of UTIs in PALTC and the impact on patient outcomes and antimicrobial stewardship. The authors suggest a 5-step process for evaluating the role of novel diagnostics in the PALTC setting. Understanding the shortcomings of newer diagnostic tests may identify needs for further investigation before their widespread use., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. All rights reserved.)

Background: Antimicrobial stewardship programmes are a critical tool for addressing the rising threat of antimicrobial resistance., Aim: To determine changes in patterns of antimicrobial use in Queensland public hospitals following introduction of the National Safety and Quality Health Service antimicrobial stewardship standard., Methods: A retrospective pre/post intervention study was conducted across Queensland public hospitals at the ecological level using Queensland Health's MedTRx database. An interrupted time-series analysis was performed using linear regression models to determine rates of antimicrobial use by quarterly aggregated defined daily dose per 1000 patient-days, for groups of hospitals stratified by peer group classification. Pre-defined time-periods for antimicrobial stewardship programme implementation in response to the introduction of the standard were analysed., Findings: In the post-intervention period, there was a decrease in overall use of systemic antimicrobials, glycopeptides, carbapenems and fluoroquinolones in principal referral and public acute group A hospitals. A decrease in overall use was also observed for smaller regional and remote public acute group C and D hospitals; however, increases in glycopeptide and fluoroquinolone use were observed. Third-generation cephalosporin use was unchanged for all hospital peer groups. The proportion of overall use that was accounted for by narrow-spectrum penicillin was low for all facilities, with modest improvements in the post-intervention period observed in principal referral facilities only., Conclusion: These findings add to current knowledge on the effectiveness of legislative quality standards on antimicrobial stewardship at the macro level and highlight gaps to target for future programmes., (Copyright © 2024. Published by Elsevier Ltd.)

Judicious use of antibiotics in the critically ill starts with the evaluation for suspected infection, including close consideration of the patient's history. If infection is present or strongly suspected, empiric antibiotics should be promptly initiated and selected based on the source of infection, patient factors, and local resistance patterns. If the surgeon decides source control is indicated, they must determine the optimal approach and timing. As soon as culture and sensitivity data are available, de-escalation to narrower spectrum agents is essential to decrease the risks of antibiotic toxicity and resistance. Importantly, surgeons should participate in antibiotic stewardship in their patients., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Our aim was to audit antibiotic prescriptions from renewed medical staff., Methods: A retrospective multicenter audit of antibiotic therapies was performed in four institutions with similar antimicrobial stewardship programs. We compared antibiotic prescriptions from physicians practicing before and after the pandemic. Antibiotic prescriptions were classified as optimal (OAT), suboptimal (SAT) or unnecessary antibiotic therapy (UAT)., Results: All in all, 165 antibiotic courses was audited in 2023: OAT, SAT and UAT rates were 21, 42 and 38% respectively. Sixty-seven out of 165 (41%) prescriptions were given by new physicians. In multivariate analysis, antibiotic prescriptions from the latter compared to former were associated with less diagnosis of infection written in patient charts: AOR [CI 95%] 3.68 [1.53-8.83], and with UAT: 2.76 [1.34-5.68]., Conclusions: Ensuring adequate antibiotic prescriptions with renewed medical staff requires a high level of education and training., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Antimicrobial stewardship (AMS) programs aim to optimize antibiotic use through a panel of interventions. The implementation of computerized clinical decision support systems (CDSSs) offers new opportunities for semiautomated antimicrobial review by AMS teams. This study aimed to evaluate the perceived facilitators, barriers and benefits of end-users related to a commercial CDSS recently implemented in a hospital and to assess its usability., Methods: A mixed-method approach was used among AMS team members nine months after the implementation of the CDSS in a university hospital in northeastern France. A qualitative analysis based on individual semistructured interviews was conducted to collect end-users' perceptions. A quantitative analysis was performed using the System Usability Scale (SUS)., Results: Eleven AMS team members agreed to participate. The qualitative analysis revealed technical, organizational and human barriers and facilitators of CDSS implementation. Effective collaboration with information technology teams was crucial for ensuring the installation and configuration of the software. CDSS adoption by the AMS team required time, human resources, training, adaptation and a clinical leader. Moreover, the CDSS had to be well designed, user-friendly and provide benefits to AMS activities. The quantitative analysis indicated that the CDSS was a "good" system in terms of perceived ease of use (median SUS score: 77.5/100)., Conclusions: This study shows the value of the studied CDSS to support AMS activities. It reveals barriers, facilitators and benefits to the implementation and adoption of the CDSS. These barriers and facilitators could be considered to facilitate the implementation of the software in other hospitals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Dental antibiotic stewardship is crucial in low- and middle-income countries where the burden of antimicrobial resistance (AMR) is high and antibiotic misuse is common. Given that India is the most populous country, the largest antibiotic consumer and has a large dental prescriber population, this study investigated the extent to which current Indian policy and practice for dental antibiotic prescribing and stewardship aligns with the global policy and best practice., Methods: The READ approach was used to identify and extract data and synthesize the findings. Policy documents on dental antimicrobial stewardship were identified using a systematic search strategy involving nine medical and grey literature databases (Medline, Global Health, Web of Science, Cochrane, CINAHL, Eldis, Global Index Medicus, Proquest and Opengrey), targeted websites (government organizations and dental regulatory bodies) and contact with experts. Framework analysis was used to code extracted data into themes related to dental antimicrobial stewardship., Results: Of the 3039 records screened, 25 documents were included in the final analysis. The analysis showed a lack of guidelines or toolkits for appropriate antibiotic prescribing in dentistry in India. The treatment guidelines for antimicrobial use in common syndromes published by the Indian Council of Medical Research had no section or content for dental practitioners. Furthermore, the undergraduate dental curriculum developed by the Dental Council of India (DCI), included little content on appropriate antibiotic prescribing and no mention of AMR or stewardship. There were no educational resources either for dental practitioners or patients in the documents., Conclusion: This document analysis showed that there was little or no mention of dental antibiotic prescribing guidelines in key policy documents such as the National Action Plan on AMR. In addition, contradictory and subjective information provided in some policy documents could encourage dentists and other health professionals such as general practitioners to prescribe antibiotics for common dental conditions for which they are contra-indicated. There is an urgent need to develop relevant guidelines and include these in Indian policy documents on AMR particularly the National Action Plan on AMR., (© 2024 The Author(s). Community Dentistry and Oral Epidemiology published by John Wiley & Sons Ltd.)

Background: Rapid identification of effective treatments for use in the community during a pandemic is vital for the well-being of individuals and the sustainability of healthcare systems and society. Furthermore, identifying treatments that do not work reduces research wastage, spares people unnecessary side effects, rationalises the cost of purchasing and stockpiling medication, and reduces inappropriate medication use. Nevertheless, only a small minority of therapeutic trials for SARS-CoV-2 infections have been in primary care: most opened too late, struggled to recruit, and few produced actionable results. Participation in research is often limited by where one lives or receives health care, and trial participants may not represent those for whom the treatments are intended., Innovative Trials: The ALIC4E, PRINCIPLE and the ongoing PANORAMIC trial have randomised over 40,500 people with COVID-19. This personal view describes how these trials have innovated in: trial design (by using novel adaptive platform designs); trial delivery (by complementing traditional site-based recruitment ('the patient comes to the research') with mechanisms to enable sick, infectious people to participate without having to leave home ('taking research to the people'), and by addressing the 'inverse research participation law,' which highlights disproportionate barriers faced by those who have the most to contribute, and benefit from, research, and; in transforming the evidence base by evaluating nine medicines to support guidelines and care decisions world-wide for COVID-19 and contribute to antimicrobial stewardship., Conclusion: The PRINCIPLE and PANORAMIC trials represent models of innovation and inclusivity, and exemplify the potential of primary care to lead the way in addressing pressing global health challenges.

Background: Antimicrobial Stewardship (AMS), the set of actions to ensure appropriate antimicrobial use, is increasingly considered a multidisciplinary endeavour. However, it is unclear how Dutch hospital-based nurses envision their contribution to AMS., Objective: To explore the views and visions of Dutch bedside nurses on their role regarding appropriate antimicrobial use., Methods: A qualitative study using semi-structured interviews was conducted. Fourteen bedside nurses in nine different Dutch hospitals participated. Data were analysed using a thematic content analysis., Results: Nurses considered their role regarding appropriate use of antibiotics as an integral part of their daily nursing practice. They envisioned their future role as an expansion of their current practice, improving or intensifying this contribution. Prompting review of antimicrobial treatment by nurses was seen as regular practice. Ward rounds were considered the best moment to exert their nursing role, by showing leadership in communicating about different aspects of AMS. Patient advocacy ("striving for the best possible care for their patient") appears to be a driver of the nursing contribution. Nurses perceived a shared responsibility with prescribers on certain aspects of the antimicrobial treatment and wished for a clarification of this role. Education and cognitive reminders such as antibiotic checklist to be used in ward rounds, can support the uptake of the nurses' role., Conclusion: Nurses envision their future role in AMS as an enhanced, elaborated and empowered version of their current daily practice. Education, formal acknowledgment and increased awareness of the nursing role, may advance the contributing role nurses already have., (© 2024. The Author(s).)

Background: Antimicrobial resistance (AMR) constitutes a major threat to global health. While antimicrobial misuse or overuse is one of the main drivers for AMR, little is known about the extent to which antibiotic misuse is due to a lack of national government-led efforts to enforce rational use in low and middle-income countries (LMICs)., Methods: To assess antimicrobial stewardship and national implementation measures currently in place for optimizing antimicrobial use and for slowing the spread of AMR, we invited public health experts from 138 LMICs to participate in a Global Survey of Experts on Antimicrobial Resistance (GSEAR). Key coverage measures, as reported by experts, were compared across countries and also juxtaposed with estimates collected in the 2020-21 World Health Organization-organized Tripartite AMR Country Self-Assessment Survey (TrACSS)., Results: A total of 352 completed surveys from 118 LMICs were analysed. Experts in 67% of the surveyed countries reported a national action plan (NAP) on AMR, 64% reported legislative policies on antimicrobial use, 58% reported national training programs for health professionals, and 10% reported national monitoring systems for antimicrobials. 51% of LMICs had specific targeted policies to limit the sale and use of protected or reserve antibiotics. While 72% of LMICs had prescription requirements for accessing antibiotics, getting antibiotics without a prescription was reported to be possible in practice in 74% of LMICs. On average, country efforts reported in TrACSS were substantially higher than those seen in GSEAR., Conclusions: In many LMICs, despite the existence of policies aimed at slowing down the spread of AMR, there are still significant gaps in their implementation and enforcement. Increased national efforts in the areas of enforcement and monitoring of antibiotic use as well as regular monitoring of national efforts are urgently needed to reduce inappropriate antibiotic use in LMICs and to slow the spread of AMR globally., (© 2024. The Author(s).)

Antibiotic stewardship is continuously evolving to incorporate results from novel research, clinical findings, and specialist recommendations. Numerous dedicated information sources, including web-based solutions, are available to keep medical practitioners informed. However, the provided information is often extensive, requiring users to extract the relevant facts. This study aimed to deliver an information platform that provides references, links, and information in a straightforward and engaging manner. Implementing a high-fidelity prototype prioritized medical and patient-oriented functionalities, structured around questions and quizzes. Additionally, the platform offers access to professional references, such as official healthcare guidelines and scientific articles. The development process adhered to design principles and included user testing with established usability measures (SUS, Nielsen's heuristics), resulting in satisfactory scores from IT experts and somewhat lower scores from users. Although designed to cater to a broader range of users, more work is needed to improve usability for the general public.

Small animal antimicrobial stewardship (AS) is emerging as a priority area in the global battle against antimicrobial resistance. Veterinary practices have limited support for implementation of AS programs, and even within veterinary schools, efforts are largely siloed and often limited in scope. Increased collaboration is needed to support and unify AS and infection prevention and control efforts, and to identify priorities for continued research. To address this, a 2-day in-person small animal AS workshop was held in August 2023. Delegates representing 23 US veterinary schools and 4 corporations/government agencies gathered for a series of lightning talks and focused group discussions in 3 domains: implementation of clinical AS programs, research opportunities and needs, and education. The workshop's goal was to identify and propose solutions for AS challenges. Meeting discussion identified a lack of resources and training as the greatest barriers to hospital AS program advancement and suggested creating standards for AS programs and a road map to support program development. Assessing antimicrobial treatment effects and performing studies to establish necessary treatment durations were considered the highest research priorities. Integrated educational practices were recommended to support unified messaging of AS concepts between preclinical and clinical training. The development of strategies to implement these suggestions was delegated to working groups with a goal to continue meeting biennially as a large group. Sharing news of these efforts is considered integral to heightening awareness and promoting implementation of AS practices moving forward in academic, specialty, and primary care settings.

Purpose: Procalcitonin (PCT) levels may play a role in decreasing the duration of antimicrobial therapy in institutions that have long durations of therapy for management of community-acquired pneumonia. We assessed the impact of the combination of pharmacist stewardship interventions assisted by a clinical decision support (CDS) tool and PCT assessment on the antimicrobial days of therapy (DOT) prescribed for respiratory tract infections (RTIs)., Methods: We conducted a quasi-experimental study in which patients in the preintervention group were admitted between April and June 2021 and patients in the intervention group were admitted between April and June 2022. In the intervention phase, a CDS tool was utilized to alert clinical pharmacists when patients met specific criteria. This alert was programmed to activate for individual patients when a reported PCT level was less than 0.25 ng/mL and the patient was on antimicrobials prescribed for an RTI as indicated by providers in the electronic health record. Stewardship interventions were made by pharmacists via prospective audit and feedback. The primary endpoint was inpatient antimicrobial DOT for RTIs., Results: There were 90 patients in the preintervention group and 104 patients in the intervention group. Although baseline characteristics were not well matched between the groups, favoring the preintervention group, the median DOT was lower in the intervention group, at 3 days (interquartile range [IQR], 2-4 days), compared to 4 days (IQR, 2.8-5 days) in the preintervention group (P = 0.001)., Conclusion: The results of our study demonstrate the utility of pharmacist interventions coupled with CDS and PCT in reducing antimicrobial DOT prescribed for RTIs. Antimicrobial stewardship programs may benefit from implementing a PCT bundle., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Implementation of dedicated pediatric antimicrobial stewardship programs (ASPs) at 2 combined adult-pediatric hospitals with existing ASPs was associated with sustained decreases in pediatric antibiotic use out of proportion to declines seen in adult inpatient units. ASPs in combined hospitals may not detect excessive pediatric antibiotic use without incorporating pediatric expertise., Competing Interests: Potential conflicts of interest. A. C. T. has received research support from the Agency for Healthcare Research and Quality (AHRQ) for antimicrobial stewardship studies, payment from the American Academy of Pediatrics (AAP) for antimicrobial stewardship lectures, and travel support from the Infectious Diseases Society of America (IDSA) to participate in pediatric infectious diseases case discussions, and is chair of the Pediatric Infectious Diseases Society (PIDS) Pediatric Committee on Antimicrobial Stewardship. M. J. S. has received research support from Merck for antimicrobial stewardship studies and from Pfizer for coronavirus disease 2019 (COVID-19) vaccine and therapeutic clinical trials, expert testimony payments from Starnes Davies Florie, LLP, and is chair of the AAP Section on Epidemiology, Public Health and Evidence, and member of the PIDS Vaccine Advocacy Committee. R. J. V. reports consulting fees and support for travel from Vermont Oxford Network, and payment from Engage Grow Thrive, LLC, for clinical expertise. G. S. M. reports no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Evidence about the clinical impact of rapid diagnostic tests (RDTs) for the diagnosis of bloodstream infections is limited, and whether RDT are superior to conventional blood cultures (BCs) embedded within antimicrobial stewardship programs (ASPs) is unknown., Methods: We performed network meta-analyses using results from studies of patients with bloodstream infection with the aim of comparing the clinical impact of RDT (applied on positive BC broth or whole blood) to conventional BC, both assessed with and without ASP with respect to mortality, length of stay (LOS), and time to optimal therapy., Results: Eighty-eight papers were selected, including 25 682 patient encounters. There was an appreciable amount of statistical heterogeneity within each meta-analysis. The network meta-analyses showed a significant reduction in mortality associated with the use of RDT + ASP versus BC alone (odds ratio [OR], 0.72; 95% confidence interval [CI], .59-.87) and with the use of RDT + ASP versus BC + ASP (OR, 0.78; 95% CI, .63-.96). No benefit in survival was found associated with the use of RDT alone nor with BC + ASP compared to BC alone. A reduction in LOS was associated with RDT + ASP versus BC alone (OR, 0.91; 95% CI, .84-.98) whereas no difference in LOS was shown between any other groups. A reduced time to optimal therapy was shown when RDT + ASP was compared to BC alone (-29 hours; 95% CI, -35 to -23), BC + ASP (-18 hours; 95% CI, -27 to -10), and to RDT alone (-12 hours; 95% CI, -20 to -3)., Conclusions: The use of RDT + ASP may lead to a survival benefit even when introduced in settings already adopting effective ASP in association with conventional BC., Competing Interests: Potential conflicts of interest . D. L. P. has research funding from Shionogi, Merck, bioMerieux, BioVersys, and Pfizer and has received consulting fees from the AMR Action Fund, CARB-X, Aurobac, Pfizer, Merck, Cepheid, bioMérieux, and Spero. P. N. A. H. reports research grants from Gilead, has served on advisory boards for OpGen, Merck, and Sandoz, and has received honoraria from OpGen, Sandoz, Pfizer, and bioMerieux. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs., Methods: Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days., Results: Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan., Conclusions: This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings., (© 2024. The Author(s).)