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Background: Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood., Methods: We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals., Results: Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (P = .001), considered valuable team members (P = .001), and comfortable recommending antibiotic changes (P = .02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had 4 distinguishing characteristics: (1) robust knowledge of and access to antibiotic stewardship guidance; (2) high-quality clinical pharmacist-physician relationships; (3) tools and infrastructure to support stewardship; and (4) highly engaged infectious diseases physicians who advocated stewardship principles., Conclusions: This mixed-methods study demonstrates the importance of organizational context for high performance in stewardship and suggests that improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions., Competing Interests: Potential conflicts of interest. S. A. F. reports grants or contracts, paid to institution, from BCBSM and AHRQ, and personal fees from Wiley Publishing. T. N. G. reports grants or contracts paid to institution from BCBSM and AHRQ. L. A. P. reports grants or contracts from BCBSM and AHRQ. W. R. B. reports participation on a data and safety monitoring board or advisory board as scientific advisor for research with The Joint Commission regarding outpatient stewardship. E. S. S. reports grants or contracts with the Centers for Disease Control and Prevention (CDC) Epicenter University of Utah (Matt Samore, principal investigator; author's role is a co-investigator); consulting fees for educational content paid to author from Prime Education LLC; travel expenses paid to the Society for Healthcare Epidemiology of America (SHEA) 2023 and to IDWeek 2022 (speaker). A. H. reports grants or contracts with CDC, AHRQ, and Patient-Centered Outcomes Research Institute, and a leadership or fiduciary role on the Pediatric Infectious Diseases Society Board. A. M. M. has received grant support from and is a physician consultant to the Michigan Department of Health and Human Services, unrelated to the submitted work; has received payment for expert testimony, unrelated to submitted work; was a member of the SHEA Board of Trustees 2020–2022; served as board member of Michigan Infectious Diseases Society; and is a shareholder of Pfizer. V. M. M. reports grants or contracts paid to institution from AHRQ, CDC, National Institutes of Health, and BCBSM. S. L. Z. reports grants or contracts to institution from AHRQ. 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) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Successful antimicrobial stewardship programs rely on engagement with hospital administrators. Antimicrobial stewards should understand the unique pressures and demands of hospital and health system administration and be familiar with key terminology and regulatory requirements. This article provides guidance on strategies for engaging hospital and health system administration to support antimicrobial stewardship, including recommendations for designing a successful antimicrobial stewardship program structure, pitching resource requests, setting meaningful and measurable goals, achieving and communicating results, and fostering ongoing relationships with hospital and health system administration., Competing Interests: Disclosures The authors report no relevant disclosures., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Central line-associated bloodstream infection (CLABSI) remains prevalent in hospitals in the United States., Objective: To evaluate the impact of a multimodal intervention in hospitals with elevated rates of health care-associated infection., Design: Pre-post observational evaluation of a prospective, national, clustered, nonrandomized initiative of 3 cohorts of hospitals., Setting: Acute care, long-term acute care, and critical access hospitals, including intensive care units and medical/surgical wards., Participants: Target hospitals had a cumulative attributable difference above the first tertile of performance for Clostridioides difficile infection and another health care-associated infection (such as CLABSI). Some hospitals that did not meet these criteria also participated., Intervention: A multimodal intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, webinars led by content experts, and access to content experts., Measurements: Rates of CLABSI and device utilization ratio pre- and postintervention., Results: Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated. Monthly preimplementation CLABSI rates ranged from 0 to 71.4 CLABSIs per 1000 catheter-days. Over the study period, the unadjusted CLABSI rate was low and decreased from 0.88 to 0.80 CLABSI per 1000 catheter-days. Between the pre- and postintervention periods, device utilization decreased from 24.05 to 22.07 central line-days per 100 patient-days. However, a decreasing trend in device utilization was also observed during the preintervention period., Limitations: The intervention period was brief. Participation in and adherence to recommended interventions were not fully assessed. Rates of CLABSI were low. Patient characteristics could not be assessed., Conclusion: In hospitals with a disproportionate burden of health care-associated infection, a multimodal intervention did not reduce rates of CLABSI., Primary Funding Source: Centers for Disease Control and Prevention.

Background: Despite focused initiatives to reduce device-associated infection among hospitalised patients, the practices US hospitals are currently using are unknown. We thus used a national survey to ascertain the use of several established and novel practices to prevent device-associated infections., Methods: We mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about the use of practices to prevent three common device-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). Using sample weights, we estimated the percentage of hospitals reporting regular use of each practice. We also conducted multivariable regression to determine associations between selected hospital characteristics (eg, perceived support from leadership) and use of CAUTI, CLABSI and VAP prevention practices., Results: The response rate was 59%. Several practices are reportedly used in over 90% of US hospitals: aseptic technique during indwelling urethral catheter insertion and maintenance (to prevent CAUTI); maximum sterile barrier precautions during central catheter insertion and alcohol-containing chlorhexidine gluconate for insertion site antisepsis (to prevent CLABSI); and semirecumbent positioning of the patient (to prevent VAP). Antimicrobial devices are used in the minority of hospitals for these three device-associated infections., Conclusions: We provide an updated snapshot of the practices US hospitals are currently using to prevent device-associated infections. Compared with previous studies using a similar design and questions, we found that the use of recommended practices increased in US hospitals, especially for CAUTI prevention., Competing Interests: Competing interests: SS reports receiving honoraria for lectures and teaching related to the prevention of hospital-acquired infection and serving on the medical advisory boards for Doximity (a social networking site for physicians) and Jvion (a health care technology company). JM reports receiving honoraria for lectures and teaching related to prevention and value-based policies involving catheter-associated urinary tract infection and hospital-acquired pressure ulcers. SS and JM hold a provisional US patent on a technology to improve aseptic placement of urinary catheters, which was not part of this study., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

ObjectiveIn preparation for a multisite antibiotic stewardship intervention, we assessed knowledge and attitudes toward management of asymptomatic bacteriuria (ASB) plus teamwork and safety climate among providers, nurses, and clinical nurse assistants (CNAs).DesignProspective surveys during January-June 2018.SettingAll acute and long-term care units of 4 Veterans' Affairs facilities.MethodsThe survey instrument included 2 previously tested subcomponents: the Kicking CAUTI survey (ASB knowledge and attitudes) and the Safety Attitudes Questionnaire (SAQ).ResultsA total of 534 surveys were completed, with an overall response rate of 65%. Cognitive biases impacting management of ASB were identified. For example, providers presented with a case scenario of an asymptomatic patient with a positive urine culture were more likely to give antibiotics if the organism was resistant to antibiotics. Additionally, more than 80% of both nurses and CNAs indicated that foul smell is an appropriate indication for a urine culture. We found significant interprofessional differences in teamwork and safety climate (defined as attitudes about issues relevant to patient safety), with CNAs having highest scores and resident physicians having the lowest scores on self-reported perceptions of teamwork and safety climates (P < .001). Among providers, higher safety-climate scores were significantly associated with appropriate risk perceptions related to ASB, whereas social norms concerning ASB management were correlated with higher teamwork climate ratings.ConclusionsOur survey revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.

In a cross-sectional survey of US acute care hospitals, antimicrobial stewardship programs were present in most Veterans Affairs and nonfederal hospitals but varied in team composition, scope, and impact. Diagnostic stewardship was common across hospitals. Veterans Affairs hospitals had increased reach in outpatient settings. Telestewardship remains an opportunity in all hospital systems. [ABSTRACT FROM AUTHOR]

The article offers information on the foundational elements addressed in the educational materials and integrated in the program interventions. Topics discussed include competency-based training for infection prevention, hand hygiene can include limited access to supplies, skin irritation from disinfectants, and role of hospital environment hygiene in infection transmission.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) remains one of the most common causes of health care-associated infection (HAI).Objective: To evaluate the effect of education and a tiered, evidence-based infection prevention strategy on rates of hospital-onset MRSA bloodstream infection (BSI).Design: Prospective, national, nonrandomized, interventional, 12-month, multiple cohort, pre-post observational quality improvement project.Setting: Acute care, long-term acute care, and critical access hospitals with a disproportionate burden of HAI.Patients: All patients admitted to participating facilities during the project period.Intervention: A multimodal infection prevention intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, Internet-based live educational presentations, and access to content experts.Measurements: Rates of hospital-onset MRSA BSI, overall and stratified by hospital type, during 12-month baseline and postintervention periods. Variation in outcomes across hospital types was examined.Results: Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated, 353 (91%) submitted MRSA data, and 172 (49%) indicated that MRSA prevention was a priority. Unadjusted overall rates of hospital-onset MRSA BSI were 0.075 (95% CI, 0.065 to 0.085) and 0.071 (CI, 0.063 to 0.080) per 1000 patient-days in the baseline and postintervention periods, respectively.Limitations: The intervention period was short. Participation and adherence to recommended interventions were not fully assessed. Baseline rates of hospital-onset MRSA BSI were relatively low. Prevention of MRSA was a priority in a minority of participating hospitals. Patient characteristics and other MRSA risk factors were not assessed.Conclusion: In hospitals with a disproportionate burden of HAIs, access to tools to assist with implementation of evidence-based prevention strategies and education resources alone may not be sufficient to prevent MRSA BSI.Primary Funding Source: Centers for Disease Control and Prevention. [ABSTRACT FROM AUTHOR]

The article presents an editorial commentary on stewardship interventions need to be tailored in large healthcare systems. Topics include antimicrobial stewardship programs (ASPs) become more prevalent in the U.S. due to policy change and national and local stakeholder interest; and Stewardship accreditation requirements from groups such as The Joint Commission, which continue to expand, also affect the urgency of needing effective and large-scale stewardship interventions in large systems.