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Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections.A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects.Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.Des programmes de gestion antimicrobienne (PGA) communautaires efficaces doivent exister, parce que 90 % des antimicrobiens sont prescrits dans la communauté. Des chercheurs ont évalué un PGA en première ligne (PGA-PL) afin d’en déterminer l’efficacité à réduire les prescriptions d’antibiotiques pour six infections courantes.Les chercheurs ont évalué un programme de formation polyvalent au moyen d’une méthodologie avant-après dans quatre cliniques de soins de première ligne entre 2015 et 2017. Le résultat clinique primaire était la différence entre les cliniques de contrôle et d’intervention pour ce qui est du total de prescriptions antibiotiques contre six infections courantes avant et après l’intervention. Les résultats cliniques secondaires incluaient des modifications à l’utilisation des antibiotiques propres au trouble de santé, le report des prescriptions d’antibiotiques, des prescriptions de plus de sept jours, l’utilisation des antibiotiques recommandés et les visites à l’urgence ou les hospitalisations dans les 30 jours. Les chercheurs ont utilisé des méthodes multimodèles tenant compte de la démographie, du mélange de cas et du regroupement par médecin pour évaluer l’effet des traitements.Les prescriptions totales d’antibiotiques dans les cliniques de contrôle et d’intervention ne différaient pas (différences des différences = 1,7 %; IC à 95 %, –12,5 % à 15,9 %), ni l’utilisation de prescriptions reportées (–5,2 %; IC à 95 %, –24,2 % à 13,8 %). Les prescriptions de plus de sept jours étaient très peu courantes (–21,3 %; IC à 95 %, –42,5 % à –0,1 %). Cependant, seulement 781 des 1 777 rencontres (44,0 %) avaient eu lieu avec des dispensateurs qui avaient suivi la formation sur le PGA. Lorsque les dispensateurs avaient suivi la formation, les reports de prescriptions augmentaient de 17,7 % (L’efficacité du PGA-PL pour l’utilisation d’antibiotiques était variable. Les dispensateurs de soins de première ligne qui y avaient participé préparaient des prescriptions de moins longue durée et reportaient davantage leurs prescriptions.

Antimicrobial stewardship (AMS) aims to optimize antimicrobial use. Auditing and reporting of antimicrobial prescribing are essential. Auditing tools for solid organ transplant (SOT) patients should tailor to their needs.We reviewed published data describing auditing tools in the general and SOT population.We focused on three internationally or nationally available auditing tools. The National Antimicrobial Prescribing Survey (NAPS) is web-based tool to report antimicrobial consumption and assess appropriateness using standardized definitions based on consensus guidelines. In the absence of guidelines, adjudication is based on AMS principles. An automated dashboard, analyses by indication or antimicrobial, and benchmarking reports are available. The National Healthcare Safety Network Antimicrobial Use/Resistance module was developed by the Centers for Disease Control and Prevention for hospitals to upload monthly data, which are standardized for benchmarking. It does not assess appropriateness or address SOT wards. The Global-Point Prevalence Survey from bioMérieux collects data on antimicrobial regimen, indication and microbial resistance. Variables unique to SOT include comorbidities and devices. Assessment of appropriateness is limited to guideline adherence, and benchmarking may require prearrangement with bioMérieux. Benchmarking requires prearrangement. Advances in electronic health record systems and clinical decision support tools can improve the efficiency of the auditing process.Each AMS auditing tool has unique features for SOT patients. Capturing immunosuppression, source control, organ dysfunction, donor-derived infection, serology, and colonization status will enhance their applicability.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based qualitative auditing platform that provides a standardized and validated tool to assist hospitals in assessing the appropriateness of antimicrobial prescribing practices. Since its release in 2013, the NAPS has been adopted by all hospital types within Australia, including public and private facilities, and supports them in meeting the national standards for accreditation. Hospitals can generate real-time reports to assist with local antimicrobial stewardship (AMS) activities and interventions. De-identified aggregate data from the NAPS are also submitted to the Antimicrobial Use and Resistance in Australia surveillance system, for national reporting purposes, and to strengthen national AMS strategies. With the successful implementation of the programme within Australia, the NAPS has now been adopted by countries with both well-resourced and resource-limited healthcare systems. We provide here a narrative review describing the experience of users utilizing the NAPS programme in Canada, Malaysia and Bhutan. We highlight the key barriers and facilitators to implementation and demonstrate that the NAPS methodology is feasible, generalizable and translatable to various settings and able to assist in initiatives to optimize the use of antimicrobials.

Homebound individuals face substantial barriers to receiving COVID-19 vaccines as they cannot or rarely leave their homes because of medical, psychiatric, cognitive, functional, transportation-related and social reasons. There are at least 75,000 Ontarians aged 65 years and above who are homebound, with the majority being women and people aged 85 years and above. Much of this older homebound population requires mobile in-home COVID-19 vaccination, which could be prioritized by residence in high SARS-CoV-2 risk neighbourhoods.

In addition to instituting public health measures for COVID-19, managing healthcare resources is important for outcomes. The experiences in Italy and New York have shown that personal protective equipment (PPE) shortages can cause increased morbidity and mortality. We demonstrate a method to predict PPE demand across a health care system.

Mount Sinai Hospital and University Health Network, two academic health science centres in Toronto, Ontario, jointly established a robust, well-resourced antimicrobial stewardship program (ASP). Over the course of four years, we spread our program to five intensive care units (ICUs), learned which change management practices worked and which did not, and leveraged our ICU successes to other areas of our hospitals. We identified the following two factors as critical to establishing ASPs in hospitals: strong leadership with clear accountability; and valid, reliable data to monitor progress. Subsequently we have led the spread of our program to 14 academic hospital ICUs, and more recently we leveraged to help community hospitals implement ASPs without in-house infectious diseases specialists. We introduced three new data fields into the provincial critical care information system: days of antibacterial therapy, days of antifungal therapy, and ICU-onset C. difficile, which will help standardize data collection moving forward. This model—starting with academic health sciences centres, and antimicrobial stewardship experts and leaders who are then supported to mentor and develop new experts and leaders—could be copied in other jurisdictions both within and outside of Canada.

Predicting the ability of the cirrhotic liver to withstand resection remains a challenge for the surgeon. This study evaluates the use of the hippurate ratio, a novel assessment of glycine conjugation of paraaminobenzoic acid by the liver, as a preoperative indicator of functional hepatic reserve. Between 1998 and 2000, sixty-one cirrhotic patients were prospectively assessed for hepatic resection using the hippurate ratio, indocyanine green retention at 15 minutes (ICG R-l5), and other standard measures of liver function. Twenty-six patients were excluded as candidates for resection on the basis of inadequate functional hepatic reserve. Patients excluded from resection had significantly higher ICG R-15 values (29% ±9% vs. 16% ±12%, P = 0.00l), higher Child-Pugh scores (5.9 ± 0.9 vs. 5.3 ± 0.4, P = 0.01), and lower hippurate ratios (30% ±14% vs. 45% ± lS%, P = 0.005). There was a significant correlation between the hippurate ratio and ICG R-l5. Other indicators of liver function such as factor V, factor VII, albumin, bilirubin, protbrombin time, and transaminases were no different between patients who did and those who did not undergo resection. Of the 35 patients resected, there were seven (20%) who developed varying degrees of liver failure with three perioperative deaths (8.5%). Patients who had some degree of liver failure had significantly lower hippurate ratios than patients who had no liver failure (29% ±10% vs. 48% ±14%, P = 0.002). There was no difference in ICG R-15 values between patients who had liver failure and those who did not. The hippurate ratio offers information on hepatocellular reserve that is not provided by other measures of liver function and may allow better selection of cirrhotic patients for liver resection.

Background Surgical site infections are common causes of healthcare-associated infections. Using surgical antimicrobial prophylaxis (SAP) is a complex process that can reduce these rates if performed correctly. While antimicrobial stewardship programs have developed guidelines for SAP, there has been less focus on understanding and modifying the behavioral and contextual factors required to optimize prophylaxis use. We performed chart reviews and workflow analyses to develop interventions based on a theoretical framework to improve SAP use in two academic hospitals. Methods SAP use during a one month period (October 2016) was analyzed for orthopedic and general surgery procedures by chart review. The primary outcomes of interest included SAP choice, preoperative timing, intraoperative re-dosing, and postoperative continuation. Structured workflow analyses were performed to understand the processes involved in SAP ordering and administration. These findings were applied to the Theoretical Domains Framework (TDF) to develop theory-based interventions. Results We reviewed 88 orthopedic and 63 general surgery procedures. Adherence to institutional guidelines for prophylaxis choice was low in both orthopedic (55%) and general surgery (70%). For general surgery, preoperative timing was incorrect in 25% of cases, re-dosing for procedure duration was incorrect in 59% of cases, and re-dosing for blood loss was not routinely performed. Alternatively, for orthopedic surgery cefazolin was re-dosed too early, at a median of 93 minutes (n = 42), and postop antibiotic use was continued for 10 days in all 14 aseptic hip revisions. There was variation in practice patterns among orthopedic surgeons. Using TDF, we identified barriers among numerous theoretical domains for re-dosing (knowledge; memory, attention, and decision processes; environmental context and resources), choice of antibiotic and postoperative duration (knowledge; beliefs about consequences; emotion; social influences). Conclusion We identified suboptimal SAP use in two surgical services, each with distinct deficiencies. Performing in-depth chart reviews and workflow analyses characterized the specific behavioural and contextual barriers that require intervention. Disclosures All authors: No reported disclosures.

Fulminant hepatic failure (FHF) is associated with high mortality; few patients survive without liver transplantation. It is important to have a sensitive, specific early predictor of outcome to distinguish potential survivors (S) from nonsurvivors (NS).Because we had previously shown that glycine conjugation of para-aminobenzoic acid (PABA) quantitatively reflects liver function in children with chronic liver disease, in this pilot study we wanted to determine whether the measurement of the glycine conjugates of PABA could distinguish S from NS in FHF in comparison with standard prognostic indices.Twenty-four patients were studied: acute severe hepatitis (n = 7), subfulminant hepatic failure (n = 7), and FHF (n = 10). Assessment of King's College criteria, measurement of factor V and VII levels, PABA testing, and transjugular liver biopsies were performed in almost all patients within 48 hours of admission. Serum PABA and its glycine conjugates (para-aminohippurate (PAHA) and para-acetamidohippurate (PAAHA)) were measured thirty minutes after oral administration by high-pressure liquid chromatography. Poor prognostic categories as previously established in the literature were defined as factor V0.20U/ml, factor VII0.08 U/ml, % necrosis70%, hippurate ratio = 0%, and PAHA = 0M.The measurement of PAHA was the best predictor of a poor outcome in patients with acute liver failure with a sensitivity of 92%, and negative predictive value (NPV) of 92% compared with a sensitivity of 54% and a NPV of 63% with King's College criteria.Measurement of serum PAHA is the best early prognostic marker of death in children who suffer from FHF.