How to measure quantitative antibiotic use in order to support antimicrobial stewardship in acute care hospitals: a retrospective observational study.

A cornerstone of antimicrobial stewardship programs (ASPs) is monitoring quantitative antibiotic use. Frequently used metrics are defined daily dose (DDD) and days of therapy (DOT). The purpose of this study was (1) to explore for the hospital setting the possibilities of quantitative data retrieval on the level of medical specialty and (2) to describe factors affecting the usability and interpretation of these quantitative metrics. We performed a retrospective observational study, measuring overall systemic antibiotic use at specialty level over a 1-year period, from December 1st 2014 to December 1st 2015, in one university and 13 non-university hospitals in the Netherlands. We distinguished surgical and non-surgical adult specialties. The association between DDDs, calculated from aggregated dispensing data, and DOTs, calculated from patient-level prescription data, was explored descriptively and related to organizational factors, data sources (prescription versus dispensing data), data registration, and data extraction. Twelve hospitals were able to extract dispensing data (DDD), three of which on the level of medical specialty; 13 hospitals were able to extract prescription data (DOT), 11 of which by medical specialty. A large variation in quantitative antibiotic use was found between hospitals and the correlation between DDDs and DOTs at specialty level was low. Differences between hospitals related to organizational factors, data sources, data registration, and data extraction procedures likely contributed to the variation in quantitative use and the low correlation between DDDs and DOTs. The differences in healthcare organization, data sources, data registration, and data extraction procedures contributed to the variation in reported quantitative use between hospitals. Uniform registration and extraction procedures are necessary for appropriate measurement and interpretation and benchmarking of quantitative antibiotic use.

Development of actionable quality indicators and an action implementation toolbox for appropriate antibiotic use at intensive care units: A modified-RAND Delphi study.

INTRODUCTION: Extensive antibiotic use makes the intensive care unit (ICU) an important focus for antibiotic stewardship programs. The aim of this study was to develop a set of actionable quality indicators for appropriate antibiotic use at ICUs and an implementation toolbox, which can be used to assess and improve the appropriateness of antibiotic use in the treatment of adult patients at an ICU. METHODS: A four round modified-RAND Delphi procedure was used. Potential indicators were identified by a multidisciplinary panel of 15 Dutch experts, from international literature and guidelines. Using an online survey, the identified indicators were rated on three criteria: relevance, actionability and feasibility. Experts discussed and rated the indicators for the second time during a face-to-face consensus meeting. During a final consensus meeting the toolbox was developed, containing potential barriers and improvement strategies which were identified using a validated checklist by Flottorp et al., and if available also containing supporting material. RESULTS: The first round resulted in 24 potential indicators. After the final meeting a set of three process indicators, one structure indicator and one quantity metric remained: 1) perform at least two sets of blood cultures before start of empirical systemic therapy; 2) perform therapeutic drug monitoring in patients treated with vancomycin or aminoglycosides; 3) perform surveillance cultures if selective digestive or oropharyngeal decontamination is applied at the ICU; 4) biannual face-to-face meetings between ICU and microbiology staff in which local resistance rates are discussed; and 5) quantitative antibiotic use at the ICU expressed in days of therapy (DOT). The toolbox contains 24 unique barriers and 37 improvement strategies. CONCLUSIONS: Our study identified a set of four actionable quality indicators and one quantity metric, together with an implementation toolbox, to improve appropriate antibiotic use at ICUs.

A Systematic Review of Quality Indicators for Appropriate Antibiotic Use in Hospitalized Adult Patients.

Many quality indicators for appropriate antibiotic use have been developed. We aimed to make a systematic inventory, including the development methodology and validation procedures, of currently available quality indicators (QIs) for appropriate antibiotic use in hospitalized adult patients. We performed a literature search in the Pubmed interface. From the included articles we abstracted i) the indicators developed ii) the type of infection the QIs applied to iii) study design used for the development of the QIs iv) relation of the QIs to outcome measures v) whether the QIs were validated and vi) the characteristics of the validation cohort. Fourteen studies were included, in which 200 QIs were developed. The most frequently mentioned indicators concerned empirical antibiotic therapy according to the guideline (71% of studies), followed by switch from IV to oral therapy (64% of studies), followed by drawing at least two sets of blood cultures and change to pathogen-directed therapy based on culture results (57% of studies). Most QIs were specifically developed for lower respiratory tract infection, urinary tract infection or sepsis. A RAND-modified Delphi procedure was used in the majority of studies (57%). Six studies took outcome measures into consideration during the procedure. Five out of fourteen studies (36%) tested the clinimetric properties of the QIs and 65% of the tested QIs were considered valid. Many studies report the development of quality indicators for appropriate antibiotic use in hospitalized adult patients. However, only a small number of studies validated the developed QIs. Future validation of QIs is needed if we want to implement them in daily practice.

Phenotypes and genetic architecture of focal primary torsion dystonia.

BACKGROUND: The focal primary torsion dystonias (FPTDs) form a group of clinical heterogeneous syndromes and can be considered a genetic complex disease; it is thought to be primed by genetic variants with variable impact and triggered by non-genetic factors. Thorough clinical description of FPTDs cohorts is sparse but essential for further progress in genetic research. OBJECTIVE: To establish suggested relations between age at onset (AaO), site and family history in a large focal dystonias cohort and gain more insight into familial clustering for genetic research. PATIENTS AND METHODS: A prospective cohort study between March 2008 and March 2011, including 676 FPTD patients attending the botulinum toxin outpatient clinics of six Dutch movement disorder centres. RESULTS AND CONCLUSIONS: Of all of the FPTD patients, 25% had a familial predisposition; in 2.4% a Mendelian inheritance pattern was noted. With a stronger family history, a significantly lower AaO was seen in all focal dystonias. In both the sporadic and familial focal dystonia groups, AaO had an effect on the distribution of dystonia, with a caudal to cranial tendency. In all focal dystonia forms, women were more frequently affected, except for writer's cramp. Careful clinical characterisation will allow the formation of phenotype subgroups. We suggest that genetic research into FPTDs will benefit from this approach and discuss genetic research strategies to decipher the complex background of focal dystonias.

Interferometric coupling of the Keck telescopes with single-mode fibers.

Here we report successful interferometric coupling of two large telescopes with single-mode fibers. Interference fringes were obtained in the 2- to 2.3-micrometer wavelength range on the star 107 Herculis by using the two Keck 10-meter telescopes, each feeding their common interferometric focus with 300 meters of single-mode fibers. This experiment demonstrates the potential of fibers for future kilometric arrays of telescopes and is the first step toward the 'OHANA (Optical Hawaiian Array for Nanoradian Astronomy) interferometer at the Mauna Kea observatory in Hawaii. It opens the way to sensitive optical imagers with resolutions below 1 milli-arc second. Our experimental setup can be directly extended to large telescopes separated by many hundreds of meters.

A limit to the speed of processing in ultra-rapid visual categorization of novel natural scenes.

The processing required to decide whether a briefly flashed natural scene contains an animal can be achieved in 150 msec (Thorpe, Fize, & Marlot, 1996). Here we report that extensive training with a subset of photographs over a 3-week period failed to increase the speed of the processing underlying such Rapid Visual Categorizations: Completely novel scenes could be categorized just as fast as highly familiar ones. Such data imply that the visual system processes new stimuli at a speed and with a number of stages that cannot be compressed. This rapid processing mode was seen with a wide range of visual complex images, challenging the idea that short reaction times can only be seen with simple visual stimuli and implying that highly automatic feed-forward mechanisms underlie a far greater proportion of the sophisticated image analysis needed for everyday vision than is generally assumed.

Speed of processing in the human visual system.

How long does it take for the human visual system to process a complex natural image? Subjectively, recognition of familiar objects and scenes appears to be virtually instantaneous, but measuring this processing time experimentally has proved difficult. Behavioural measures such as reaction times can be used, but these include not only visual processing but also the time required for response execution. However, event-related potentials (ERPs) can sometimes reveal signs of neural processing well before the motor output. Here we use a go/no-go categorization task in which subjects have to decide whether a previously unseen photograph, flashed on for just 20 ms, contains an animal. ERP analysis revealed a frontal negativity specific to no-go trials that develops roughly 150 ms after stimulus onset. We conclude that the visual processing needed to perform this highly demanding task can be achieved in under 150 ms.

Near infrared astronomical light collector.

A 4-m aperture light collector has been built using the mosaic principle specifically for high resolution stellar spectroscopy in the near infrared by the Fourier multiplex technique. The most novel feature is complete servo control of all optical elements to bring individual images to a common point. Initial goals were a spectral survey of ir objects, and the testing of techniques for a larger future collector. However, the project has been stopped by lack of interest and support; the finished collector will not be used.