Development and implementation of "handshake rounds": An antibiotic stewardship intervention for hospitalized adult patients with hematologic malignancies.

Objective: To design and implement "handshake rounds" as an antibiotic stewardship intervention to reduce inpatient intravenous (IV) antibiotic use in patients with hematologic malignancies. Design: Quasi-experimental analysis of antibiotic use (AU) and secondary outcomes before and and after handshake rounds were implemented. Setting: Quaternary-care, academic medical center. Patients: Hospitalized adults with hematologic malignancies receiving IV antibiotics. Methods: We performed a retrospective review of a preintervention cohort prior to the intervention. A multidisciplinary team developed criteria for de-escalation of antibiotics, logistics of handshake rounds, and outcome metrics. Eligible patients were discussed during scheduled handshake rounds between a hematology-oncology pharmacist and transplant-infectious diseases (TID) physician. Prospective data were collected over 30 days in the postintervention cohort. Due to small sample size, 2:1 matching was used to compare pre- to and postintervention AU. Total AU in days of therapy per 1,000 patient days (DOT/1,000 PD) was reported. Mean AU per patient was analyzed using Wilcoxon rank-sum test. A descriptive analysis of secondary outcomes of pre- and postintervention cohorts was performed. Results: Total AU was substantially lower after the intervention, with 517 DOT/1,000 PD compared to 865 DOT/1,000 PD before the intervention. There was no statistically significant difference in the mean AU per patient between the 2 cohorts. There was a lower rate of 30-day mortality in the postintervention cohort and rates of ICU admissions were similar. Conclusions: Conducting handshake rounds is a safe and effective way to implement an antibiotic stewardship intervention among high-risk patient population such as those with hematologic malignancies.

Association of antibiotics with veteran visit satisfaction and antibiotic expectations for upper respiratory tract infections.

Background and objective: Veterans' Affairs (VA) healthcare providers perceive that Veterans expect and base visit satisfaction on receiving antibiotics for upper respiratory tract infections (URIs). No studies have tested this hypothesis. We sought to determine whether receiving and/or expecting antibiotics were associated with Veteran satisfaction with URI visits. Methods: This cross-sectional study included Veterans evaluated for URI January 2018-December 2019 in an 18-clinic ambulatory VA primary-care system. We evaluated Veteran satisfaction via the Patient Satisfaction Questionnaire Short Form (RAND Corporation), an 18-item 5-point Likert scale survey. Additional items assessed Veteran antibiotic expectations. Antibiotic receipt was determined via medical record review. We used multivariable regression to evaluate whether antibiotic receipt and/or Veteran antibiotic expectations were associated with satisfaction. Subgroup analyses focused on Veterans who accurately remembered antibiotic prescribing during their URI visit. Results: Of 1,329 eligible Veterans, 432 (33%) participated. Antibiotic receipt was not associated with differences in mean total satisfaction (adjusted score difference, 0.6 points; 95% confidence interval [CI], -2.1 to 3.3). However, mean total satisfaction was lower for Veterans expecting an antibiotic (adjusted score difference -4.4 points; 95% CI -7.2 to -1.6). Among Veterans who accurately remembered the visit and did not receive an antibiotic, those who expected an antibiotic had lower mean satisfaction scores than those who did not (unadjusted score difference, -16.6 points; 95% CI, -24.6 to -8.6). Conclusions: Veteran expectations for antibiotics, not antibiotic receipt, are associated with changes in satisfaction with outpatient URI visits. Future research should further explore patient expectations and development of patient-centered and provider-focused interventions to change patient antibiotic expectations.

Development of the Three Antimicrobial Stewardship E's (TASE) Framework and Association Between Stewardship Interventions and Intended Results Analysis to Identify Key Facility-Specific Interventions and Strategies for Successful Antimicrobial Stewardship.

BACKGROUND: Successful antimicrobial stewardship (AS) interventions have been described previously. Currently, a uniform operational approach to planning and implementing successful AS interventions does not exist. From 2015 to 2019, concomitant vancomycin and piperacillin-tazobactam use (CVPTU) for >48 hours at Vanderbilt University Medical Center (VUMC) significantly decreased through AS efforts. We analyzed the interventions that led to this change and created a model to inform future intervention planning and development. METHODS: Adult admissions at VUMC from January 2015 to August 2019 were evaluated for CVPTU. The percentage of admissions receiving CVPTU for >48 hours, the primary outcome, was evaluated using statistical process control charts. We created the Three Antimicrobial Stewardship E's (TASE) framework and Association between Stewardship Interventions and Intended Results (ASIR) analysis to assess potential intensity and impact of interventions associated with successful change during this time period and to identify guiding principles for development of future initiatives. RESULTS: The mean percentage of admissions receiving CVPTU per month declined from 4.2% to 0.7%. Over 8 time periods, we identified 4 periods with high, 3 with moderate, and 1 with low intervention intensity. Continuous provider-level AS education was present throughout. Creation and dissemination of division and department algorithms and reinforcement via computerized provider order entry sets preceded the largest reduction in CVPTU and sustained prescribing practice changes. CONCLUSIONS: The TASE framework and ASIR analysis successfully identified pivotal interventions and strategies needed to effect and sustain change at VUMC. Further research is needed to validate the effectiveness of this framework as a stewardship intervention planning tool at our institution and others.

Antimicrobial de-escalation in patients with high-risk febrile neutropenia: Attitudes and practices of adult hospital care providers.

In a survey of adult hospital providers regarding antibiotic use in the treatment of febrile neutropenia, clinical fellows, and pharmacists showed higher comfort levels with early antimicrobial de-escalation compared to hematology-oncology and transplant infectious diseases physicians. These frontline team members are ideal partners to champion antimicrobial stewardship interventions in febrile neutropenia.

Changes in antimicrobial utilization during the coronavirus disease 2019 (COVID-19) pandemic after implementation of a multispecialty clinical guidance team.

OBJECTIVE: Evaluate changes in antimicrobial use during COVID-19 and after implementation of a multispecialty COVID-19 clinical guidance team compared to pre-COVID-19 antimicrobial use. DESIGN: Retrospective observational study. SETTING: Tertiary-care academic medical center. PARTICIPANTS: Internal medicine and medical intensive care unit (MICU) provider teams and hospitalized COVID-19 patients. METHODS: Difference-in-differences analyses of antibiotic days of therapy per 1,000 patient days present (DOT) for internal medicine and MICU teams treating COVID-19 patients versus teams that did not were performed for 3 periods: before COVID-19, initial COVID-19 period, and after implementation of a multispecialty COVID-19 clinical guidance team which included daily, patient-specific antimicrobial stewardship recommendations. Patient characteristics associated with antibiotic DOT were evaluated using multivariable Poisson regression. RESULTS: In the initial COVID-19 period, compared to the pre-COVID-19 period, internal medicine and MICU teams increased weekly antimicrobial use by 145.3 DOT (95% CI, 35.1-255.5) and 204.0 DOT (95% CI, -16.9 to 424.8), respectively, compared to non-COVID-19 teams. In the intervention period, internal medicine and MICU COVID-19 teams both had significant weekly decreases of 362.3 DOT (95% CI, -443.3 to -281.2) and 226.3 DOT (95% CI, -381.2 to -71.3). Of 131 patients hospitalized with COVID-19, 86 (65.6%) received antibiotics; no specific patient factors were significantly associated with an expected change in antibiotic days. CONCLUSIONS: Antimicrobial use initially increased for COVID-19 patient care teams compared to pre-COVID-19 levels but significantly decreased after implementation of a multispecialty clinical guidance team, which may be an effective strategy to reduce unnecessary antimicrobial use.

Creating a Framework to Integrate Residency Program and Medical Center Approaches to Quality Improvement and Patient Safety Training.

Quality improvement and patient safety (QIPS) are core components of graduate medical education (GME). Training programs and affiliated medical centers must partner to create an environment in which trainees can learn while meaningfully contributing to QIPS efforts, to further the shared goal of improving patient care. Numerous challenges have been identified in the literature, including lack of resources, lack of faculty expertise, and siloed QIPS programs. In this article, the authors describe a framework for integrated QIPS training for residents in the University of Washington Internal Medicine Residency Program, beginning in 2014 with the creation of a dedicated QIPS chief resident position and assistant program director for health systems position, the building of a formal curriculum, and integration with medical center QIPS efforts. The postgraduate year (PGY) 1 curriculum focused on the culture of patient safety and entering traditional patient safety event (PSE) reports. The PGY-2 curriculum highlighted QIPS methodology and how to conduct mentored PSE reviews of cases that were of educational value to trainees and a clinical priority to the medical center. Additional PGY-2/PGY-3 training focused on the active report, presentation, and evaluation of cases during morbidity and mortality conferences while on clinical services, as well as how to lead longitudinal QIPS work. Select residents led mentored QI projects as part of an additional elective. The hallmark feature of this framework was the depth of integration with medical center priorities, which maximized educational and operational value. Evaluation of the program demonstrated improved attitudes, knowledge, and behavior changes in trainees, and significant contributions to medical center QIPS work. This specialty-agnostic framework allowed for training program and medical center integration, as well as horizontal integration across GME specialties, and can be a model for other institutions.

A Narrative Review of Early Oral Stepdown Therapy for the Treatment of Uncomplicated Staphylococcus aureus Bacteremia: Yay or Nay?

Historically, intravenous (IV) antibiotics have been the cornerstone of treatment for uncomplicated Staphylococcus aureus bacteremia (SAB). However, IV antibiotics are expensive, increase the rates of hospital readmission, and can be associated with catheter-related complications. As a result, the potential role of oral antibiotics in the treatment of uncomplicated SAB has become a subject of interest. This narrative review article aims to summarize key arguments for and against the use of oral antibiotics to complete treatment of uncomplicated SAB and evaluates the available evidence for specific oral regimens. We conclude that evidence suggests that oral step-down therapy can be an alternative for select patients who meet the criteria for uncomplicated SAB and will comply with medical treatment and outpatient follow-up. Of the currently studied regimens discussed in this article, linezolid has the most support, followed by fluoroquinolone plus rifampin.

Analysis of a high-prescribing state's 2016 outpatient antibiotic prescriptions: Implications for outpatient antimicrobial stewardship interventions.

OBJECTIVE: To identify prescriber characteristics that predict antibiotic high-prescribing behavior to inform statewide antimicrobial stewardship interventions. DESIGN: Retrospective analysis of 2016 IQVIA Xponent, formerly QuintilesIMS, outpatient retail pharmacy oral antibiotic prescriptions in Tennessee. SETTING: Statewide retail pharmacies filling outpatient antibiotic prescriptions. PARTICIPANTS: Prescribers who wrote at least 1 antibiotic prescription filled at a retail pharmacy in Tennessee in 2016. METHODS: Multivariable logistic regression, including prescriber gender, birth decade, specialty, and practice location, and patient gender and age group, to determine the association with high prescribing. RESULTS: In 2016, 7,949,816 outpatient oral antibiotic prescriptions were filled in Tennessee: 1,195 prescriptions per 1,000 total population. Moreover, 50% of Tennessee's outpatient oral antibiotic prescriptions were written by 9.3% of prescribers. Specific specialties and prescriber types were associated with high prescribing: urology (odds ratio [OR], 3.249; 95% confidence interval [CI], 3.208-3.289), nurse practitioners (OR, 2.675; 95% CI, 2.658-2.692), dermatologists (OR, 2.396; 95% CI, 2.365-2.428), physician assistants (OR, 2.382; 95% CI, 2.364-2.400), and pediatric physicians (OR, 2.340; 95% CI, 2.320-2.361). Prescribers born in the 1960s were most likely to be high prescribers (OR, 2.574; 95% CI, 2.532-2.618). Prescribers in rural areas were more likely than prescribers in all other practice locations to be high prescribers. High prescribers were more likely to prescribe broader-spectrum antibiotics (P < .001). CONCLUSIONS: Targeting high prescribers, independent of specialty, degree, practice location, age, or gender, may be the best strategy for implementing cost-conscious, effective outpatient antimicrobial stewardship interventions. More information about high prescribers, such as patient volumes, clinical scope, and specific barriers to intervention, is needed.