Last data update: Sep 23, 2024. (Total: 47723 publications since 2009)
Records 1-26 (of 26 Records) |
Query Trace: Neuhauser MM [original query] |
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Stewardship prompts to improve antibiotic selection for pneumonia: The INSPIRE Randomized Clinical Trial
Gohil SK , Septimus E , Kleinman K , Varma N , Avery TR , Heim L , Rahm R , Cooper WS , Cooper M , McLean LE , Nickolay NG , Weinstein RA , Burgess LH , Coady MH , Rosen E , Sljivo S , Sands KE , Moody J , Vigeant J , Rashid S , Gilbert RF , Smith KN , Carver B , Poland RE , Hickok J , Sturdevant SG , Calderwood MS , Weiland A , Kubiak DW , Reddy S , Neuhauser MM , Srinivasan A , Jernigan JA , Hayden MK , Gowda A , Eibensteiner K , Wolf R , Perlin JB , Platt R , Huang SS . Jama 2024 IMPORTANCE: Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. OBJECTIVE: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. INTERVENTION: CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. MAIN OUTCOMES AND MEASURES: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. RESULTS: Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. CONCLUSIONS AND RELEVANCE: Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03697070. |
Stewardship prompts to improve antibiotic selection for urinary tract infection: The INSPIRE Randomized Clinical Trial
Gohil SK , Septimus E , Kleinman K , Varma N , Avery TR , Heim L , Rahm R , Cooper WS , Cooper M , McLean LE , Nickolay NG , Weinstein RA , Burgess LH , Coady MH , Rosen E , Sljivo S , Sands KE , Moody J , Vigeant J , Rashid S , Gilbert RF , Smith KN , Carver B , Poland RE , Hickok J , Sturdevant SG , Calderwood MS , Weiland A , Kubiak DW , Reddy S , Neuhauser MM , Srinivasan A , Jernigan JA , Hayden MK , Gowda A , Eibensteiner K , Wolf R , Perlin JB , Platt R , Huang SS . Jama 2024 IMPORTANCE: Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. OBJECTIVE: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). INTERVENTIONS: CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. MAIN OUTCOMES AND MEASURES: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. RESULTS: Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. CONCLUSIONS AND RELEVANCE: Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03697096. |
Leveraging Health Systems to Expand and Enhance Antibiotic Stewardship in Outpatient Settings
Rodzik RH , Buckel WR , Hersh AL , Hicks LA , Neuhauser MM , Stenehjem EA , Hyun DY , Zetts RM . Jt Comm J Qual Patient Saf 2024 50 (4) 289-295 The widespread implementation of antibiotic stewardship programs across all health care settings is critical to slow the development of antibiotic resistance and ensure that patients receive the best medical care. Currently, most hospitals and long-term care facilities have reported implementation of antibiotic stewardship programs (95.0% of hospitals and 76.6% of long-term care facilities in 2021).1,2 However, more work is needed to expand antibiotic stewardship efforts into outpatient health care practices—including primary care, urgent care, and retail clinics, and within care provided through telemedicine services. These health care settings account for the majority of antibiotics prescribed in the United States, and previous studies have shown high rates of inappropriate prescribing.3., 4., 5., 6. | | Successful outpatient antibiotic stewardship implementation requires a coordinated effort between a diverse group of health care stakeholders to ensure that individual practices and clinicians have the resources and support they need to improve their prescribing practices. One key stakeholder group with the ability to support stewardship expansion into outpatient practices is health systems. Health care delivery in the United States has become increasingly consolidated, with one study finding that around 72% of hospitals and 49% of primary care physicians were affiliated with health systems in 2018.7 Health systems offer the ability to provide resources and infrastructure that can support antibiotic stewardship efforts across multiple outpatient practices. |
Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013-2020
McCarthy NL , Baggs J , Wolford H , Kazakova SV , Kabbani S , Attell BK , Neuhauser MM , Walker L , Yi SH , Hatfield KM , Reddy S , Hicks LA . Infect Control Hosp Epidemiol 2024 1-7 OBJECTIVE: The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. We evaluated annual trends in length of therapy (LOT) in adults hospitalized with uncomplicated CAP from 2013 through 2020. METHODS: We conducted a retrospective cohort study among adults with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases Ninth and Tenth Revision codes in MarketScan and the Centers for Medicare & Medicaid Services databases. We included patients with length of stay (LOS) of 2-10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. We estimated inpatient LOT based on LOS from the PINC AI Healthcare Database. The total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT. We examined trends from 2013 to 2020 in patients with total LOT >7 days, which was considered an indicator of likely excessive LOT. RESULTS: There were 44,976 and 400,928 uncomplicated CAP hospitalizations among patients aged 18-64 years and ≥65 years, respectively. From 2013 to 2020, the proportion of patients with total LOT >7 days decreased by 25% (68% to 51%) among patients aged 18-64 years and by 27% (68%-50%) among patients aged ≥65 years. CONCLUSIONS: Although likely excessive LOT for uncomplicated CAP patients decreased since 2013, the proportion of patients treated with LOT >7 days still exceeded 50% in 2020. Antibiotic stewardship programs should continue to pursue interventions to reduce likely excessive LOT for common infections. |
An update from the National Healthcare Safety Network on hospital antibiotic stewardship programs in the United States, 2014-2021
O'Leary EN , Neuhauser MM , McLees A , Paek M , Tappe J , Srinivasan A . Open Forum Infect Dis 2024 11 (2) ofad684 BACKGROUND: In 2014, the Centers for Disease Control and Prevention (CDC) released the Core Elements of Hospital Antibiotic Stewardship Programs (ASPs) and began monitoring uptake through the National Healthcare Safety Network (NHSN) Annual Hospital Survey. In 2019, CDC updated the Core Elements and in 2022 released the Priorities for Hospital Core Element Implementation. We describe Core Element uptake from 2014 to 2021, provide a snapshot of specific ASP practices in acute care hospitals in 2021, and describe how we plan to monitor stewardship moving forward. METHODS: We used the NHSN Annual Hospital Survey to summarize facility demographics and ASP practices and to monitor uptake of Core Elements. Questions have been updated over time, so not all data could be compared across years. RESULTS: Uptake of all 7 Core Elements increased from 41% in 2014 to 95% in 2021. Uptake of all 6 Priority Elements was 10% in 2021, though 46% of hospitals met 4 or 5 of the possible 6 elements. Antibiotic stewardship was specifically listed in a contract or job description for about 60% of program leaders. The percentage of physician-pharmacist co-led programs rose from 23% to 64%. Seventy-six percent of hospitals reported implementing audit with feedback interventions. CONCLUSIONS: With nearly all acute care hospitals reporting uptake of the 7 Core Elements in 2021, and with more evidence for which ASP practices are most effective, the Priorities for Hospital Core Element Implementation were released in 2022 to help enhance the quality and impact of existing ASPs. |
National Healthcare Safety Network Antimicrobial Use Option reporting .. finding the path forward
Neuhauser MM , Webb AK , Srinivasan A . Antimicrob Steward Healthc Epidemiol 2023 3 (1) e183 Through the Centers for Medicare and Medicaid Services Promoting Interoperability Program, more hospitals will be reporting to the National Healthcare Safety Network Antimicrobial Use (AU) Option. We highlight the next steps and opportunities for measurement of AU to optimize prescribing. © Society for Healthcare Epidemiology of America, 2023. |
Antibiotic use among hospitalized patients with COVID-19 in the United States, March 2020-June 2022
Kim C , Wolford H , Baggs J , Reddy S , Hicks LA , Neuhauser MM , Kabbani S . Open Forum Infect Dis 2023 10 (11) ofad503 We conducted a retrospective study to describe antibiotic use among US adults hospitalized with a COVID-19 diagnosis. Despite a decrease in overall antibiotic use, most patients hospitalized with COVID-19 received antibiotics on admission (88.1%) regardless of critical care status, highlighting that more efforts are needed to optimize antibiotic therapy. |
Defining access without excess: expanding appropriate use of antibiotics targeting multidrug-resistant organisms
Patel TS , Sati H , Lessa FC , Patel PK , Srinivasan A , Hicks LA , Neuhauser MM , Tong D , van der Heijden M , Alves SC , Getahun H , Park BJ . Lancet Microbe 2023 Antimicrobial resistance remains a significant global public health threat. Although development of novel antibiotics can be challenging, several new antibiotics with improved activity against multidrug-resistant Gram-negative organisms have recently been commercialised. Expanding access to these antibiotics is a global public health priority that should be coupled with improving access to quality diagnostics, health care with adequately trained professionals, and functional antimicrobial stewardship programmes. This comprehensive approach is essential to ensure responsible use of these new antibiotics. |
Impact of the COVID-19 pandemic on inpatient antibiotic use in the United States, January 2019 through July 2022
O'Leary EN , Neuhauser MM , Srinivasan A , Dubendris H , Webb AK , Soe MM , Hicks LA , Wu H , Kabbani S , Edwards JR . Clin Infect Dis 2023 Antimicrobial use (AU) data reported to the National Healthcare Safety Network's Antimicrobial Use and Resistance Module between January 2019 and July 2022 were analyzed to assess the impact of the COVID-19 pandemic on inpatient antimicrobial use. |
Evaluation of antifungal use in long-term care facilities using pharmacy dispensing data in the USA, 2019
Dickinson DT , Gouin KA , Neuhauser MM , Benedict K , Cincotta S , Kabbani S . J Antimicrob Chemother 2022 78 (1) 309-311 Antimicrobials are one of the most commonly prescribed medications in long-term care (LTC) settings.1–3 Cross-sectional surveys have estimated that antifungals account for 0.1%–5% of antimicrobials administered to LTC residents.2,3 However, these prevalence surveys did not capture use over time or characterize the prescribing of specific agents. Dispensing data from LTC pharmacies can be leveraged to track and report LTC antimicrobial use.4 Due to the risk of adverse events and drug interactions among older adults, characterizing antifungal use and describing variability in antifungal prescribing can inform antimicrobial stewardship efforts to ensure resident safety.5–7 |
Use of leading practices in US hospital antimicrobial stewardship programs
Stenehjem EA , Braun BI , Chitavi SO , Hyun DY , Schmaltz SP , Fakih MG , Neuhauser MM , Davidson LE , Meyer MJ , Tamma PD , Dodds-Ashley ES , Baker DW . Infect Control Hosp Epidemiol 2022 44 (6) 1-8 OBJECTIVE: To determine the proportion of hospitals that implemented 6 leading practices in their antimicrobial stewardship programs (ASPs). Design: Cross-sectional observational survey. SETTING: Acute-care hospitals. PARTICIPANTS: ASP leaders. METHODS: Advance letters and electronic questionnaires were initiated February 2020. Primary outcomes were percentage of hospitals that (1) implemented facility-specific treatment guidelines (FSTG); (2) performed interactive prospective audit and feedback (PAF) either face-to-face or by telephone; (3) optimized diagnostic testing; (4) measured antibiotic utilization; (5) measured C. difficile infection (CDI); and (6) measured adherence to FSTGs. RESULTS: Of 948 hospitals invited, 288 (30.4%) completed the questionnaire. Among them, 82 (28.5%) had <99 beds, 162 (56.3%) had 100-399 beds, and 44 (15.2%) had ≥400+ beds. Also, 230 (79.9%) were healthcare system members. Moreover, 161 hospitals (54.8%) reported implementing FSTGs; 214 (72.4%) performed interactive PAF; 105 (34.9%) implemented procedures to optimize diagnostic testing; 235 (79.8%) measured antibiotic utilization; 258 (88.2%) measured CDI; and 110 (37.1%) measured FSTG adherence. Small hospitals performed less interactive PAF (61.0%; P = .0018). Small and nonsystem hospitals were less likely to optimize diagnostic testing: 25.2% (P = .030) and 21.0% (P = .0077), respectively. Small hospitals were less likely to measure antibiotic utilization (67.8%; P = .0010) and CDI (80.3%; P = .0038). Nonsystem hospitals were less likely to implement FSTGs (34.3%; P < .001). CONCLUSIONS: Significant variation exists in the adoption of ASP leading practices. A minority of hospitals have taken action to optimize diagnostic testing and measure adherence to FSTGs. Additional efforts are needed to expand adoption of leading practices across all acute-care hospitals with the greatest need in smaller hospitals. |
Development of an electronic algorithm to target outpatient antimicrobial stewardship efforts for acute bronchitis and pharyngitis
Lautenbach E , Hamilton KW , Grundmeier R , Neuhauser MM , Hicks LA , Jaskowiak-Barr A , Cressman L , James T , Omorogbe J , Frager N , Menon M , Kratz E , Dutcher L , Chiotos K , Gerber JS . Open Forum Infect Dis 2022 9 (7) ofac273 BACKGROUND: A major challenge for antibiotic stewardship programs is the lack of accurate and accessible electronic data to target interventions. We developed and validated separate electronic algorithms to identify inappropriate antibiotic use for adult outpatients with bronchitis and pharyngitis. METHODS: We used International Classification of Diseases, 10th Revision, diagnostic codes to identify patient encounters for acute bronchitis and pharyngitis at outpatient practices between 3/15/17 and 3/14/18. Exclusion criteria included immunocompromising conditions, complex chronic conditions, and concurrent infections. We randomly selected 300 eligible subjects each with bronchitis and pharyngitis. Inappropriate antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm, which was constructed using only data in the electronic data warehouse. Criteria for appropriate prescribing, choice of antibiotic, and duration were based on established guidelines. RESULTS: Of 300 subjects with bronchitis, 167 (55.7%) received an antibiotic inappropriately based on chart review. The electronic algorithm demonstrated 100% sensitivity and 95.3% specificity for detection of inappropriate prescribing. Of 300 subjects with pharyngitis, 94 (31.3%) had an incorrect prescribing decision. Among 29 subjects with a positive rapid streptococcal antigen test, 27 (93.1%) received an appropriate antibiotic and 29 (100%) received the correct duration. The electronic algorithm demonstrated very high sensitivity and specificity for all outcomes. CONCLUSIONS: Inappropriate antibiotic prescribing for bronchitis and pharyngitis is common. Electronic algorithms for identifying inappropriate prescribing, antibiotic choice, and duration showed excellent test characteristics. These algorithms could be used to efficiently assess prescribing among practices and individual clinicians. Interventions based on these algorithms should be tested in future work. |
Pharmacist-driven transitions of care practice model for prescribing oral antimicrobials at hospital discharge
Mercuro NJ , Medler CJ , Kenney RM , MacDonald NC , Neuhauser MM , Hicks LA , Srinivasan A , Divine G , Beaulac A , Eriksson E , Kendall R , Martinez M , Weinmann A , Zervos M , Davis SL . JAMA Netw Open 2022 5 (5) e2211331 IMPORTANCE: Although prescribers face numerous patient-centered challenges during transitions of care (TOC) at hospital discharge, prolonged duration of antimicrobial therapy for common infections remains problematic, and resources are needed for antimicrobial stewardship throughout this period. OBJECTIVE: To evaluate a pharmacist-driven intervention designed to improve selection and duration of oral antimicrobial therapy prescribed at hospital discharge for common infections. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used a nonrandomized stepped-wedge design with 3 study phases from September 1, 2018, to August 31, 2019. Seventeen distinct medicine, surgery, and specialty units from a health system in Southeast Michigan participated, including 1 academic tertiary hospital and 4 community hospitals. Hospitalized adults who had urinary, respiratory, skin and/or soft tissue, and intra-abdominal infections and were prescribed antimicrobials at discharge were included in the analysis. Data were analyzed from February 18, 2020, to February 28, 2022. INTERVENTIONS: Clinical pharmacists engaged in a new standard of care for antimicrobial stewardship practices during TOC by identifying patients to be discharged with a prescription for oral antimicrobials and collaborating with primary teams to prescribe optimal therapy. Academic and community hospitals used both antimicrobial stewardship and clinical pharmacists in a multidisciplinary rounding model to discuss, document, and facilitate order entry of the antimicrobial prescription at discharge. MAIN OUTCOMES AND MEASURES: The primary end point was frequency of optimized antimicrobial prescription at discharge. Health system guidelines developed from national guidelines and best practices for short-course therapies were used to evaluate optimal therapy. RESULTS: A total of 800 patients prescribed oral antimicrobials at hospital discharge were included in the analysis (441 women [55.1%]; mean [SD] age, 66.8 [17.3] years): 400 in the preintervention period and 400 in the postintervention period. The most common diagnoses were pneumonia (264 [33.0%]), upper respiratory tract infection and/or acute exacerbation of chronic obstructive pulmonary disease (214 [26.8%]), and urinary tract infection (203 [25.4%]). Patients in the postintervention group were more likely to have an optimal antimicrobial prescription (time-adjusted generalized estimating equation odds ratio, 5.63 [95% CI, 3.69-8.60]). The absolute increase in optimal prescribing in the postintervention group was consistent in both academic (37.4% [95% CI, 27.5%-46.7%]) and community (43.2% [95% CI, 32.4%-52.8%]) TOC models. There were no differences in clinical resolution or mortality. Fewer severe antimicrobial-related adverse effects (time-adjusted generalized estimating equation odds ratio, 0.40 [95% CI, 0.18-0.88]) were identified in the postintervention (13 [3.2%]) compared with the preintervention (36 [9.0%]) groups. CONCLUSIONS AND RELEVANCE: The findings of this quality improvement study suggest that targeted antimicrobial stewardship interventions during TOC were associated with increased optimal, guideline-concordant antimicrobial prescriptions at discharge. |
National Healthcare Safety Network 2018 baseline neonatal Standardized Antimicrobial Administration Ratios
O'Leary EN , Edwards JR , Srinivasan A , Neuhauser MM , Soe MM , Webb AK , Edwards EM , Horbar JD , Soll RF , Roberts J , Hicks LA , Wu H , Zayack D , Braun D , Cali S , Edwards WH , Flannery DD , Fleming-Dutra KE , Guzman-Cottrill JA , Kuzniewicz M , Lee GM , Newland J , Olson J , Puopolo KM , Rogers SP , Schulman J , Septimus E , Pollock DA . Hosp Pediatr 2022 12 (2) 190-198 BACKGROUND: The microbiologic etiologies, clinical manifestations, and antimicrobial treatment of neonatal infections differ substantially from infections in adult and pediatric patient populations. In 2019, the Centers for Disease Control and Prevention developed neonatal-specific (Standardized Antimicrobial Administration Ratios SAARs), a set of risk-adjusted antimicrobial use metrics that hospitals participating in the National Healthcare Safety Network's (NHSN's) antimicrobial use surveillance can use in their antibiotic stewardship programs (ASPs). METHODS: The Centers for Disease Control and Prevention, in collaboration with the Vermont Oxford Network, identified eligible patient care locations, defined SAAR agent categories, and implemented neonatal-specific NHSN Annual Hospital Survey questions to gather hospital-level data necessary for risk adjustment. SAAR predictive models were developed using 2018 data reported to NHSN from eligible neonatal units. RESULTS: The 2018 baseline neonatal SAAR models were developed for 7 SAAR antimicrobial agent categories using data reported from 324 neonatal units in 304 unique hospitals. Final models were used to calculate predicted antimicrobial days, the SAAR denominator, for level II neonatal special care nurseries and level II/III, III, and IV NICUs. CONCLUSIONS: NHSN's initial set of neonatal SAARs provides a way for hospital ASPs to assess whether antimicrobial agents in their facility are used at significantly higher or lower rates compared with a national baseline or whether an individual SAAR value is above or below a specific percentile on a given SAAR distribution, which can prompt investigations into prescribing practices and inform ASP interventions. |
Trends in Antibiotic Use in United States Hospitals During the Coronavirus Disease 2019 Pandemic.
Rose AN , Baggs J , Wolford H , Neuhauser MM , Srinivasan A , Gundlapalli AV , Reddy S , Kompaniyets L , Pennington AF , Grigg C , Kabbani S . Open Forum Infect Dis 2021 8 (6) ofab236 We described antibiotic use among inpatients with coronavirus disease 2019 (COVID-19). Most COVID-19 inpatients received antibiotic therapy. We also described hospital-wide antibiotic use during 2020 compared with 2019, stratified by hospital COVID-19 burden. Although total antibiotic use decreased between years, certain antibiotic use increased with higher COVID-19 burden. |
Assessment of the Appropriateness of Antimicrobial Use in US Hospitals
Magill SS , O'Leary E , Ray SM , Kainer MA , Evans C , Bamberg WM , Johnston H , Janelle SJ , Oyewumi T , Lynfield R , Rainbow J , Warnke L , Nadle J , Thompson DL , Sharmin S , Pierce R , Zhang AY , Ocampo V , Maloney M , Greissman S , Wilson LE , Dumyati G , Edwards JR , Chea N , Neuhauser MM . JAMA Netw Open 2021 4 (3) e212007 IMPORTANCE: Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. OBJECTIVE: To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. EXPOSURE: Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. MAIN OUTCOMES AND MEASURES: The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. RESULTS: Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). CONCLUSIONS AND RELEVANCE: The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally. |
National Healthcare Safety Network Standardized Antimicrobial Administration Ratios (SAARs): A progress report and risk modeling update using 2017 data
O'Leary EN , Edwards JR , Srinivasan A , Neuhauser MM , Webb AK , Soe MM , Hicks LA , Wise W , Wu H , Pollock DA . Clin Infect Dis 2020 71 (10) e702-e709 BACKGROUND: The Standardized Antimicrobial Administration Ratio (SAAR) is a risk-adjusted metric of antimicrobial use (AU) developed by the CDC in 2015 as a tool for hospital antimicrobial stewardship programs (ASPs) to track and compare AU to a national benchmark. In 2018, CDC updated the SAAR by expanding the locations and antimicrobial categories for which SAARs can be calculated and by modeling adult and pediatric locations separately. METHODS: We identified eligible patient care locations and defined SAAR antimicrobial categories. Predictive models were developed for eligible adult and pediatric patient care locations using negative binomial regression applied to nationally aggregated AU data from locations reporting >/=9 months of 2017 data to the National Healthcare Safety Network (NHSN). RESULTS: 2017 baseline SAAR models were developed for seven adult and eight pediatric SAAR antimicrobial categories using data reported from 2,156 adult and 170 pediatric locations across 457 hospitals. The inclusion of step-down units and general hematology-oncology units in adult 2017 baseline SAAR models and the addition of SAARs for narrow-spectrum beta-lactam agents, antifungals predominantly used for invasive candidiasis, antibacterial agents posing the highest risk for Clostridioides difficile infection, and azithromycin (pediatrics only) expand the role SAARs can play in ASP efforts. Final risk-adjusted models are used to calculate predicted antimicrobial days, the denominator of the SAAR, for 40 SAAR types displayed in NHSN. CONCLUSIONS: SAARs can be used as a metric to prompt investigation into potential overuse or underuse of antimicrobials and to evaluate the effectiveness of ASP interventions. |
Leading Practices in Antimicrobial Stewardship: Conference Summary
Baker DW , Hyun D , Neuhauser MM , Bhatt J , Srinivasan A . Jt Comm J Qual Patient Saf 2019 45 (7) 517-523 The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors' experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. METHODS: The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. RESULTS: The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician's perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. CONCLUSION: The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs. |
Collaborative solutions to antibiotic stewardship in small community and critical access hospitals
Bhatt J , Smith B , Neuhauser MM , Srinivasan A , Moore P , Hyun DY . Acad Med 2019 94 (10) 1419-1421 The overuse and misuse of antibiotics affects patients in many ways, including by driving antibiotic resistance, a serious public health threat in the United States and around the world. To improve patient safety and address rising rates of resistance, an increasing number of health care facilities have created antibiotic stewardship programs (ASPs). ASPs have been successful in slowing the emergence of resistance and improving patient outcomes. However, there are serious geographic and resource barriers to ASP adoption in small community hospitals and critical access hospitals. Fortunately, many barriers can be overcome by using collaborative models to bring together key stakeholders, including large hospitals and health systems and academic medical centers; hospital associations; federal, state, and local public health organizations; and federal and state offices of rural health. These stakeholders are ideally positioned to assist with stewardship efforts in small community and critical access hospitals and, in doing so, can improve patient safety while stemming the spread of resistant bacteria. |
Using NHSN's antimicrobial use option to monitor and improve antibiotic stewardship in neonates
O'Leary EN , van Santen KL , Edwards EM , Braun D , Buus-Frank ME , Edwards JR , Guzman-Cottrill JA , Horbar JD , Lee GM , Neuhauser MM , Roberts J , Schulman J , Septimus E , Soll RF , Srinivasan A , Webb AK , Pollock DA . Hosp Pediatr 2019 9 (5) 340-347 BACKGROUND: The Antimicrobial Use (AU) Option of the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) is a surveillance resource that can provide actionable data for antibiotic stewardship programs. Such data are used to enable measurements of AU across hospitals and before, during, and after stewardship interventions. METHODS: We used monthly AU data and annual facility survey data submitted to the NHSN to describe hospitals and neonatal patient care locations reporting to the AU Option in 2017, examine frequencies of most commonly reported agents, and analyze variability in AU rates across hospitals and levels of care. We used results from these analyses in a collaborative project with Vermont Oxford Network to develop neonatal-specific Standardized Antimicrobial Administration Ratio (SAAR) agent categories and neonatal-specific NHSN Annual Hospital Survey questions. RESULTS: As of April 1, 2018, 351 US hospitals had submitted data to the AU Option from at least 1 neonatal unit. In 2017, ampicillin and gentamicin were the most frequently reported antimicrobial agents. On average, total rates of AU were highest in level III NICUs, followed by special care nurseries, level II-III NICUs, and well newborn nurseries. Seven antimicrobial categories for neonatal SAARs were created, and 6 annual hospital survey questions were developed. CONCLUSIONS: A small but growing percentage of US hospitals have submitted AU data from neonatal patient care locations to NHSN, enabling the use of AU data aggregated by NHSN as benchmarks for neonatal antimicrobial stewardship programs and further development of the SAAR summary measure for neonatal AU. |
Antimicrobials in acute and long-term care: a point in time along the way to improved use
Neuhauser MM , Weber JT . Euro Surveill 2018 23 (46) Antimicrobial use is the most important modifiable factor contributing to resistance [1]. One key strategy against antimicrobial resistance that has the potential to improve patient outcomes is to optimise antimicrobial use. Understanding how antimicrobials are being used informs stewardship efforts in acute care, long-term care and outpatient settings [2]. In the acute care setting, stewardship programs encompass tracking and reporting aggregate antimicrobial use metrics, such as days of therapy or defined daily doses. Benchmarking use within and across facilities is helpful in identifying where action is needed. Antimicrobial use point prevalence surveys (PPS) complement the aggregate metrics by providing information on patient-level use, such as indication and site of infection during the specified time period [3,4]. This approach is able to reveal more targeted quality improvements and enables comparisons of antimicrobial use at the national, regional or local level. PPS may be particularly useful for resource-limited hospitals and long-term care facilities (LTCF) with restricted capabilities for capturing use data on a continual basis [5,6]. Since PPS evaluate antimicrobial use during a single time period, they need to be repeated at regular intervals to monitor trends over time. |
The Standardized Antimicrobial Administration Ratio: A new metric for measuring and comparing antibiotic use
van Santen KL , Edwards JR , Webb AK , Pollack LA , O'Leary E , Neuhauser MM , Srinivasan A , Pollock DA . Clin Infect Dis 2018 67 (2) 179-185 Background: To provide a standardized, risk-adjusted method for summarizing antibiotic use (AU) and to enable hospitals to track their AU over time and compare their AU data to national benchmarks, CDC developed a new metric, the Standardized Antimicrobial Administration Ratio (SAAR). Methods: Hospitals reporting to the National Healthcare Safety Network (NHSN) AU Option collect and submit aggregated AU data electronically as antimicrobial days of therapy per patient days present. SAARs were developed for specific NHSN adult and pediatric patient care locations and cover five antimicrobial agent categories: (1) broad-spectrum agents predominantly used for hospital-onset/multi-drug resistant bacteria, (2) broad-spectrum agents predominantly used for community-acquired infections, (3) anti-MRSA agents, (4) agents predominantly used for surgical site infection prophylaxis, and (5) all antibiotic agents. The SAAR is an observed-to-predicted use ratio in which the predicted use is estimated from a statistical model; a SAAR of 1 indicates that observed use and predicted use are equal. Results: Most location-level SAARs were statistically significantly different than 1; in adult locations up to 52% lower than 1 and up to 41% higher than 1. Median SAARs in adult and pediatric ICUs had a range of 0.667- 1.119. SAAR distributions serve as an external comparison to national SAARs. Conclusion: This is the first aggregate AU metric that uses point-of-care, antimicrobial administration data electronically reported to a national surveillance system to enable risk adjusted, AU comparisons across multiple hospitals. The SAAR metric is endorsed by the National Quality Forum and provides a set of AU benchmarks that stewardship programs can use to identify higher than predicted AU to help drive improvements. |
Executive Summary: Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America
Barlam TF , Cosgrove SE , Abbo LM , MacDougall C , Schuetz AN , Septimus EJ , Srinivasan A , Dellit TH , Falck-Ytter YT , Fishman NO , Hamilton CW , Jenkins TC , Lipsett PA , Malani PN , May LS , Moran GJ , Neuhauser MM , Newland JG , Ohl CA , Samore MH , Seo SK , Trivedi KK . Clin Infect Dis 2016 62 (10) 1197-202 Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics. |
Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America
Barlam TF , Cosgrove SE , Abbo LM , MacDougall C , Schuetz AN , Septimus EJ , Srinivasan A , Dellit TH , Falck-Ytter YT , Fishman NO , Hamilton CW , Jenkins TC , Lipsett PA , Malani PN , May LS , Moran GJ , Neuhauser MM , Newland JG , Ohl CA , Samore MH , Seo SK , Trivedi KK . Clin Infect Dis 2016 62 (10) e51-77 Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics. |
Variation in outpatient antibiotic prescribing for acute respiratory infections in the veteran population: a cross-sectional study
Jones BE , Sauer B , Jones MM , Campo J , Damal K , He T , Ying J , Greene T , Goetz MB , Neuhauser MM , Hicks LA , Samore MH . Ann Intern Med 2015 163 (2) 73-80 BACKGROUND: Despite efforts to reduce antibiotic prescribing for acute respiratory infections (ARIs), information on factors that drive prescribing is limited. OBJECTIVE: To examine trends in antibiotic prescribing in the Veterans Affairs population over an 8-year period and to identify patient, provider, and setting sources of variation. DESIGN: Retrospective, cross-sectional study. SETTING: All emergency departments and primary and urgent care clinics in the Veterans Affairs health system. PARTICIPANTS: All patient visits between 2005 and 2012 with primary diagnoses of ARIs that typically had low proportions of bacterial infection. Patients with infections or comorbid conditions that indicated antibiotic use were excluded. MEASUREMENTS: Overall antibiotic prescription; macrolide prescription; and patient, provider, and setting characteristics extracted from the electronic health record. RESULTS: The proportion of 1 million visits with ARI diagnoses that resulted in antibiotic prescriptions increased from 67.5% in 2005 to 69.2% in 2012 (P < 0.001). The proportion of macrolide antibiotics prescribed increased from 36.8% to 47.0% (P < 0.001). Antibiotic prescribing was highest for sinusitis (adjusted proportion, 86%) and bronchitis (85%) and varied little according to fever, age, setting, or comorbid conditions. Substantial variation was identified in prescribing at the provider level: The 10% of providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, and the 10% who prescribed the least did so during 40% or fewer of their ARI visits. LIMITATION: Some clinical data that may have influenced the prescribing decision were missing. CONCLUSION: Veterans with ARIs commonly receive antibiotics, regardless of patient, provider, or setting characteristics. Macrolide use has increased, and substantial variation was identified in antibiotic prescribing at the provider level. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention. |
Prevalence of antimicrobial use in US acute care hospitals, May-September 2011
Magill SS , Edwards JR , Beldavs ZG , Dumyati G , Janelle SJ , Kainer MA , Lynfield R , Nadle J , Neuhauser MM , Ray SM , Richards K , Rodriguez R , Thompson DL , Fridkin SK . JAMA 2014 312 (14) 1438-46 IMPORTANCE: Inappropriate antimicrobial drug use is associated with adverse events in hospitalized patients and contributes to the emergence and spread of resistant pathogens. Targeting effective interventions to improve antimicrobial use in the acute care setting requires understanding hospital prescribing practices. OBJECTIVE: To determine the prevalence of and describe the rationale for antimicrobial use in participating hospitals. DESIGN, SETTING, AND PARTICIPANTS: One-day prevalence surveys were conducted in acute care hospitals in 10 states between May and September 2011. Patients were randomly selected from each hospital's morning census on the survey date. Data collectors reviewed medical records retrospectively to gather data on antimicrobial drugs administered to patients on the survey date and the day prior to the survey date, including reasons for administration, infection sites treated, and whether treated infections began in community or health care settings. MAIN OUTCOMES AND MEASURES: Antimicrobial use prevalence, defined as the number of patients receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed patients. RESULTS: Of 11,282 patients in 183 hospitals, 5635 (49.9%; 95% CI, 49.0%-50.9%) were administered at least 1 antimicrobial drug; 77.5% (95% CI, 76.6%-78.3%) of antimicrobial drugs were used to treat infections, most commonly involving the lower respiratory tract, urinary tract, or skin and soft tissues, whereas 12.2% (95% CI, 11.5%-12.8%) were given for surgical and 5.9% (95% CI, 5.5%-6.4%) for medical prophylaxis. Of 7641 drugs to treat infections, the most common were parenteral vancomycin (1103, 14.4%; 95% CI, 13.7%-15.2%), ceftriaxone (825, 10.8%; 95% CI, 10.1%-11.5%), piperacillin-tazobactam (788, 10.3%; 95% CI, 9.6%-11.0%), and levofloxacin (694, 9.1%; 95% CI, 8.5%-9.7%). Most drugs administered to treat infections were given for community-onset infections (69.0%; 95% CI, 68.0%-70.1%) and to patients outside critical care units (81.6%; 95% CI, 80.4%-82.7%). The 4 most common treatment antimicrobial drugs overall were also the most common drugs used for both community-onset and health care facility-onset infections and for infections in patients in critical care and noncritical care locations. CONCLUSIONS AND RELEVANCE: In this cross-sectional evaluation of antimicrobial use in US hospitals, use of broad-spectrum antimicrobial drugs such as piperacillin-tazobactam and drugs such as vancomycin for resistant pathogens was common, including for treatment of community-onset infections and among patients outside critical care units. Further work is needed to understand the settings and indications for which reducing antimicrobial use can be most effectively and safely accomplished. |
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