The objective of this study was to determine the impact of an antimicrobial stewardship intervention in six non-intensive care services. A review of all patients on their 3rd and 10th day of broad-spectrum antibiotic therapy was conducted at Sunnybrook Health Sciences Centre using a stepped–wedge randomized design. The primary outcome was broad-spectrum antimicrobial utilization in the intervention period compared to the control period. Despite high volumes and uptake of stewardship recommendations, a non-significant reduction in targeted antimicrobial utilization was achieved; however, median length of stay of the patients included was ~4 days, limiting the ability of the intervention to make a significant impact on inpatient antimicrobial utilization. Careful consideration of the targeted patient population is, therefore, warranted when planning and implementing antimicrobial stewardship interventions. Future work may focus on intervening earlier in the course of therapy.

The objective of this study was to determine the impact of an antimicrobial stewardship intervention in six non-intensive care services. A review of all patients on their 3rd and 10th day of broad-spectrum antibiotic therapy was conducted at Sunnybrook Health Sciences Centre using a stepped–wedge randomized design. The primary outcome was broad-spectrum antimicrobial utilization in the intervention period compared to the control period. Despite high volumes and uptake of stewardship recommendations, a non-significant reduction in targeted antimicrobial utilization was achieved; however, median length of stay of the patients included was ~4 days, limiting the ability of the intervention to make a significant impact on inpatient antimicrobial utilization. Careful consideration of the targeted patient population is, therefore, warranted when planning and implementing antimicrobial stewardship interventions. Future work may focus on intervening earlier in the course of therapy.

Background: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). Conclusion: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Medicine. Johannesburg, 2017. / Antimicrobial stewardship (AMS) programmes along with infection and prevention control measures have been shown to reduce the burden of antimicrobial resistance (AMR) in hospitals. There is a global campaign by infectious diseases physicians and other stakeholders for hospitals to implement AMS programmes. In Africa, there have been a limited number of AMS studies conducted although South African private hospitals have published some outcomes on initiation of these programmes in the continent, with the aim of improving patients’ clinical outcomes and reducing the development of resistance to prescribed antibiotics. A formal AMS programme is yet to be implemented in the surgery departments of the Charlotte Maxeke Johannesburg Academic Hospital. This study was conducted in two surgical wards of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). It was a quantitative study combining a prevalence cross-sectional observational stage, and an intervention study. It involved a retrospective review of patient records in the baseline stage followed by an intervention which took the form of a weekly antibiotic round led by an infectious diseases specialist. The appropriateness of antibiotic prescriptions was assessed using the criteria developed by Gyssens and colleagues, while the appropriateness of surgical prophylaxis was determined based on the recommendations of the South African Antibiotic Stewardship Programme (SAASP) and current Standard Treatment Guidelines and Essential Medicines Lists for South Africa. The prices of the antibiotics used were obtained from the central pharmacy of the CMJAH and Masters Price Catalogue list of the National Department of Health, while the prices of laboratory tests were obtained from the Tariff database. The volume of antibiotics consumed was determined by Defined Daily Doses (DDDs)/1000 patient days. In both stages of the study amoxicillin/clavulanic acid was the most frequently used agent. The intravenous route was the most commonly used route of drug administration in both stages of the study. There was a reduction in the proportion of patients who were treated with antibiotics for more than seven days in the intervention stage, from 6.19% in the baseline stage to 2.07% in the intervention stage. A significant reduction in the duration of antibiotic therapy for two days and more was observed from 4.74 ± 4.58 days in the baseline stage compared to 3.96 ± 2.04 days in the intervention stage (p = 0.01). A shift from empiric to culture directed therapy was also observed in the intervention stage compared to the baseline stage. There was a significant reduction in the volume of antibiotic consumption from a total of 739.30 DDDs/1000 patient days in the baseline stage to 564.93 DDDs/1000 patient days in the intervention stage (p = 0.038). Overall, there was a significant reduction of inappropriate antibiotic utilisation from 35% in the baseline stage to 26% in the intervention stage (p = 0.006). A high percentage of inappropriate surgical prophylaxis was found which was mostly due to the incorrect choice of agent with 64.75% and 61.54% in the baseline and intervention stages, respectively. The average antibiotic cost per patient was reduced from R 268.23 ± 389.32 to R 228.03 ± 326.88 in the Vascular Surgery Ward compared to the General Surgery Ward where there was an increase in average cost per patient from R 219.80 ± 400.75 in the baseline stage to R 284.06 ± 461.28 in the intervention stage. Gram-negative bacteria were the most prevalent pathogens in both stages of the study at 53% in the baseline and 54% during the intervention stage. The findings of this study show an improvement in the appropriateness of antibiotic utilisation, reduction in antibiotic consumption and cost reduction in one of the study wards, following implementation of an AMS programme. Also, there was an improvement in culture directed therapy, requests for an appropriate biological specimen for culture, with a consequent increase in the cost of laboratory investigations per patient during the intervention stage, which was due to increases in culture request. Rational antimicrobial prescribing habits, strong AMS interventions along with infection and prevention control measures, sound government policies and surveillance of resistant organisms in Africa will go a long way in preserving our antibiotics and preventing the spread of multidrug-resistant pathogens. / LG2018

The goal of antibiotic stewardship is to improve antibiotic use, often by reducing unnecessary treatment. Bedside dysphagia screening tools help identify patients at high risk of aspiration following stroke. Presence of dysphagia does not indicate a need for antibiotic treatment. Therefore, this retrospective, cohort study was developed to evaluate the association of dysphagia and antibiotic prescribing following stroke. There were 117 patients included. Patients were placed into 2 cohorts based on the results of the dysphagia screening, with 55 patients positive for dysphagia and 62 patients negative for dysphagia. Patients with dysphagia tended to be older, had higher National Institutes of Health stroke scores, and lower renal function. Patients with dysphagia were prescribed more empiric antibiotics than those without dysphagia (18.2% vs. 3.2%, p = 0.01). This resulted in 53 antibiotic days of therapy in the dysphagia cohort compared to 19 antibiotic days of therapy in the no dysphagia cohort (p = 0.1). No patients later developed pneumonia and only one patient was started antibiotics after 48 h. Two cases of Clostridioides difficile were reported. Both patients were in the dysphagia cohort and received antibiotics. Multivariable logistic regression demonstrated that positive chest x-ray findings and failed dysphagia screen were independent conditions associated with initiating antibiotics. These findings indicate that antibiotic use was higher in patients following stroke with a positive dysphagia screen. Close monitoring of stroke patients, particularly when positive for dysphagia, might be an under-recognized antibiotic stewardship opportunity.

La résistance aux antibiotiques est une menace sérieuse pour la santé publique en Europe, entrainant une augmentation des coûts de la santé, des échecs thérapeutiques, et de la mortalité (ECDC, 2011). Le développement de l'antibiorésistance est principalement lié à la consommation d'antibiotiques chez l'Homme et les animaux. Depuis le début des années 2000, les pays européens ont limité cette consommation et en 2006, l'UE a interdit l'utilisation d'antibiotiques comme promoteurs de croissance. Ceci a favorisé le développement de diverses alternatives à l'utilisation d'antibiotiques. L'objectif principal de ce projet de thèse est d'évaluer l'utilisation d'alternatives spécifiques et non spécifiques à l'utilisation d'antibiotiques dans les élevages de porcs européens. L'étude sera organisée en trois parties: i) une évaluation technique, visant à quantifier le lien entre l'utilisation d'antibiotiques et les performances techniques des élevages, ii) une évaluation économique, basée sur une analyse coût-efficacité et coûts-bénéfices des stratégies alternatives aux antibiotiques et iii) une évaluation psychosociologique, décrivant les attitudes et les comportements des éleveurs, vétérinaires et scientifiques vis-à-vis de l'utilisation d'antibiotiques en élevage porcin. Ce projet impliquera à la fois la réalisation de visites d'élevages français, l'utilisation d'outils statistiques variés et de méthodes de recherche qualitative et d'évaluation des risques. Ainsi, ce projet fournira les bases d'une compréhension globale des facteurs techniques, économiques et psychosociologiques qui orientent les décisions des éleveurs et des vétérinaires au sujet de la santé et de la production porcine et qui, par conséquent, définissent les possibles interventions sur l'utilisation d'antibiotiques. Cette étude fait partie du projet de recherche du Consortium MINAPIG financé par le programme Emida Era-Net. Un financement supplémentaire est fourni par l'Office vétérinaire fédéral suisse. / Antimicrobial resistance is a serious threat to public health in Europe, leading to mounting healthcare costs, treatment failure, and deaths (ECDC, 2011). The development of antimicrobial resistance is mainly due to antimicrobial consumption in humans and animals. From early 2000s, European countries have implemented restriction measures and in 2006, EU banned the use of antibiotics as growth promoters in animal feed. This has promoted the development of various alternatives to antimicrobial. The main objective of this PhD project is to assess and evaluate specific and unspecific alternatives to antimicrobials in the European pig industry. The study will be organised in three main parts: i) a technical assessment, quantifying the link between antimicrobial use and technical performances of the pig farms, ii) an economic evaluation, conducting cost-effectiveness and cost-benefit analyses of alternative strategies in comparison with antimicrobial usage, and iii) a psycho-sociological evaluation, describing farmers, veterinarians and pig experts attitudes, beliefs and behaviours regarding the use of antimicrobials in pig farming. The project will involve field work in France, statistical analysis using a range of methods, qualitative research methods, conceptual work and the use of risk assessment methods. We expect this PhD project to provide the foundation for an integrated understanding of technical, economical and psychological factors driving decisions of farmers and veterinarians about pig health and production and the consequential interventions, particularly the use of antimicrobials. This study is part of the MINAPIG Consortium Research project funded by the Era-Net programme Emida. Additional funding is available through the Federal Veterinary Office of Switzerland.

Introduction: The Antimicrobial Self-assessment Toolkit for Acute NHS Trusts (ASAT) was developed by a pharmacist reference group of an Advisory Non-Departmental Public Body on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI). It was developed in conjunction with the Department of Health. The primary purpose of the ASAT is to identify and to measure the methods of implementation of antimicrobial stewardship programmes in acute NHS trusts. The face validity was previously tested by ARHAI. The overall aims of this programme of work were to investigate the validity of the ASAT and to make iterative changes to improve its validity. Ethical approval was not required for this PhD project because it was categorised as service evaluation by the LREC. Also, ethical approval from the University of Manchester Research Ethics Committee was deemed unnecessary at the time of the PhD project due to the nature of the data collected. Methods: A mixed methodology approach utilising a sequential exploratory strategy was used to investigate the validity of the ASAT. This PhD project was composed of four sequential studies which resulted in iterative changes to the ASAT, that is, from ASAT v15a to ASAT v18. In Study 1, cognitive interviews were conducted with eight antimicrobial pharmacists in order to investigate the content validity of ASAT v15a. In Study 2, both cognitive interviews and semi-structured interviews were conducted with 10 clinical microbiologists in order to investigate the content validity of ASAT v16. In Study 3, Rasch modelling and analyses using the Partial Credit Model (PCM) were conducted on the responses to ASAT v17 from 33 NHS trusts across England. In Study 4, simple OLS regression analyses were conducted using the NHS trust ‘ability’ estimates or calibrations and Clostridium difficile (CDI) rates of participating NHS trusts in order to investigate model fit and the predictive validity of the ASAT. Results: The cognitive interviews conducted in study 1 indicated that AMPs encountered cognitive difficulties along the cognitive processing pathway in response to ASAT v15a. These difficulties included comprehension in 27 (32.5%) questions and response generation/formatting in 13 (15.7%) questions. Also respondents indicated that the role of clinical microbiologists in ASPs was underrepresented in ASAT v15a. The interviews conducted in Study 2 were confirmatory in nature as they reflected the findings of Study 1. For example terms such as ‘formulary’ and ‘policy’ were misinterpreted by respondents. Rasch modelling and analysis showed that there were items within ASAT v17 which were underfitting and overfitting the Partial Credit Model. Item fit was investigated after removal of these items which resulted in improved fit for domains 2 and 5. ASAT v18 was developed after these analyses and was included items that were productive for measurement. On examination of the OLS regression analyses conducted in Study 4, it was seen that there was poor model fit and very limited predictive validity of the model. Conclusion: The iterative methodology utilised to investigate the validity and subsequently improve the ASAT was effective in establishing content and construct validity. However, the predictive validity of the ASAT was limited. This may be due to the outcome variable chosen for the OLS regression modelling. A more sensitive outcome measure such as compliance to treatment or prophylaxis guidelines may have been more effective at establishing predictive validity. The findings of this programme of work highlighted that there is further work required to validate the ASAT such as the determination of the appropriate weights and scores for ASAT domains and also the determination of the appropriate outcomes measures to determine the efficacy of ASPs. It is recommended that further validity testing should be conducted before a further iteration of the ASAT is used as a set of quality standards or as a hospital benchmarking tool

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Staying current on literature related to antimicrobial stewardship can be challenging given the ever-increasing number of published articles. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship–related peer-reviewed literature that detailed an actionable intervention for 2019. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the actionable intervention used by antimicrobial stewardship programs to provide key stewardship literature for teaching and training and to identify potential intervention opportunities within one’s institution.

With an increasing number of antimicrobial stewardship-related articles published each year, attempting to stay current is challenging. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship-related peer-reviewed literature that detailed an "actionable" intervention for 2017. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the "actionable" intervention used by antimicrobial stewardship programs to provide key stewardship literature for training and teaching and identify potential intervention opportunities within their institutions.