Kavita K. Trivedi

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

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.

Executive Summary: Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

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.

The State of Antimicrobial Stewardship Programs in California

OBJECTIVE To assess antimicrobial stewardship programs (ASPs) and strategies in California general acute care hospitals and to describe the effect of state legislation (Senate Bill 739) requiring hospitals to develop processes for evaluating the judicious use of antimicrobials. DESIGN Web-based survey of general acute care hospitals. PARTICIPANTS All 422 general acute care hospital campuses in California were invited to participate. RESULTS Responses from 223 (53%) of Californias general acute care hospital campuses were included and were statistically representative of all acute care hospital campuses by region but not bed size or rurality. Community hospitals represented 73% of respondents. Fifty percent of hospitals described a current ASP and 30% reported planning an ASP; of these, 51% reported measuring outcomes. Twenty percent of hospitals reported no planned ASP or uncertainty whether an ASP existed and described barriers including staffing constraints (47%), lack of funding (42%), and lack of initiation of a formal proposal to start an ASP (42%). Of 135 responding hospitals, 22% reported that Senate Bill 739 influenced initiation of their ASP. CONCLUSIONS Although many studies have been published that describe hospital-specific ASPs, most have been described within academic centers, and there are limited assessments of ASP strategies across hospital systems. Our study verifies that many ASPs exist in California, particularly in community settings where a scarcity of antimicrobial restriction was thought to exist. Additionally, Senate Bill 739 appears to have played a role in initiating many hospital ASPs, which supports the adoption of similar legislation in other states and nationally.

Antimicrobial Stewardship: A Collaborative Partnership between Infection Preventionists and Healthcare Epidemiologists

Misuse and overuse of antimicrobials, primarily involving therapeutic agents used to treat infection in humans, is considered one of the worlds most pressing public health problems. Not only does such inappropriate use diminish the therapeutic benefit of essential medications, it also facilitates the development and spread of multidrug-resistant organisms (MDROs). Antimicrobial resistance and the rise in MDROs globally are associated with increased morbidity and mortality, cross-transmission within and between healthcare settings, and increased consumption of limited patient-care resources. Despite elevated awareness, publication of guidelines on antimicrobial stewardship, and several initiatives, the proportion of resistant strains causing both health care- and community-associated infections continues to increase and the number of new antimicrobials continues to decline.

Antimicrobial stewardship: A collaborative partnership between infection preventionists and health care epidemiologists

It is clear that the widespread and injudicious use of antimicrobials has greatly increased the presence of MDROs that threaten the health of all. There is worldwide acknowledgement that this threat is growing, and that prudent use of antimicrobials combined with infection prevention can prevent harm and improve patient safety. Antimicrobial stewardship programs must harness the talents of all members of the health care team to effectively identify the organism, determine its susceptibility, institute any precautions required, and prescribe the narrowest-acting antibiotic that will destroy it. IPs/HEs play a pivotal role in this approach, by assisting with early organism and infected patient identification, by promoting compliance with standard and transmission-based precautions and other infection prevention strategies such as care bundle practices, hand hygiene, and by educating staff, patients, and visitors.

Identifying Best Practices Across Three Countries: Hospital Antimicrobial Stewardship in the United Kingdom, France, and the United States

Rational antimicrobial use can be achieved through antimicrobial stewardship--a coordinated set of strategies designed to improve the appropriate use of antimicrobial agents. There are encouraging examples of antimicrobial stewardship programs from different parts of the world; however, the structure of these programs varies by hospital and country. In an effort to identify best practices in hospitals, we describe legislative requirements, antimicrobial stewardship program infrastructure, strategies and outcomes in 3 countries that have established programs--the United Kingdom, France, and the United States.

Multidrug-resistant Acinetobacter baumannii infection, colonization, and transmission related to a long-term care facility providing subacute care.

OBJECTIVE To investigate Acinetobacter baumannii infection, colonization, and transmission related to a long-term care facility (LTCF) providing subacute care (facility A). METHODS We reviewed facility A and affiliated local hospital records for facility A residents with A. baumannii isolated during the period January 2009 through February 2010 and compared A. baumannii antimicrobial resistance patterns of residents with those of hospital patients. During March 2010, we implemented a colonization survey of facility A residents who received respiratory support or who could provide sputum samples and looked for A. baumannii colonization risks. Available clinical and survey isolates underwent pulsed-field gel electrophoresis (PFGE); PFGE strains were linked with overlapping stays to identify possible transmission. RESULTS During the period January 2009 through February 2010, 33 facility A residents had A. baumannii isolates; all strains were multidrug resistant (MDR), which was a significantly higher prevalence of MDR strains than that found among isolates from hospital patients (81 [66%] of 122 hospital patient isolates were MDR; P < .001). The sputum survey found that 14 (20%) of 70 residents had A. baumannii colonization, which was associated with ventilator use (adjusted odds ratio, 4.24 [95% confidence interval, 1.06-16.93]); 12 (86%) of 14 isolates were MDR. Four facility A resident groups clustered with 3 PFGE strains and overlapping stays. One of these facility A residents also clustered with 3 patients at an affiliated hospital. CONCLUSIONS We documented substantial MDR A. baumannii infections and colonization with probable intra- and interfacility spread associated with a single LTCF providing subacute care. Given the limited infection prevention and antimicrobial stewardship resources in such settings, regional collaborations among facilities across the spectrum of health care are needed to address this MDR threat.

The Role of Public Health in Antimicrobial Stewardship in Healthcare

Education, surveillance, and promotion of antimicrobial stewardship align with the goals of public health to prevent disease, promote health, and prolong life. Many US federal and state public health organizations are already engaged in antimicrobial stewardship activities. Healthcare providers are encouraged to work with public health officials on appropriate local antimicrobial stewardship strategies to attain the common goal of reducing antimicrobial resistance and preserving antimicrobials for future generations.

The Legislative Momentum of Antimicrobial Stewardship: the US Perspective

Opinion statementThe aim of this review is to describe new and evolving legislation concerning antimicrobial stewardship at both the state and national level.Antimicrobial resistance is a challenge to health worldwide. Recently, the US federal government has issued reports recognizing it as a serious threat to public health and national security acknowledging the need for judicious antimicrobial use. California has been a pioneer in mandating and implementing antimicrobial stewardship initiatives in healthcare institutions. With the White House Executive Order 13676, a number of healthcare organizations have committed to making antimicrobial stewardship policy and regulatory changes, and it will likely soon be mandatory for all states to comply with a newly created set of standards relating to antimicrobial stewardship in US hospitals and nursing homes.With numerous changes, including governmental and organizational mandates, on the horizon, it is crucial for healthcare institutions to understand and be prepared for this new era in antimicrobial stewardship. The adoption of these new standards by institutions is of an imminent nature. Key Points:• United States federal agencies and the executive branch have recently issued reports characterizing antimicrobial resistance as threats to public health and national security.• The state of California has implemented regulations requiring the establishment of antimicrobial stewardship programs (ASPs) in all acute-care hospitals and long-term care facilities.• A goal of the National Action Plan for Combating Antimicrobial Resistance is establishment of ASPs in acute care hospitals.• Veterans Affairs and Department of Defense facilities have already adopted the ASP requirement; for non-federal hospitals, this mandate will likely be achieved through regulators such as the Centers for Medicaid and Medicare Services.

Outbreak Response and Incident Management: SHEA Guidance and Resources for Healthcare Epidemiologists in United States Acute-Care Hospitals

David B. Banach, MD, MPH, MS; B. Lynn Johnston, MD, MS, FRCPC; Duha Al-Zubeidi, MD; Allison H. Bartlett, MD, MS; Susan Casey Bleasdale, MD; Valerie M. Deloney, MBA; Kyle B. Enfield, MD, MS; Judith A. Guzman-Cottrill, DO; Christopher Lowe, MD, MSc; Luis Ostrosky-Zeichner, MD; Kyle J. Popovich, MD, MS; Payal K. Patel, MD; Karen Ravin, MD, MS; Theresa Rowe, DO, MS; Erica S. Shenoy, MD, PhD; Roger Stienecker, MD; Pritish K. Tosh, MD; Kavita K. Trivedi, MD; and the Outbreak Response Training Program (ORTP) Advisory Panel