How do hospital respiratory clinicians perceive antimicrobial stewardship?

Broom, J. et al. Journal of Hospital Infection | Published online: 5 May 2017

Background: Suboptimal antibiotic use in respiratory infections is widespread both in hospital medicine and primary care. Antimicrobial stewardship (AMS) teams within hospitals, commonly led by infectious diseases physicians, are frequently charged with optimising respiratory antibiotic use, but there is limited information on what drives antibiotic use in this area of clinical medicine, or on how AMS is perceived.

Aim: This study explores the perceptions of hospital respiratory clinicians on AMS in respiratory medicine.

Conclusions: AMS processes are introduced in hospitals with established social structures and knowledge bases. AMS in respiratory medicine is reported by these clinicians to challenge and conflict with many of these dynamics. If the influence of these dynamics is not considered, AMS processes may not be effective in containing antibiotic use in hospital respiratory medicine.

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Toolkit Offers Framework to Assess, Review and Improve Antibiotic Stewardship

The AAAHC Institute for Quality Improvement has released a new toolkit to enhance antibiotic stewardship programs | Infection Control Today

The AAAHC Institute designed the Antibiotic Stewardship Toolkit to aid ambulatory health facilities in promoting appropriate antibiotic selection while reducing overuse through an overview of illnesses for which inappropriate antibiotic prescriptions are written.

The Centers for Disease Control and Prevention (CDC) define antibiotic stewardship activities as efforts to improve and measure antibiotic prescribing by minimizing inappropriate antibiotic prescribing and overuse, as well as ensuring the right drug, dose and duration are selected when antibiotics are needed.

Providers in ambulatory health care settings use the AAAHC Institute Antibiotic Stewardship Toolkit checklist as both a baseline assessment of policies and practices, and a resource for reviewing and expanding activities on a regular basis.

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Supporting better decision making for acute infection management in secondary care



The inappropriate use of antimicrobials drives antimicrobial resistance. We conducted a study to map physician decision-making processes for acute infection management in secondary care to identify potential targets for quality improvement interventions.


Physicians newly qualified to consultant level participated in semi-structured interviews. Interviews were audio recorded and transcribed verbatim for analysis using NVIVO11.0 software. Grounded theory methodology was applied. Analytical categories were created using constant comparison approach to the data and participants were recruited to the study until thematic saturation was reached.


Twenty physicians were interviewed. The decision pathway for the management of acute infections follows a Bayesian-like step-wise approach, with information processed and systematically added to prior assumptions to guide management. The main emerging themes identified as determinants of the decision-making of individual physicians were (1) perceptions of providing ‘optimal’ care for the patient with infection by providing rapid and often intravenous therapy; (2) perceptions that stopping/de-escalating therapy was a senior doctor decision with junior trainees not expected to contribute; and (3) expectation of interactions with local guidelines and microbiology service advice. Feedback on review of junior doctor prescribing decisions was often lacking, causing frustration and confusion on appropriate practice within this cohort.


Interventions to improve infection management must incorporate mechanisms to promote distribution of responsibility for decisions made. The disparity between expectations of prescribers to start but not review/stop therapy must be urgently addressed with mechanisms to improve communication and feedback to junior prescribers to facilitate their continued development as prudent antimicrobial prescribers.

Full reference: Timothy Miles Rawson, T. M. et al: Mapping the decision pathways of acute infection management in secondary care among UK medical physicians: a qualitative study BMC Medicine 2016 14:208

The burden of healthcare associated Clostridium difficile infection in a non-metropolitan setting

Bond, S.E. et al. The Journal of Hospital Infections. Published online: December 18 2016

Objective: Healthcare-associated Clostridium difficile infection (HCA-CDI) remains a major cause of morbidity and mortality in industrialised countries. However, few data exist on the burden of HCA-CDI in multisite non-metropolitan settings. This study examined the introduction of an antimicrobial stewardship program (ASP) in relation to HCA-CDI rates and the effect of HCA-CDI on length of stay (LOS) and hospital costs.


Conclusions: HCA-CDI placed a significant burden on our regional and rural health service through increased LOS and hospital costs. Interventions targeting HCA-CDI could be employed to consolidate the effects of ASPs.

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Post-prescription antibiotic review based on computerized tools

Bouchand, F. et al. The Journal of Hospital Infection. Published online: November 25 2016



Background: Controlling antibiotic use in healthcare establishments limits their consumption and the emergence of bacterial resistance.

Aim: We evaluated the efficiency of an innovative antibiotic-stewardship strategy implemented over 3 years in a university hospital.


Conclusion: This computerized, shared-access, antibiotic-stewardship strategy seems to be time-saving and effectively limited misuse of broad-spectrum antibiotics.

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Social media as a tool for antimicrobial stewardship

Pisano, J. et al (2016) American Journal of Infection Control44(11) pp. 1231–1236


  • Medical trainees can be engaged through the use of social media.
  • Social media can be used to increase awareness and use of educational tools.
  • Clinical pathway use increased through increased awareness and periodic reminders.
  • Antibiotic knowledge increased as a result of following our program on social media.


mobile-phone-1704781_960_720Background: To increase the reach of our antimicrobial stewardship program (ASP), social media platforms, Facebook and Twitter, were used to increase internal medicine residents’ (IMRs’) antibiotic (Abx) knowledge and awareness of ASP resources.

Methods: Fifty-five of 110 (50%) IMRs consented to participate; 39 (71%) completed both pre- and postintervention surveys and followed our ASP on social media. Along with 20 basic Abx and infectious diseases (IDs) questions, this survey assessed IMR awareness of ASP initiatives, social media usage, and attitudes and beliefs surrounding Abx resistance. Over 6 months, IMRs received posts and Tweets of basic Abx/IDs trivia while promoting use of educational tools and clinical pathways on our ASP Web site. To compare pre- and postsurvey responses, McNemar test or Stuart-Maxwell test was used for categorical variables, and paired t test or Wilcoxon signed-rank test was used for continuous variables, as appropriate.

Results: Of the IMRs, 98% and 58% use Facebook and Twitter, respectively. To compare pre- and postintervention, median scores for Abx knowledge increased from 12 (interquartile range, 8-13) to 13 (interquartile range, 11-15; P = .048); IMRs knowing how to access the ASP Web site increased from 70% to 94%. More IMRs indicated that they used the clinical pathways “sometimes, frequently, or always” after the intervention (33% vs 61%, P = .004).

Conclusions: Social media is a valuable tool to reinforce ASP initiatives while encouraging the use of ASP resources to promote antimicrobial mindfulness.

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Association Between High-Risk Medication Usage and Healthcare Facility-Onset C. difficile Infection

Patterson, J.A. Infection Control & Hospital Epidemiology.Published online: 21 April 2016

Image shows transmission electron micrograph of Clostridium difficile

Objective: National hospital performance measures for C. difficile infection (CD) are available; comparing antibacterial use among performance levels can aid in identifying effective antimicrobial stewardship strategies to reduce CDI rates.

Design: Hospital-level, cross-sectional analysis.

Methods:Hospital characteristics (ie, demographics, medications, patient mix) were obtained for 77 hospitals for 2013. Hospitals were assigned 1 of 3 levels of a CDI standardized infection ratio (SIR): ‘Worse than,’ ‘Better than,’ or ‘No different than’ a national benchmark. Analyses compared medication use (total and broad-spectrum antibacterials) for 3 metrics: days of therapy per 1,000 patient days; length of therapy; and proportion of patients receiving a medication across SIR levels. A multivariate, ordered-probit regression identified characteristics associated with SIR categories.

Results: Regarding total average antimicrobial use per patient, there was a significant difference detected in mean length of therapy: ‘No different’ hospitals having the longest (4.93 days) versus ‘Worse’ (4.78 days) and ‘Better’ (4.43 days) (P<.01). ‘Better’ hospitals used fewer total antibacterials (693 days of therapy per 1,000 patient days) versus ‘No different’ (776 days) versus ‘Worse’ (777 days) (P<.05). The ‘Better’ hospitals used broad-spectrum antibacterials for a shorter average length of therapy (4.03 days) versus ‘No different’ (4.51 days) versus ‘Worse’ (4.38 days) (P<.05). ‘Better’ hospitals used fewer broad-spectrum antibacterials (310 days of therapy per 1,000 patient days) versus ‘No different’ (364 days) versus ‘Worse’ (349 days) (P<.05). Multivariate analysis revealed that the proportion of elderly patients and chemotherapy days of therapy per 1,000 patient days was significantly negatively associated with the SIR.

Conclusions: These findings have potential implications regarding the need to fully account for hospital patient mix when carrying out inter-hospital comparisons of CDI rates.

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