We evaluated how antibiotic use changed after implementation of a multifaceted intervention that sent providers individualized peer-comparison feedback on their antibiotic use for respiratory conditions that do not warrant antibiotics (never-events).

An interrupted time-series analysis was performed with a baseline (January 2018–January 2020) and intervention period (November 2021–December 2023), while controlling for COVID-19 era (February 2020–February 2022).

Walk-in ambulatory clinics.

Providers caring for patients in walk-in clinics.

We conducted a mixed-methods study across 7 walk-in clinics in one health system. We included data from visits from 2018–2023 and conducted 17 semi-structured interviews with 10 providers.

After intervention implementation, antibiotic use for all visits decreased 8% (RR 0.92, 95% CI 0.86–0.97), then began to increase by 1% per month (RR 1.01, 95% CI 1.00–1.01). Once the intervention started, the use of never-event diagnostic codes decreased by 24% (RR 0.69–0.83) and continued to decrease by 1% per month (RR 0.99, 95% CI 0.98–0.99). Antibiotic use for never-event visits showed no immediate change after the intervention started (RR 0.80, 95% CI 0.61–1.04), then decreased by 3% per month (RR 0.97, 95% CI 0.96–0.98). Some providers valued receiving feedback on the metric; others admitted to shifting their codes.

Delivering feedback to walk-in clinic providers was associated with temporary reductions in antibiotic-prescribing across all visits but also changes in diagnostic coding (ie, “gaming”). Antibiotic stewardship programs should monitor for changes in both when implementing new outpatient metrics.

The current study was done to evaluate the impact of a plan-do-check-act (PDCA)-based AMS program implemented at a tertiary trauma center.

Inpatients admitted to an Advanced Trauma Centre of a tertiary care hospital in North India.

This implementation research study was conducted in four phases from March 2019 to November 2024. The AMS strategies included prospective audits, feedback mechanisms, education, and multidisciplinary collaboration. Descriptive statistics were used for antibiotic prescription practices, adherence to guidelines, and patient outcomes. Metrics for antibiotics utilization and appropriateness of prescription were the key performance indicators analyzed.

A total of 767 patients were enrolled during this period. The practice of antibiotic prescription changed from being prophylactic to culture-based—increasing from 0.7% in phase 1 to 21.4% in phase 4. Compliance to feedback increased from 75.8% in phase 3 to 90.7% in phase 4. There was a fall in aggregate defined daily dose to 658.4, from 808.2 per 1000 patient days, and length of therapy also improved. There was a marked increase in the number of culture-based interventions. The educational programs and multidisciplinary team rounds further reinforced the practice of AMS.

The PDCA cycle significantly improved the use of antimicrobials, adherence to treatment guidelines, and patient outcomes in a resource-constrained setting. This approach provides a scalable model for implementing AMS in surgical units despite challenges such as limited microbiological resources.

Although antimicrobial consumption data are routinely collected, linking these data to the actual antimicrobial stewardship program (ASP) remains challenging. The objective of the present study is to explore association between temporal trends in three categories of antimicrobial consumption and actually implemented of ASPs, in acute care hospitals through structured interviews.

Multicenter retrospective study with structured interviews.

Japanese hospitals.

Temporal trends in three antimicrobial consumption data including days of therapy (DOT) per 1,000 patient-days (PD), days of antibiotic spectrum coverage (DASC) per 1,000 PD, and DASC/DOT were collected from 10 hospitals between 2016 and 2024. Structured interviews to identify current ASP progression and challenges related to ASP promotion were conducted.

Ten hospitals participated in the study. Although all participating hospitals had implemented ASPs, most had introduced one or two core ASP interventions. The most commonly implemented ASP was post-prescription review and feedback for broad-spectrum antimicrobials. Despite the presence of ASPs, 50% of hospitals (5/10) demonstrated unfavorable changes in trends across all three metrics, characterized by increasing DASC, DOT, and DASC/DOT. Structured interviews identified various barriers to advancing ASP, including clinical pharmacist shortages, suboptimal infrastructure, limited financial or political support and insufficient knowledge and clinical experience related to ASP activities.

The presence of ASPs in Japan did not consistently lead to changes in antimicrobial prescribing practices, as reflected in antimicrobial consumption metrics. Integrating longitudinal antimicrobial consumption data with structured qualitative assessments provides a more comprehensive understanding of ASP progression and promotion at the institutional level.

Antimicrobial resistance (AMR) and healthcare-associated infections pose serious public health threats, particularly in Africa with limited health resources. Weak infection prevention and control (IPC) implementation worsens these challenges. To address this, Africa Centre for Disease Control (CDC) developed the IPC legal framework. This study compares Kenya, Nigeria, and Tanzania’s IPC guidelines with the framework and evaluates their alignment.

This policy analysis compares the IPC guidelines of three countries and assesses their alignment against the attributes of the Africa CDC Legal IPC Framework. Scores were assigned based on the level of alignment with the attributes, aggregated into percentages, and compared across countries. This study was developed under the 2023–24 cohort 3, of Ducit Blue Foundation’s pioneering and award-winning AMR One Health Pan-African Internship/Mentorship Program.

Facility-level IPC budgeting was included in Nigeria and Tanzania’s guidelines but absent in Kenya. Training responsibilities differed, with Kenya and Tanzania authorizing national and regional bodies, while Nigeria assigned this solely to facility IPC teams. Overall alignment of the IPC guidelines with the Africa CDC Legal Framework was 69%. Tanzania had 76% alignment, while Kenya and Nigeria recorded 65% each. There were no significant variations in alignment between countries with the benchmark framework (X2 = 3.75, p-value = .153).

This study represents the first attempt at a detailed policy analysis of IPC guidelines across Africa against a backdrop of the relevant regional instruments. The countries show good IPC alignment with the benchmark instrument, reflecting both regional commitment and local adaptation.

Long-term oral antibiotic regimens are increasingly prescribed in place of outpatient parenteral antimicrobial therapy(OPAT). Many of these oral agents are used at higher doses and for longer durations than studied previously. The aim of this study was to describe the rates of adverse drug events (ADEs) among patients discharged on long-term oral antibiotic regimens at our center.

This is a retrospective cohort study of adult patients discharged between January 1, 2021, and December 31, 2022, on oral antibiotic regimens of at least two weeks planned duration under the direction of an Infectious Diseases (ID) physician. The primary outcome was the occurrence of an ADE while on antibiotics up to ninety days after discharge.

Of 174 patients included, 46 (26%) experienced at least one ADE. Gastrointestinal ADE were most common, and were most frequently associated with linezolid (11.3 ADE/1,000 COpAT-days), rifampin (8.0 ADE/1,000 COpAT-days), and fluoroquinolones (5.4 ADE/1,000 COpAT-days). Other ADE included hyperkalemia and nephrotoxicity from trimethoprim-sulfamethoxazole (3.9 and 6.2 ADE/1,000 COpAT-days respectively), and bone marrow suppression from linezolid (7.5 ADE/1,000 COpAT-days). Linezolid (22.6 ADE/1,000 COpAT-days, 95% CI [9.81–35.39]) and trimethoprim-sulfamethoxazole (14.61 ADE/1,000 COpAT-days, [9.00–20.23]) were associated with the highest rates of ADE, while amoxicillin-clavulanate (3.28 ADE/1,000 COpAT-days, [0.66–5.91]), tetracyclines (3.28 ADE/1,000 COpAT-days, [0.07–6.50]), and amoxicillin (5.80 ADE/1,000 COpAT-days, [0.00–12.37]) had the lowest.

Most patients tolerated oral therapy well with gastrointestinal adverse events being the most common ADE. Linezolid and trimethoprim-sulfamethoxazole were associated with the highest rates of adverse events.

Community-acquired intra-abdominal infections (CA-IAIs) are a leading cause of US hospitalizations. Piperacillin-tazobactam is often used to empirically treat CA-IAIs, despite national guidelines recommending narrower-spectrum antibiotics for these infections. The overuse of broad-spectrum agents such as piperacillin-tazobactam contributes to antibiotic resistance, which poses serious public health challenges. This resident-led quality improvement initiative aimed to reduce unnecessary piperacillin-tazobactam use for treating CA-IAIs measured as DOT/1,000 patient-days by 10% without adversely affecting hospital length of stay (LOS).

Using the DMAIC (define, measure, analyze, improve, control) framework, we identified barriers to appropriate antibiotic use and developed a treatment algorithm for CA-IAIs that included clear guidelines and exclusion criteria. This algorithm was disseminated to internal medicine residents and emergency department physicians along with educational sessions to highlight updated CA-IAI treatment recommendations, antibiotic resistance, and appropriate antibiotic ordering via the electronic health record. Antimicrobial stewardship pharmacists provided overnight support to assist with de-escalation. Data were collected over a 10-month period spanning 2 intervention phases. The primary outcome was piperacillin-tazobactam use, measured as days of therapy (DOT) per 1,000 patient-days and DOT per patient LOS. Mean LOS served as the balancing measure.

Piperacillin-tazobactam use was significantly reduced (P < .001) after the interventions without increasing the mean LOS.

This project raised awareness of antibiotic resistance and led to lasting improvements in reducing the inappropriate use of piperacillin-tazobactam to treat CA-IAIs, without affecting the mean LOS. This was attributed to the strong collaboration among a multidisciplinary team of infectious disease physicians, antimicrobial stewardship team members, residents, emergency department physicians, and faculty.

People with substance use disorder (SUD) make up an increasing proportion of patients hospitalized for infections that require outpatient parenteral antimicrobial therapy (OPAT). In many settings, patients with SUD may be unable to receive home-based OPAT, and so stay in the hospital or get discharged to skilled nursing facilities (SNF) for ongoing treatment. Our objective was to compare outcomes, especially engagement in SUD treatment, among patients with SUD who received OPAT in SNF versus other settings.

Retrospective cohort study.

Two academic medical centers.

Patients with a history of SUD and discharged on OPAT.

We used a multivariate logistic regression to determine predictors of outcomes among patients discharged to SNF versus other locations.

Among 350 patients with SUD discharged on OPAT, 285 (81.4%) were discharged to SNF. Hospital readmissions, emergency department visits, infection relapse, catheter complications, and adverse drug events related to OPAT were similar in the two groups. Median length of stay was longer in patients discharged to SNF (16 d vs 12 d, P = .001). Being discharged to a SNF was associated with a lower likelihood of engaging in SUD treatment at 30 days postdischarge (adjusted odds ratio: 0.48, 95% confidence interval: 0.26–0.87).

Patients with SUD requiring OPAT discharged to SNF may have decreased engagement in SUD treatment.

Point-of-care testing (POC) is an important tool for diagnosing SARS-CoV-2. This objective of this study was to evaluate the real-world performance of rapid molecular (rPCR) and rapid antigen (rAg) methods and their impact on antibiotic prescribing.

We retrospectively analyzed adult patients tested for SARS-CoV-2 at outpatient clinics within an integrated health network from December 2021 to March 2023 to determine antibiotic use in settings where POC testing for SARS-CoV-2 were deployed. Patients were included if their initial test was with rPCR or rAg. We conducted a 3:1 propensity score matching analysis to compare rPCR and rAg testing outcomes. Univariate and multivariate logistic regression analyses were used to identify predictors of antibiotic use within 24 hours of a positive test.

Of 104,364 patients that underwent testing with a rapid test in the ambulatory setting, 24,133 (29.0%) tested positive for SARS-CoV-2. Molecular testing had the highest percent positive compared to antigen testing (26.2% vs 20.8%). Overall, antibiotics were prescribed to 10% of positive cases, with higher rates following rAg testing (13% vs 10%, P < .001). Chronic lung disease (OR: 1.4 [1.2–1.7], P < .001) and white non-Hispanic race (OR: 1.5 [1.1–2.1], P = .014) were associated with an increased odds of receiving antibiotics while a rPCR test (OR: 0.8 [0.7–1.0], P = .03) was associated with a significantly decreased odds or receiving antibiotics.

POC molecular testing outperformed antigen testing in SARS-CoV-2 detection and was associated with lower antibiotic prescribing, supporting its role in antimicrobial stewardship.

Developing, implementing, and evaluating the effectiveness of outpatient pediatric antimicrobial stewardship interventions via tele-stewardship

Baseline data collected between January and December 2022. Intervention data collected from February 2023 to December 2024. Interrupted time series with regression discontinuity analysis used to compare rates of antibiotic prescription between the periods.

Three pediatric primary care clinics and three emergency departments associated with Vanderbilt University Medical Center that served rural and suburban communities.

All encounters with patients less than 18 years of age at participating sites.

Intervention bundle included patient/caregiver educational materials, antibiotic use commitment posters, prescriber education through quarterly teaching sessions on common pediatric infections, communication skills training, app-based microlearning modules, access to local guidelines using the Firstline app, and quarterly audit and feedback with peer comparison on guideline-concordant antibiotic use.

Among a total of 147,357 encounters (43,157 baseline, 100,200 intervention), overall percent of encounters with one or more antibiotics prescribed decreased from 12.4% to 11.9% (P = .01). Percent change varied by site and patient demographics. Overall guideline-concordant prescribing increased significantly for acute otitis media (77.7% baseline vs 85.7% intervention, P < .001), streptococcal pharyngitis (73.8% baseline vs 81.7% intervention, P < .001), and urinary tract infections (41.9% baseline vs 57.1% intervention P < .001). Five-day antibiotic courses increased significantly (6.3% baseline vs 19.7% intervention, P < .001). There was a significant decrease in rapid streptococcal testing (10.9% baseline vs 7.6% intervention, P < .001).

Tele-stewardship interventions were effective in outpatient pediatric primary care and emergency department settings, but effectiveness varied by site.

The impact of organism species and underlying comorbidities on long-term clinical outcomes for patients with carbapenem-resistant Enterobacterales (CRE) infections is unknown.

Patients with CRE-positive cultures from 2011 to 2019 were monitored for 1-year. Patients without signs of infection were categorized as colonization. Recurrent cases were defined as isolation of the same CRE species >90 days after the index case.

720 patients met inclusion criteria and accounted for 749 index cases, which decreased over time. The median (range) age was 61 (20–97) years, 53% (397/749) were male, 20% (151/749) received solid organ transplant (SOT), and 44% resided in the ICU at the time of CRE isolation. The colonization rate was 34% (257/749). Pneumonia and bacteremia represented the most common infection types accounting for 25% (185/749) and 13% (95/749) of all cases, respectively. Klebsiella pneumoniae was most common pathogen (58%), followed by Enterobacter cloacae complex (23%), and Escherichia coli (10%). Of the 554 sequenced isolates, 35% (195/554) were KPC-2, 32% (175/554) KPC-3, and 32% (177/554) non-KPC-producing. This changed over time where KPC-2-producing CRE were most prevalent in 2011, KPC-3 most prevalent between 2015–2017, and non-KPC from 2018–2019. Among 90-day survivors, the CRE recurrence rate was 21% (108/513). Charlson comorbidity index (OR: 1.11; 95% CI: 1.05–1.18; P < .001), isolation of a prior CR pathogen (OR: 2.49; 95% CI 1.32–4.72; P = .005), and ICU admission (OR: 3.35; 95% CI 2.14–5.24; P < .001) were independently associated with 90-day mortality, while SOT was associated with lower 90-day mortality (OR: 0.55; 95% CI 0.32–0.94; P = .029). Overall, 90-day mortality rates were lower among patients with CRE-positive cultures between years 2016 – 2019 (24% [63/262]) compared to years 2011 – 2015 (35.5% [173/487]; P = .001).

CRE are increasingly diverse and associated with significant morbidity and healthcare utilization across varying patient groups. Long-term survival of patients infected with CRE has improved over time while overall incidence of CRE has decreased.

Inappropriate antibiotic prescribing contributes to antibiotic resistance threats. In outpatient settings, antibiotics are often incorrectly prescribed for acute respiratory illnesses (ARI). Characteristics associated with inappropriate antibiotic prescribing at New York City (NYC) outpatient ARI visits were assessed to identify opportunities for interventions.

Using IQVIA’s commercial Medical Claims and Longitudinal Prescription datasets, medical diagnosis codes identified outpatient visits for ARI during 2019–2022, which were linked to antibiotics obtained at a pharmacy (as a proxy for prescribed antibiotics) within 3 days post-visit. Univariate analyses were conducted describing visit, patient, and provider characteristics. Modified Poisson regression with robust error variance was used to calculate unadjusted relative risks (RR) and 95% CI for visit-level characteristics associated with inappropriate prescribing.

Among 3,493,444 ARI outpatient visits, 5.1% linked to an inappropriate antibiotic prescription. Among all ARI, bronchitis/bronchiolitis had the highest percentage (25.5% of bronchitis/bronchiolitis visits) and highest risk of inappropriate prescribing relative to asthma/allergy (RR: 18.03; 95% CI: 17.70, 18.38). Adults aged 65–79 years were over twice as likely to be prescribed inappropriate antibiotics relative to children (RR: 2.21; 95% CI: 2.17, 2.25). Inappropriate prescribing was highest in urgent care (8.4%) (RR: 1.25; 95% CI: 1.23, 1.27) relative to offices and among internal medicine physicians (8.0%); relative to these physicians, risk of inappropriate prescribing among all other physician specialties was lower.

Inappropriate antibiotic prescribing at ARI outpatient visits was uncommon. Tailoring interventions to providers such as internal medicine physicians or those in urgent care settings may improve prescribing practices.