To assess the impact of a pharmacist-led anti-methicillin-resistant Staphylococcus aureus (MRSA) agents’ time-out and identify clinical areas most likely to benefit.

Single-center before–after interrupted time-series study.

An 813-bed tertiary hospital in Tokyo, Japan.

Inpatients receiving intravenous anti-MRSA agents.

Stewardship pharmacists alerted physicians to reassess intravenous anti-MRSA therapy at 72 hours after its start. Monthly days of therapy per 1,000 patient-days (DOT) were compared between October 2017 to September 2022 and October 2022 to September 2024 after stratification by ward and department. Acceptance rate and therapeutic drug monitoring (TDM) tests were also assessed.

Hospital-wide DOT showed an immediate non-significant decrease (−19.23; 95% confidence interval [CI] −59.17 to 20.72; P = .35) and no significant trend change (+0.82; 95% CI −1.18 to 2.82; P = .42). In emergency medicine, DOT decreased in critical care (slope change −20.3; 95% CI −36.25 to −4.28; P = .01) and general wards (−31.6; 95% CI −61.4 to −1.79; P = .04). In emergency medicine critical care, vancomycin use decreased (level change −406.1; 95% CI −801.3 to −10.9; P = .04) with a reduced trend (slope change −24.5; 95% CI −41.2 to −7.8; P < .001). Acceptance was higher in critical care than in general wards (77.1% [27/35] vs 33.6% [40/119]). TDM tests per 1,000 patient-days decreased (8.47 ± 2.39 to 6.55 ± 1.18; P < .001), with no increase in length of stay or in-hospital mortality.

Targeting an implementation to areas most likely to benefit from it may improve antimicrobial stewardship when resources are limited. Complementary strategies may be needed if acceptance is poor.

Inappropriate antibiotic allergy labeling often leads to the unnecessary avoidance of first-line therapies. The present study aimed to evaluate the current status of antibiotic allergy documentation and its assessment in patients undergoing surgery for which cefazolin was the recommended first-line prophylaxis in a Japanese hospital.

This retrospective observational study was conducted at a university hospital in Tokyo from 2021 to 2023; included patients with a history of antimicrobial allergy who underwent surgery for which cefazolin was recommended; and assessed patient demographics, details of the allergies in electronic health records (EHR), and perioperatively administered antimicrobial agents.

Of 2,402 eligible patients, 243 (10.1%) had a registered antimicrobial allergy. The drug classes most frequently recorded in the EHR were cephalosporins (25.0%) and penicillins (24.0%). Documentation of allergy assessments by a physician (9.0%) or specialist (7.0%) was rare. Although 51.9% of the labeled patients had received cefazolin, non-first-line agents had also been frequently administered. Notably, clindamycin had been administered to 30% of the cases and had been widely used even among patients with only a penicillin allergy label despite the low risk of cross-reactivity.

Antibiotic allergy labels in the EHR were often incomplete, infrequently assessed, and associated with substantial avoidance of first-line prophylaxis. Redesigning the EHR format to allow allergies to be distinguished from adverse events while retaining the standard evaluation pathways is essential to optimizing perioperative antimicrobial stewardship.

Multiplex gastrointestinal polymerase chain reaction (GI-PCR) tests of the stool for the evaluation of infectious diarrhea are prone to false-positive target detections. However, there is no recommended testing approach in immunocompromised cancer patients who are often excluded from diagnostic stewardship protocols. The aim of this study was to evaluate the performance characteristics of the BioFire® FilmArray® GI-PCR and assess whether the findings support a diagnostic stewardship approach to limit testing among hospitalized cancer patients.

A retrospective study of 29,727 GI-PCR tests was performed at Memorial Sloan Kettering Cancer Center in New York City, evaluating data from February 1, 2020, to January 29, 2025. All tests sent from all locations and across all patient types were included in the study.

The overall GI-PCR positivity rate was greatest in the outpatient setting at 23.4% and dropped at 15.6% in the early stage of admission (hospital days 0–2) and 10.1% in the late stage of admission (hospital day 3 and beyond). Across all subgroups analyzed, norovirus and Enteropathogenic E. coli (EPEC) were the most frequently detected targets with all remaining targets detected at rates below 2%. The low pathogen detection rate was preserved among patients with neutropenia and recipients of recent cellular therapy.

BioFire FilmArray GI panel has low utility in the inpatient setting including for severely immunosuppressed hosts. These observations identify a potential opportunity for diagnostic stewardship and suggest that commonly applied testing restrictions may warrant further evaluation in immunocompromised oncology populations.

Plasma cell-free DNA metagenomic next-generation sequencing (cf-mNGS) tests offer the ability to detect microbial DNA from a single blood sample; however, its clinical utility in infants remains incompletely characterized. This study aims to evaluate the real-world clinical impact of plasma cf-mNGS testing in the neonatal and infant population.

Retrospective cohort study

A large academic medical center in Los Angeles, California

95 hospitalized neonates and infants (≤12 months of age).

Clinical impact was adjudicated using predefined criteria.

We reviewed 95 unique plasma cf-mNGS testing episodes performed between February 2018 and August 2024. The mean age at testing was 4.2 months (SD, 3.8). All patients were hospitalized in the intensive care unit at the time of testing. Tests were most frequently performed for evaluation of “culture-negative sepsis” (30.5%), unexplained hospital-onset fevers (25.3%), and multiorgan failure (21.1%). Plasma cf-mNGS testing did not influence clinical management in the majority of cases (86.3%; 95% CI, 78.0%–91.8%). Positive clinical impact occurred in 5/95 cases (5.3%; 95% CI, 2.3%–11.7%), where plasma mNGS results assisting in antimicrobial de-escalation/discontinuation or earlier/new diagnoses. Negative clinical impact occurred in 4/95 cases (4.2%; 95% CI, 1.6%–10.3%), with plasma cf-mNGS results prompting unnecessary investigations or treatment.

Our findings do not support the routine use of plasma cf-mNGS testing for indications including “culture-negative sepsis” in neonatal and infant populations.

Ordering urine cultures in the absence of urinary symptoms contributes to unnecessary antibiotic prescribing for urinary tract infection (UTI). The aim of this study was to develop and implement an electronic health record (EHR)-integrated, nurse-led clinical decision support (CDS) tool for UTI symptom triage to support outpatient antibiotic stewardship.

Exploratory sequential mixed-methods study.

Urban academic family medicine practice.

Eleven nurses.

In the qualitative phase, workflow mapping and semi-structured interviews informed development of an EHR-integrated CDS consisting of a symptom score calculator and triage algorithm. In the quantitative phase, implementation was evaluated using a pre–post design with interrupted time series analysis over 15 months. Implementation outcomes included adoption, fidelity, and usability. Clinical outcomes included symptom documentation, urine testing practices, and antibiotic prescribing. Safety outcomes included pyelonephritis within 30 days.

Qualitative analysis identified four barriers: incomplete symptom documentation, reflexive urine testing, medicolegal concerns about missing pyelonephritis, and patient pressure for antibiotics. The CDS was adopted by all nurses, with 77.8% fidelity and high usability. Documentation of ≥2 UTI-specific symptoms increased at implementation with sustained improvement (slope + 2.4%/month; 95% CI, 0.1–4.7). Urine cultures without microscopy showed sustained reduction (slope −5.5%/month; 95% CI, −7.9 to −3.2). Antibiotic prescribing for asymptomatic bacteriuria decreased (20% to 3%; P = .003) with no increase in pyelonephritis.

Nurse-led, EHR-integrated clinical decision support for UTI triage was associated with sustained improvements in symptom documentation, reduced unnecessary urine culture ordering, and decreased antibiotic treatment of asymptomatic bacteriuria without compromising safety.

Most children 2 years and older with uncomplicated acute otitis media (AOM) are prescribed 10-day antibiotic durations, despite national guidelines recommending antibiotics for 5–7 days. Costs are often cited as a barrier to stewardship efforts. As part of a larger clinical trial including 2 systems and 46 clinics, we developed a low-intensity and a high-intensity intervention aimed at reducing antibiotic duration for AOM and evaluated implementation and sustainability for the interventions.

Costs associated with each implementation activity were recorded over time, including material/supply costs (eg, printing) and personnel time costs. Sustainability costs were estimated based on ongoing implementation expenses. For each system, we assessed total intervention, activity-specific, and sustainability costs. Aggregate results were reported as the median across systems.

The total median implementation costs were $3,606 (range $2,540–$4,672) for the low-intensity intervention and $9,203 (range $7,557–$10,849) for the high-intensity intervention. For the low-intensity intervention, the primary cost driver was electronic health record modifications totaling $2,292 (range $1,615–$2,968). For the high-intensity intervention, the primary cost driver was audit and feedback system activation totaling $5,597 (range $2,885–$8,309). Personnel time accounted for over 90% of costs in both study arms. Sustainability costs were $133/year (range $77–$190) for the low-intensity intervention and $764/year (range $628–$901) for the high-intensity intervention.

Overall costs were low. The high-intensity intervention resulted in higher costs compared to the low-intensity intervention.

Little is known about implementation of antimicrobial stewardship (AMS) programs in retirement homes, a setting with an older adult population which is at increased risk of antibiotic-related harm. This study evaluated a pharmacist-led prospective audit and feedback (PAF) pilot program in retirement homes.

This quasi-experimental study evaluated antibiotic use in 9 intervention homes and 396 control homes from June 2022 to May 2023 (baseline period), compared to June 2023 to December 2024 (intervention period). PAF was conducted remotely by long-term care pharmacists; recommendations were provided to the prescriber via fax. The primary outcome was antibiotic days of therapy (DOT) per 1000 resident-days. Determinants to implementation were gathered from participating pharmacists and mapped to the Theoretical Domains Framework.

During the intervention, of 794 antibiotic assessments, 89 recommendations were made and 27 (30%) were accepted. Total antibiotic use measured in DOT per 1,000 resident days in intervention homes was similar before and after PAF (54.0 before vs. 57.9 after). Similarly, usage in the control group was relatively stable (49.0 before vs. 51.6 after) (DiD Analysis: +2.4 DOT/1,000 resident days, 95% CI −7.8, 12.3). Barriers to PAF implementation included communication challenges (communication via fax) and limited clinical information (lack of indication on prescription). Facilitators included organizational support and pharmacist motivation.

While this pilot had limited uptake and was not associated with a change in antibiotic use, it highlighted important barriers and facilitators for AMS in retirement homes. This initiative strengthened local capabilities for antibiotic use surveillance to support future AMS interventions.

Many studies have evaluated the safety and efficacy of oral stepdown therapy for treatment of gram-negative bacteremia (GNB). There are currently no studies comparing the safety and effectiveness of various dosing strategies of sulfamethoxazole-trimethoprim (SMX-TMP) in these patients.

This retrospective cohort study included adult patients at 6 hospitals within a health system with GNB, excluding Stenotrophomonas spp. that received at least 72 hours of oral SMX-TMP. Patients were grouped based on high- (≥8 mg/kg) or low-dose (<8 mg/kg) SMX-TMP. The primary outcome was a composite of all-cause mortality and recurrence at 30 days. Secondary outcomes included readmission, hyperkalemia requiring intervention, acute kidney injury, and intolerance leading to SMX-TMP discontinuation.

There were 176 patients included (25.6% high-dose, 74.4% low-dose) in this study. Baseline characteristics were similar except for age, sex, and dosing body weight. Median total duration of therapy for both groups was approximately 14 days; time to initiation of antibiotics was similar between groups. Six patients met the composite outcome (high-dose: 4.4% vs. low-dose: 3.1%; P = .646). Secondary outcomes did not differ significantly between groups.

SMX-TMP is commonly used as oral stepdown therapy in GNB. Results of this study indicate that low-dose (<8 mg/kg) SMX-TMP may be sufficient, as outcomes were similar between the groups. To date, this is the first study evaluating different dosing strategies of SMX-TMP for this indication.

Emergency department (ED) urine culture stewardship may reduce low-value testing, but downstream effects on antibiotic use and postdischarge utilization remain uncertain.

We evaluated an intervention in which an infectious diseases physician and microbiologist reviewed pyuric urinalysis-with-reflex encounters, assessed culture indications, and contacted clinicians to recommend cancellation when absent. Adult ED encounters from February–July 2025 to September 2025-February 2026 were included; August was washout. Outcomes were urinalysis with reflex within 24 hours, urine culture within 24 hours, antibiotic days of therapy (DOT) per 100 patient-days, length of stay (LOS), and 30-day ED revisit among ED discharges. We fit biweekly interrupted time series models.

Among 17,621 encounters, the intervention was associated with lower postintervention slopes for urinalysis with reflex within 24 hours (−0.5 percentage points per biweekly period; 95% CI, −0.9 to −0.1) and urine culture within 24 hours (−0.2 percentage points; 95% CI, −0.4 to −0.0). DOT showed no sustained change (postintervention slope change, 0.00; 95% CI, −0.23 to 0.24). LOS showed a lower postintervention slope (−0.05 d; 95% CI, −0.08 to −0.02). Thirty-day ED revisit showed a higher postintervention slope (0.8 percentage points; 95% CI, 0.3 to 1.3).

The intervention reduced urinary testing but did not reduce antibiotic DOT and was associated with increased 30-day ED revisit. Diagnostic stewardship in the ED may need to be paired with antimicrobial stewardship and prospective safety monitoring.

To determine the scope and characteristics of healthcare-associated parechovirus-A infection (HA-PI).

Cross-sectional survey.

Hospitals with neonatal units in Japan.

Patients with parechovirus-A infection in 2023 in Japan.

A 2-step questionnaire survey included the primary survey ascertaining the number of patients with HA-PI in 2023, followed by the secondary survey investigating the details of the patients with HA-PI.

Of the 408 hospitals, 226 (55.4%) responded. Seven sporadic patients were reported from 6 (2.7%) hospitals between May and September 2023, diagnosed as having sepsis (n = 5) or sepsis-like illness (n = 2). The median gestational age was 37.7 weeks (IQR, 36.2–38.3). They were second-born (n = 6) or third-born (n = 1), without first-born. The median days of onset of illness were 7 days (IQR, 6–15). The locations were the newborn nursery (n = 3), growth care (n = 3), or neonatal intensive care units (n = 1). No sequelae were found at least 10 months in all patients. Parechovirus-A genotype analyses demonstrated A3 (n = 6) and unknown (n = 1). The identified sources of infection were from the mother (n = 5) or unknown (n = 2). Among the 5 mothers, 2 were symptomatic. Notably, the siblings of patients in 3 asymptomatic mothers, who had no direct contact with the patients, were all symptomatic.

This nationwide survey in Japan demonstrated HA-PI can occur in neonatal units, with potential risks for nosocomial outbreaks. Suspecting HA-PI and preventive measures are critical in neonatal units.

Antibiotics are frequently prescribed for acute sinusitis despite national guidelines recommending antibiotics only if specific symptom criteria are met. We aimed to define the proportion of acute sinusitis encounters meeting criteria for antibiotic prescribing, characterize prescribing practices, and identify factors associated with guideline-discordant prescribing.

This retrospective cohort study included 1,000 randomly selected adult ambulatory encounters with a primary diagnosis of acute sinusitis between January 1, 2024 and March 31, 2024. Encounter notes were reviewed for appropriate antibiotic prescribing criteria as per national guidelines. Encounters were evaluated for drug selection and duration concordance based on local guidelines. A multivariable logistic regression analysis was performed to identify predictors of inappropriate antibiotic prescribing.

Emergency departments, urgent care centers, and primary care clinics.

Antibiotic prescribing criteria were met for 67.6% of included encounters. Antibiotics were prescribed in 93.5% of encounters that met prescribing criteria, and 80.2% of encounters that did not. Both drug selection and duration were guideline-concordant in 49.2% of total encounters. On multivariable analysis, predictors of inappropriate antibiotic prescribing included cough (OR 2.15, 95% CI 1.08–4.29; P = 0.03) and symptom duration between 7 and 9 days (compared to <6 days; OR 7.70, 95% CI 3.24–18.31; P < 0.001). Electronic encounters were associated with lower odds of prescribing compared to in-person encounters (OR 0.03, 95% CI 0.01–0.09; P < 0.001).

Most encounters for acute sinusitis result in an antibiotic prescription, despite prescribing criteria not being met. These findings may aid antimicrobial stewardship programs in benchmarking and optimizing antibiotic prescribing for acute sinusitis.

Surgical site infections (SSI) after colorectal surgery are common. Epidural anesthesia (EA) has demonstrated multiple beneficial effects for patients undergoing open colorectal surgery. However, research regarding the relationship between EA and SSI after open colorectal surgery remains limited.

This retrospective study analyzed 2022–2023 data from the American College of Surgeons National Surgical Quality Improvement Project registry. Patients were included if they received a colorectal procedure without additional minor or major therapeutic procedures. Generalized additive models evaluated 30-day occurrence of any SSI (primary outcome), as well as incisional SSI and organ-space SSI (secondary outcomes). A sensitivity analysis of the primary outcome incorporated propensity score weighting to account for treatment selection.

Of the 6,343 patients included in the data set, 1,495 (24%) received EA and 3,391 (53%) received colorectal resection. EA was not significantly associated with any SSI (OR 1.11, 95% confidence interval (CI) 0.93–1.33, P = .26), superficial/deep incisional SSI (OR = 1.24, 95% CI 0.96–1.61, P = .11), or organ-space SSI (OR 1.00, 95% CI 0.80–1.25, P = .98). The primary findings were consistent in the sensitivity analysis (OR 0.91, 95% CI 0.77–1.08, P = .27). Patients undergoing enterostomy procedures were more likely to experience all three SSI outcomes relative to those who received colorectal resections without enterostomies.

There was a lack of significant differences in the odds of SSI between patients who did and did not receive EA for elective open colorectal surgery.