To review the variety of antimicrobial tele-stewardship strategies and their applicability to the rural outpatient context.

Narrative review of antimicrobial tele-stewardship activities and their potential adaptability to rural outpatient settings.

Few studies evaluate implementation and outcomes of antimicrobial stewardship in rural settings. In this review we summarize the variety of methods that have been used in tele-stewardship implementation research, and how each can be adapted to the rural outpatient setting, including: audit and feedback, peer comparison, provider education, guideline creation, consultation with infectious disease providers, and electronic medical record nudges.

Tele-stewardship activities are likely to benefit outpatient rural settings, though further implementation research is needed.

The aim of this study was to describe the efficacy of decolonization treatments given in Hospital District of Southwest Finland (HDSWF) in 2007–2016 and to analyze the key elements for successful decolonization treatment. Duration of follow-up varied from 12 to 15 months.

All new MRSA cases detected between 2007 and 2016 in HDSWF (population 475,000) and their MRSA follow-up screening results within 12–15 months were retrospectively analyzed. This study focused on the outpatient carriers having received decolonization treatment during the study period.

Of the 983 MRSA cases detected during 2007–2016, 117 carriers went through decolonization treatment. Of those successfully followed up, 72/92 (78.3%) were successfully decolonized. Multisite carriage was a risk factor for unsuccessful decolonization.

Decolonization treatment, including nasal mupirocin, chlorhexidine containing skin washes and in selected cases, also systemic antibiotics, was effective in outpatient settings, resulting in long-term clearance of the MRSA carriage.

Unnecessary and suboptimal antibiotic use causes adverse outcomes at both the level of individuals and health systems. Prospective audit and feedback, a core aspect of antibiotic stewardship program (ASP) efforts, reduces such use, but is inefficient in the absence of a pre-screening process. To address this, we used a machine learning approach to stratify antibiotic orders based on the likelihood of benefiting from ASP review, and to identify the factors most influential in the model’s predictions.

Machine learning model developed using expert-labeled point-prevalence data.

Single-center adult academic hospital.

Hospitalized patients 18 years or older on internal medicine services between May 2021 and August 2022.

Infectious disease experts assessed antibiotic orders for necessity and optimal use to create labels which were used as ground truth to train a machine learning model that uses automatically queried data from the electronic health record including vital signs, laboratory values, microbiological data, and medication administration records.

Our model achieved an area under the receiver operating characteristic curve of 0.89 for antibiotic necessity and 0.80 for optimal use. Model predictions were driven largely by markers of clinical instability, inflammation, and infection. Simpler clinical indices of infection had no predictive ability.

We describe a model that predicts antibiotic necessity and optimal use using routinely available data that can be automatically aggregated from medical records. This makes it a promising option for early identification and intervention on orders most likely to benefit from ASP review.

To identify risk factors for surgical site infections (SSIs) following abdominal hysterectomy in patients cared for in a large urban public hospital system.

Retrospective case control study.

Multicenter safety net hospital system.

Women undergoing hysterectomy from 2015–2023.

Propensity score matching, using Centers for Medicare and Medicaid Services (CMS) risk variables, created control groups. Receiver operating characteristics curves were created using current and augmented risk adjustment variables.

There were 6142 hysterectomy surgeries reported during the 9-year time period, with 160 (2.61%) with reportable SSIs. Compared to a matched control group, patients with SSIs were more likely to be of Black race, to have longer duration of surgery, to have open surgery (vs. laparoscopic), and to have received a clindamycin ± gentamicin for surgical prophylaxis. The addition of duration of surgery, endoscopic surgery, and wound class to current CMS risk variables significantly improved the prediction for SSI when all SSIs were included, but did not when patients with superficial SSIs were excluded from analysis.

Predicting SSIs following hysterectomy is complex and current CMS risk assessments are overly simplistic. Until more robust and comprehensive risk assessment criteria are developed, use of SSIs following hysterectomy as a quality measure for reimbursement should be reconsidered.

Effectively addressing poultry farmers’ antibiotic use and its role in antimicrobial resistance (AMR) presents a significant challenge, but improving their knowledge and practices is crucial for mitigating AMR risks and safeguarding public health. This study aimed to assess farmers’ understanding and behaviors to identify public health risks and inform targeted interventions.

Survey-based cross-sectional study.

200 poultry farms in Enugu State, Nigeria.

Poultry farmers.

A cross-sectional survey of 200 poultry farms in Enugu State, Nigeria, was conducted using a validated questionnaire targeting farmers responsible for key farm decisions. The questionnaire covered sociodemographic data, AMR knowledge, and antibiotic use practices. Ethical approval was obtained, and participants provided oral consent.

Findings showed that 90.5% of farmers used antibiotics, primarily for treating infections (80.5%) and for growth promotion or prophylaxis (61%). Ampicillin (75%), ciprofloxacin (71.5%), and doxycycline (71%) were the most commonly used antibiotics, with monthly administration being prevalent (48%). Additionally, 89% of respondents believed antibiotics promote poultry growth. Alarmingly, 65% were unaware of AMR, and only 16% recognized its health risks.

The heavy reliance on antibiotics, particularly ampicillin, raises concerns about beta-lactamase selection amid Nigeria’s carbapenem resistance issues. The significant knowledge gap among farmers highlights the urgent need for targeted education and stricter antibiotic regulation to mitigate AMR risks in poultry farming.

Increasing evidence demonstrates that medical personnel and the clinical environment such as surfaces and equipment are often sources of infections. However, limited data exists on the bacterial contamination of the hospital mortuary environment within a hospital setting.

This study aimed to determine bacterial profiles, assess antimicrobial susceptibility patterns, and evaluate infection prevention and control (IPC) practices at the Mbarara Regional Referral Hospital (MRRH) mortuary in southwestern Uganda.

This was a cross-sectional study involving qualitative and quantitative data collection methods. Ninety-three (93) surface swab samples from the inanimate surfaces were collected. Using standard operating protocols, the collected samples were processed at the microbiology laboratory. All isolates were cultured and identified by Gram staining and biochemical tests. Antimicrobial susceptibility testing was done on each isolate following the Kirby-Bauer disk diffusion method. Data was entered and analyzed using SPSS version 26 and results were explained by percentages and tables.

Klebsiella species were the most predominant isolated bacteria (44.7%) followed by Staphylococcus aureus (40.3%). Methicillin-resistant Staphylococcus aureus (MRSA) was detected at a high frequency (98%). Resistance patterns showed that most isolates exhibited multidrug resistance, with high resistance to commonly used antibiotics. However, Azithromycin and Ciprofloxacin demonstrated the highest efficacy against both Gram-positive and Gram-negative isolates.

Inanimate surfaces and equipment of the mortuary are heavily contaminated with multidrug-resistant bacteria such as Methicillin-resistant Staphylococcus aureus. Improper disinfection and waste segregation may contribute to bacterial contamination in the mortuary. Regular and enhanced cleaning with disinfectants, proper use of clean aprons, and displaying safety signage for workers and visitors can help improve infection prevention and control.

Discharge is a pivotal transition of care moment; however, discharge antibiotic stewardship efforts have historically been limited. Our institution has a mandatory indication field for inpatient antibiotic orders. Using the last-ordered inpatient antibiotic indication (“Last Inpatient Indication”), we assessed the utility of this field compared to the ICD-10 in inferring clinician intent for discharge antibiotics, to forgo the need for manual chart review to assess antibiotic appropriateness.

We extracted electronic medical record data on adult inpatient encounters in 2023 with ≤2 discharge antibiotics. We reviewed a random subset of 300 encounters to determine if the ICD-10 or Last Inpatient Indication had higher agreement with clinician intent for discharge antibiotics, as determined by chart notes. To facilitate comparison, we created a dictionary classifying ICD-10 indications.

We included 3,414 encounters. The most common discharge antibiotics were amoxicillin/clavulanate (24%) and ciprofloxacin (15%). The most common ICD-10s were non-infectious (48%) and sepsis (18%). In the subset of chart-reviewed encounters, the Last Inpatient Indication agreed with the documented clinician intent for discharge antibiotic more often than the ICD-10 (84% vs 28%). Applying institutional guidelines, we were able to use the Last Inpatient Indication to assess appropriate duration and choice of discharge antibiotics for select infections.

The Last Inpatient Indication outperformed ICD-10s in inferring clinician intent for discharge antibiotics and can be used to efficiently assess antibiotic appropriateness without need for manual chart review. Usefulness of ICD-10s was limited by high percentage of non-infectious and sepsis codes.

The objective of the study was to assess the implementation of antimicrobial stewardship (AMS) in the referral hospitals in the South West Region of Cameroon.

A cross-sectional survey was carried out in November 2024 across four hospitals in the South West Region of Cameroon: Limbe Regional Hospital, Buea Regional Hospital Annex, Baptist Hospital Mutengene, and Kumba Baptist Health Center. For data collection, we used the standard WHO checklist to assess AMS activities at the healthcare facilities designed for low- and middle-income countries. Key informant interview involving the AMS focal persons of various hospitals enabled data collection.

Limbe Regional Hospital has the highest full implementation rate of AMS activities (67%), while Buea regional hospital is the least of fully implemented activities (19%). An average of 49% of all AMS activities are fully implemented across the healthcare facilities, partially implemented activities made up 28%, only 3% of the activities are in the planning phase but not yet started. A 13% of the activities are not implemented across the studied facilities, while 7% of the activities are not implemented but identified as a priority.

Although the rate is still low, there is good progress in implementation of AMS activities with most activities either fully or partially implemented; however, no health facility included AMS activities in their annual plans with key performance indicators, no management of any hospital allocated financial and human resources to initiate AMS activities. Strengthening institutional commitment and AMS training are recommended.

Most self-reported beta-lactam antibiotic (BLA) allergies are inaccurate. This study evaluated a digital tool designed to reassess beta-lactam allergies and enable the use of standard perioperative antibiotic prophylaxis (PAP) without the need for prior allergy testing.

In this retrospective, observational single-center cohort study, a digital five-step questionnaire was utilized during preoperative anesthesia evaluations for surgical patients reporting beta-lactam allergies. The algorithm assessed the likelihood of a beta-lactam allergy and provided recommendations for either standard PAP or the use of an alternative agent. Adherence to the algorithm’s recommendations and the incidence of allergic reactions following PAP were analyzed.

Between September 2020 and October 2022, 983 surgical patients reported beta-lactam allergies. Of these, 322 patients (33%) either did not receive anesthesia or did not require PAP. Among the remaining 661 patients, the algorithm recommended standard prophylaxis for 420 (64%). Of these, 262 patients received BLA, resulting in 2 allergic reactions (0.8%; negative predictive value: 99.2%), while 158 received alternative antibiotics contrary to the recommendation, leading to 3 allergic reactions (1.9%). For the 241 patients (36%) in whom the algorithm indicated a high probability of beta-lactam allergy, 197 (82%) received alternative antibiotics with 4 allergic reactions (2%). Forty-four patients (18%) received BLA contrary to the algorithm’s recommendation, with no allergic reactions observed.

The digital five-step algorithm was a simple and effective tool during preoperative assessment, enabling safe administration of standard PAP in 64% of surgical patients with reported beta-lactam allergies.

Antimicrobial stewardship (AMS) is crucial for improving infectious disease outcomes and mitigating antimicrobial resistance. Healthcare systems provide an ideal setting for implementing comprehensive AMS, but face challenges related to scale and complexity.

This report describes Ascension’s system-wide AMS program, a model built upon establishing program structures, standardized processes, and fostering empowerment and partnerships. The program is structured around eight key pillars: system-level governance, market-level support, data-driven decision-making, multidisciplinary collaboration, data tracking and reporting, targeted interventions, empowering frontline teams, and stakeholder partnerships.

The system’s AMS program has yielded benefits, including the development and dissemination of standardized guidelines, the support of data-driven decisions through robust analytics and performance dashboards, and the deployment of clinical decision support tools. Capacity building has been enhanced through multidisciplinary collaboration and empowering frontline teams. Data tracking and reporting allow for the monitoring of key metrics.

Healthcare systems can build capacity and support sustainability to AMS programs through developing structures, standardized processes, and empowerment to achieve optimal outcomes.

The BioFire FilmArray Pneumonia (BFP) panel is a multiplexed nucleic acid test intended to detect respiratory pathogens from sputum or bronchoalveolar lavage (BAL) specimens. Efficacy and safety of de-escalation strategies in patients with negative BFP results remain unclear.

This was a multicenter, retrospective analysis of patients with suspected pneumonia and negative BFP and respiratory cultures. Patients were stratified into two groups: those whose antibiotic therapy was discontinued or withheld within 48 hours of a negative BFP (ATDW group) and those whose antibiotic therapy was continued (ATC group). We evaluated composite primary outcome of in-hospital mortality and 30-day readmission due to pneumonia (PNA) or recurrent PNA during index admission and secondary safety outcomes.

Among 500 patients with negative BFP assay, a total of 185 patients were included in the final analysis (59 ATDW vs. 126 ATC). The ATDW group had significantly shorter total duration of antibiotic therapy (1 day vs 7 days, p < 0.001). The primary composite outcome was similar between ATDW and ATC groups (23.1% vs 35.3%, P = 0.15). Multivariate analysis identified ICU admission and/or intubation (OR 7.5, 95% CI 3.17–17.52, P < 0.001) as only independent predictor of the composite primary outcome. The ATDW group experienced fewer rates of acute kidney injury (AKI)(8% vs 37%, P = 0.004).

Antimicrobial optimization based on negative results from both BFP and respiratory culture may potentially reduce unnecessary antibiotic exposure and AKI in hospitalized patients with suspected pneumonia without increasing the risk of mortality and readmission.

During the coronavirus disease 2019 (COVID-19) pandemic, strict infection prevention and control (IPC) measures were implemented in healthcare settings.

To evaluate the effect of enhanced IPC practices implemented during the COVID-19 pandemic on the prevalence of hospital-acquired infections (HAIs) in a Tunisian university hospital.

A multimodal IPC strategy was implemented from March to September 2020 at Sahloul University Hospital, Sousse, Tunisia. This strategy included promoting hand hygiene (HH), enhancing adherence to standard precautions and universal masking. We compared the prevalence of HAIs and compliance with IPC practices before the pandemic (pre-intervention phase) and during the pandemic (post-intervention phase).

A total of 306 patients were surveyed in 2019 and 228 in 2021. The prevalence of HAIs increased slightly from 9.4% to 10.08% (p = 0.814). HH compliance improved significantly from 38.3% to 51.6% and sharp waste sorting compliance rose from 60.3% to 77.6%. The use of personal protective equipment also increased, with FFP2 respirator consumption increasing nearly 247-fold.

This study found no significant change in HAI prevalence despite the implementation of enhanced IPC strategies. However, the small sample size was a major limitation that may have reduced the statistical power to detect meaningful differences. Larger-scale studies are needed to confirm these findings and better assess the impact of IPC strategies in this context.

Not applicable.