Shorter antibiotic courses and transition to oral therapy for uncomplicated gram-negative bloodstream infections (GN-BSI) are evidence-supported yet remain challenging to implement. Here we report our experience with a GN-BSI antimicrobial stewardship (AS) quality improvement initiative in a large health system.

We implemented two sequential AS interventions in adult patients hospitalized with uncomplicated GN-BSI: (1) mandatory AS review of patients discharging on intravenous (IV) antibiotics (“OPAT review”) and (2) a clinical guideline informing oral antibiotic transition and duration, in our 22-hospital system. We evaluated the initiative from January 2018 to September 2024. Pre- and postimplementation rates of (1) IV antibiotics at discharge and (2) total length of antibiotic therapy were calculated across the following periods: preintervention, after OPAT review, and after guideline implementation. Secondary outcomes included duration <10 days, oral antibiotic prescribing, and guideline-recommended dosing.

3,231 patients (preintervention: 666, postOPAT review: 1,357, postguideline: 1,208) were included. We observed decreases in IV antibiotics at discharge (22.7% preintervention, 10.7% postOPAT review, and 9.2% postguideline, p < 0.001) and median length of treatment (13.5 days preintervention to 10.7 days postguideline, p < 0.001). We also observed improvement in durations <10 days (19.1% vs 45%, p < 0.001), oral antibiotic prescriptions, and appropriate dosing (2.8% vs 33.5%, p < 0.001), but no difference in rates of BSI recurrence, mortality, or C. difficile infection.

After implementing GN-BSI-focused AS initiatives in our large health system, we observed a shift toward more frequent oral rather than IV antibiotics at discharge, and shorter overall antibiotic durations, without obvious changes in adverse outcomes.

Staphylococcus aureus bacteriuria (SABU) may represent bacteremia in a subset of patients. We describe the impact of a microbiology alert recommending follow-up blood cultures (FUBC) for patients with SABU in a large integrated health system.

We conducted a quasi-experimental implementation study in adult ambulatory patients with documented SABU. We excluded patients with confirmed SAB up to 14 days prior to index SABU culture and with blood cultures obtained on the day of SABU. The primary outcome was rate of FUBC (collected between 1 and 5 days of SABU) among all cases of SABU. Secondary outcomes included percentage of patients with early SAB (collected between 1 and 5 days of SABU). We used interrupted time series analysis to compare rates of FUBC pre vs postintervention.

A total of 2 540 patients were identified; 1 213 (48%) were male. By the end of the postintervention period, the rate of FUBC (20.6%) had increased by 6.3 percentage points (P = .005) compared to the counterfactual (14.2%) had no intervention taken place (44.5% relative increase). Early SAB detection due to FUBC increased from .6% preintervention to 2.0% postintervention (P = .004).

The microbiology alert initiative increased FUBC in patients with SABU by 44%, but the overall rate of FUBC remained low. The intervention increased early SAB detection. Risk-targeted strategies are needed to optimize FUBC collection in patients with SABU.

Antibiotic stewardship programs (ASPs) target hospitalized children, but most do not routinely review antibiotic prescriptions at discharge, despite 30% of discharged children receiving additional antibiotics. Our objective is to describe discharge antibiotic prescribing in children hospitalized for uncomplicated community-acquired pneumonia (CAP), skin/soft tissue infection (SSTI), and urinary tract infection (UTI).

Retrospective cohort study.

Four academic children’s hospitals with established ASPs.

ICD-10 codes identified 3,847 encounters for children <18 years admitted from January 1, 2021 to December 31, 2021 and prescribed antibiotics at discharge for uncomplicated CAP, SSTI, or UTI. After excluding children with medical complexity and encounters with concomitant infections, >7 days hospital stay, or intensive care unit stay, 1,206 encounters were included.

Primary outcomes were the percentage of subjects prescribed optimal (1) total (inpatient plus outpatient) duration of therapy (DOT) and (2) antibiotic choice based on current national guidelines and available evidence.

Of 226 encounters for CAP, 417 for UTI, and 563 for SSTI, the median age was 4 years, 52% were female, and the median DOT was 9 days (8 for CAP, 10 for UTI, and 9 for SSTI). Antibiotic choice was optimal for 77%, and DOT was optimal for 26%. Only 20% of antibiotic courses included both optimal DOT and antibiotic choice.

At 4 children’s hospitals with established ASPs, 80% of discharge antibiotic courses for CAP, UTI, and SSTI were suboptimal either by choice of antibiotic or DOT. Discharge antibiotic prescribing represents an opportunity to improve antibiotic use in children.

Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that β-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of β-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes.

This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with β-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children’s hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs.

In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with β-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients.

Hospitalized pediatric patients with β-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.