Skin and soft tissue infections (SSTIs) account for over 2.8 million annual emergency department (ED) visits and often result in suboptimal antibiotic therapy. The objective of this study was to evaluate a set of interventions in minimizing inappropriate prescription of antibiotics for presumed SSTIs in the ED.

Case vignette survey.

A national sample of emergency medicine (EM) physicians.

Each vignette described a clinical scenario of a presumed SSTI (cellulitis or abscess) and included a unique combination of zero to five interventions (outpatient follow-up, inappropriate antibiotic request flag, thermal imaging for cellulitis or rapid wound MRSA PCR for abscess, patient education/shared decision-making, and clinical decision support). Out of 64 possible vignettes, we asked participants to respond to eight vignettes. Following each vignette, we asked participants if they would prescribe an antibiotic in their everyday practice (yes/no). We built adjusted hierarchical logistic regression models to estimate the probability of prescribing an antibiotic for each intervention and vignette.

Surveys were completed by 113 EM physicians. The thermal imaging, rapid wound MRSA PCR, and patient education/shared decision-making interventions showed the largest decrease (15–20%) in antibiotic prescribing probability. Vignettes with a combination of both a diagnostic intervention (thermal imaging or rapid wound MRSA PCR) and a patient education/shared decision-making intervention had the lowest prescribing probabilities.

We recommend future research focuses on the development and integration of novel diagnostic tools to identify true infection and incorporate shared decision-making to improve diagnosis and management of SSTIs.

Using a large, geographically diverse, hospital-based database in the United States (Premier PINC AI Healthcare Database), we aimed to describe the proportion and characteristics of patients receiving phenotype-desirable antimicrobial therapy (PDAT) among those hospitalized with Enterobacterales bloodstream infections.

Adult patients with an admission between January 1, 2017 and June 30, 2022 with ≥1 blood culture positive for Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Proteus mirabilis and receiving an empiric antibiotic therapy on blood culture collection (BCC) Days 0 or 1 were included. Receiving PDAT (defined as receipt of any antimicrobial categorized as “desirable” for the respective phenotype) on BCC Days 0−2 was defined as receiving early PDAT.

Among 35,880 eligible patients, the proportion of patients receiving PDAT increased (from 6.8% to 22.8%) from BCC Day 0−4. Patients who received PDAT (8,193, 22.8%) were more likely to visit large (500 + beds, 36% vs 31%), teaching (45% vs 39%), and urban (85% vs 82%) hospitals in the Northeast (22% vs 13%) compared to patients not receiving PDAT (all P <. 01). Among patients receiving PDAT, 61.4% (n = 5,033) received it early; they had a lower mean comorbidity score (3.2 vs 3.6), were less likely to have severe or extreme severity of illness (71% vs 79%), and were less likely to have a pathogen susceptible to narrow-spectrum β-lactams (31% vs 71%) compared to patients in the delayed PDAT group (all P < .01).

The proportion of patients receiving desirable therapy increased between BCC Day 0 and 4. Receipts of PDAT and early PDAT were associated with hospital, clinical, and pathogen characteristics.

Clostridioides difficile infection (CDI) may be misdiagnosed if testing is performed in the absence of signs or symptoms of disease. This study sought to support appropriate testing by estimating the impact of signs, symptoms, and healthcare exposures on pre-test likelihood of CDI.

A panel of fifteen experts in infectious diseases participated in a modified UCLA/RAND Delphi study to estimate likelihood of CDI. Consensus, defined as agreement by >70% of panelists, was assessed via a REDCap survey. Items without consensus were discussed in a virtual meeting followed by a second survey.

All fifteen panelists completed both surveys (100% response rate). In the initial survey, consensus was present on 6 of 15 (40%) items related to risk of CDI. After panel discussion and clarification of questions, consensus (>70% agreement) was reached on all remaining items in the second survey. Antibiotics were identified as the primary risk factor for CDI and grouped into three categories: high-risk (likelihood ratio [LR] 7, 93% agreement among panelists in first survey), low-risk (LR 3, 87% agreement in first survey), and minimal-risk (LR 1, 71% agreement in first survey). Other major factors included new or unexplained severe diarrhea (e.g., ≥ 10 liquid bowel movements per day; LR 5, 100% agreement in second survey) and severe immunosuppression (LR 5, 87% agreement in second survey).

Infectious disease experts concurred on the importance of signs, symptoms, and healthcare exposures for diagnosing CDI. The resulting risk estimates can be used by clinicians to optimize CDI testing and treatment.

Urine-culture diagnostic stewardship aims to decrease misdiagnosis of urinary tract infections (UTIs); however, these interventions are not widely adopted. We examined UTI diagnosis and management practices to identify barriers to and facilitators of diagnostic stewardship implementation.

Using a qualitative descriptive design, we conducted semistructured interviews at 3 Veterans’ Affairs medical centers. Interviews were conducted between November 2021 and May 2022 via Zoom videoconferencing using an interview guide and visual prototypes of proposed interventions. Interviewees were asked about current practices and thoughts on proposed interventions for urine-culture ordering, processing, and reporting. We used a rapid analysis matrix approach to summarize key interview findings and compare practices and perceptions across sites.

We interviewed 31 stakeholders and end users. All sites had an antimicrobial stewardship program but limited initiatives targeting appropriate diagnosis and management of UTIs. The majority of those interviewed identified the importance of diagnostic stewardship. Perceptions of specific interventions ranged widely by site. For urine-culture ordering, all 3 sites agreed that documentation of symptomology would improve culturing practices but did not want it to interrupt workflow. Representatives at 2 sites expressed interest in conditional urine-culture processing and 1 was opposed. All sites had similar mechanisms to report culture results but varied in perceptions of the proposed interventions. Feedback from end users was used to develop a general diagnostic stewardship implementation checklist.

Interviewees thought diagnostic stewardship was important. Qualitative assessment involving key stakeholders in the UTI diagnostic process improved understanding of site-specific beliefs and practices to better implement interventions for urine-culture ordering, processing, and reporting.

Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship.

A discrete choice experiment presented participants with a vignette consisting of the same “stem” plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3–4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute.

The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States.

In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99–1.3), hypotension (utility, 0.88; 95% CI, 0.74–1.03), fever (utility, 0.76; 95% CI, 0.62–0.91) and copious sputum (utility, 0.75; 95% CI, 0.60–0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17–0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05–0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate.

Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.

In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention.

We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression.

The study included 6 acute-care hospitals within the Veterans’ Health Administration across the United States.

Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included.

At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days.

The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49).

Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.