To evaluate antibiotic prescribing knowledge and confidence before versus after deployment of a web-based clinical decision support tool at an academic dental center.

Pre and post survey instrument.

Academic dental center in the United States.

Dental students, residents, and faculty.

Participants completed a series of seven clinical vignettes assessing their antibiotic prescribing knowledge and confidence using 5-point Likert scale questions pre (2022) and post (2025) deployment of a web-based educational tool. The survey questions included content about antibiotic prophylaxis and treatment for dental infections. Mean Likert scale responses were compared before and after deployment of the tool. The responses were analyzed individually, pooled, and stratified by training level. Sensitivity analyses were conducted comparing results between tool users and non-users.

Two hundred and thirteen participants completed the pretool deployment survey, and 116 participants completed the post survey. Respondents were slightly less likely to prescribe antibiotics after having access to the tool (median pooled 5-point Likert Scale score 2.55 vs 2.67; P = .07). However, antibiotic prescribing confidence did not change significantly (median pooled score 3.37 vs 3.24; P = .21). Stratified results showed substantial variability based on individual vignette. Self-reported users of the tool (n = 37) demonstrated no differences in knowledge versus non-users (n = 97; P = .76) but did demonstrate a trend toward more confidence in their decisions (P = .07).

Uptake of a web-based antibiotic prescribing tool was low overall and was not associated with any change in antibiotic prescribing knowledge and confidence. Additional interventions are needed to improve tool use in dental settings.

We evaluated usability of a web-based clinical decision support tool designed to support antibiotic stewardship by helping clinicians differentiate asymptomatic bacteriuria from true urinary tract infections.

Mixed methods usability evaluation with qualitative think-aloud sessions and survey.

Private academic medical center.

Clinicians who evaluate and treat older adults with suspected asymptomatic bacteriuria or urinary tract infections.

Participants used the tool to assess three standardized clinical scenarios, verbalizing their thoughts as they used the tool, followed by a short debrief interview and survey. Transcripts of audio recordings were analyzed using qualitative content analysis across four usability domains: navigation, content, functionality, and layout.

Seven clinicians (four attending physicians, three advanced practice providers) practicing in primary care, outpatient, and inpatient settings participated. The mean System Usability Score was 85.4 (SD = 10.5; range 75–100), indicating “excellent” usability. Three qualitative themes emerged: (1) positive responses to the tool’s speed, simple entry, and reassuring guidance; (2) content-related challenges, including missing symptoms, unclear fever thresholds, undefined terminology, and absent caveats for allergies, resistant organisms, or unique populations; and (3) suggested navigational changes, including links opening in new tabs, preserving entered clinical data, and reorganizing the symptom checklist. Participants highlighted electronic health record integration as necessary for sustained use.

Participants found the tool usable and clinically valuable, particularly when infectious disease expertise is limited. Targeted refinements will be addressed before testing in a randomized study with a larger more representative sample. Future work will also pursue electronic health record integration via an embedded hyperlink for broader deployment.

Antimicrobial resistance (AMR) is a growing public health threat, and we currently lack accurate measures to track and trend this resistance. We developed the antibiotic resistance index (ARI) that aggregates resistance of Gram-negative bacilli (GNB) into a single metric which can be tracked across healthcare settings and over time.

Culture data were collected from adult patients who met the CDC adult sepsis event criteria across 10 Barnes-Jewish HealthCare (BJC) hospitals between January 2018 and December 2023. An antibiotic’s effective spectrum (AES) was calculated as the ratio of susceptible GNB to all identified GNB. The ARI was calculated as the sum of the AES to which the isolate was resistant. Using the 20 most common GNB and 15 most common anti-GNB antibiotics routinely tested in antibiograms, we calculated the ARI for each BJC hospital during the study years.

18,854 GNB cultured from 12,803 patients meeting CDC adult sepsis event criteria were included. AES varied between 0.15 for ampicillin and 0.94 for amikacin. A. calcoaceticus-baumannii complex had the highest ARI of 6.64 (IQR 4.00–9.28). Median hospital-level ARI fluctuated between 2.12 (IQR 0.40–3.83) in 2018 to 2.20 (IQR 0.34–3.86) in 2023. The ARI trajectories over time varied by medical center.

ARI aggregates AMR in GNB and may facilitate monitoring across locations and over time. ARI and antibiotic effective spectra redefine narrow and broad spectrum of activity and offer a starting point for antibiotic utilization metrics.

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.

To explore older adults’ and caregivers’ knowledge and perceptions of guidelines for appropriate antibiotics use for bacteria in the urine.

Semi-structured qualitative interviews.

Infectious disease clinics, community senior living facilities, memory care clinics, and general public.

Patients 65 years or older diagnosed with a urinary tract infection (UTI) in the past two years, or caregivers of such patients.

We conducted interviews between March and July 2023. We developed an interview guide based on the COM-B (capability, opportunity, motivation-behavior) behavior change framework. We thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques.

Thirty participants (21 patients, 9 caregivers) enrolled. Most participants understood UTI symptoms such as pain during urination and frequent urination. However, communication with multiple clinicians, misinformation, and unclear symptoms that overlapped with other health issues clouded their understanding of asymptomatic bacteriuria (ASB) and UTIs. Some participants worried that clinicians would be dismissive of symptoms if they suggested a diagnosis of ASB without prescribing antibiotics. Many participants felt that the benefits of taking antibiotics for ASB outweighed harms, though some mentioned fears of personal antibiotic resistance if taking unnecessary antibiotics. No participants mentioned the public health impact of potential antibiotic resistance. Most participants trusted information from clinicians over brochures or websites but wanted to review information after clinical conversations.

Clinician-focused interventions to reduce antibiotic use for ASB should also address patient concerns during clinical visits, and provide standardized high-quality educational materials at the end of the visit.

To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital.

Retrospective observational study.

1,278-bed academic hospital.

Adults admitted to non-ICU medicine services.

A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention.

The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality.

The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.

We performed a preimplementation assessment of workflows, resources, needs, and antibiotic prescribing practices of trainees and practicing dentists to inform the development of an antibiotic-stewardship clinical decision-support tool (CDST) for dentists.

We used a technology implementation framework to conduct the preimplementation assessment via surveys and focus groups of students, residents, and faculty members. Using Likert scales, the survey assessed baseline knowledge and confidence in dental providers’ antibiotic prescribing. The focus groups gathered information on existing workflows, resources, and needs for end users for our CDST.

Of 355 dental providers recruited to take the survey, 213 (60%) responded: 151 students, 27 residents, and 35 faculty. The average confidence in antibiotic prescribing decisions was 3.2 ± 1.0 on a scale of 1 to 5 (ie, moderate). Dental students were less confident about prescribing antibiotics than residents and faculty (P < .01). However, antibiotic prescribing knowledge was no different between dental students, residents, and faculty. The mean likelihood of prescribing an antibiotic when it was not needed was 2.7 ± 0.6 on a scale of 1 to 5 (unlikely to maybe) and was not meaningfully different across subgroups (P = .10). We had 10 participants across 3 focus groups: 7 students, 2 residents, and 1 faculty member. Four major themes emerged, which indicated that dentists: (1) make antibiotic prescribing decisions based on anecdotal experiences; (2) defer to physicians’ recommendations; (3) have limited access to evidence-based resources; and (4) want CDST for antibiotic prescribing.

Dentists’ confidence in antibiotic prescribing increased by training level, but knowledge did not. Trainees and practicing dentists would benefit from a CDST to improve appropriateness of antibiotic prescribing.

Dental healthcare personnel (DHCP) are at high risk of exposure to coronavirus disease 2019 (COVID-19). We sought to identify how DHCP changed their use of personal protective equipment (PPE) as a result of the COVID-19 pandemic, and to pilot an educational video designed to improve knowledge of proper PPE use.

The study comprised 2 sets of semistructured qualitative interviews.

The study was conducted in 8 dental clinics in a Midwestern metropolitan area.

In total, 70 DHCP participated in the first set of interviews; 63 DHCP participated in the second set of interviews.

In September–November 2020 and March–October 2021, we conducted 2 sets of semistructured interviews: (1) PPE use in the dental community during COVID-19, and (2) feedback on the utility of an educational donning and doffing video.

Overall, 86% of DHCP reported having prior training. DHCP increased the use of PPE during COVID-19, specifically N95 respirators and face shields. DHCP reported real-world challenges to applying infection control methods, often resulting in PPE modification and reuse. DHCP reported double masking and sterilization methods to extend N95 respirator use. Additional challenges to PPE included shortages, comfort or discomfort, and compatibility with specialty dental equipment. DHCP found the educational video helpful and relevant to clinical practice. Fewer than half of DHCP reported exposure to a similar video.

DHCP experienced significant challenges related to PPE access and routine use in dental clinics during the COVID-19 pandemic. An educational video improved awareness and uptake of appropriate PPE use among DHCP.

To determine the impact of various aerosol mitigation interventions and to establish duration of aerosol persistence in a variety of dental clinic configurations.

We performed aerosol measurement studies in endodontic, orthodontic, periodontic, pediatric, and general dentistry clinics. We used an optical aerosol spectrometer and wearable particulate matter sensors to measure real-time aerosol concentration from the vantage point of the dentist during routine care in a variety of clinic configurations (eg, open bay, single room, partitioned operatories). We compared the impact of aerosol mitigation strategies (eg, ventilation and high-volume evacuation (HVE), and prevalence of particulate matter) in the dental clinic environment before, during, and after high-speed drilling, slow–speed drilling, and ultrasonic scaling procedures.

Conical and ISOVAC HVE were superior to standard-tip evacuation for aerosol-generating procedures. When aerosols were detected in the environment, they were rapidly dispersed within minutes of completing the aerosol-generating procedure. Few aerosols were detected in dental clinics, regardless of configuration, when conical and ISOVAC HVE were used.

Dentists should consider using conical or ISOVAC HVE rather than standard-tip evacuators to reduce aerosols generated during routine clinical practice. Furthermore, when such effective aerosol mitigation strategies are employed, dentists need not leave dental chairs fallow between patients because aerosols are rapidly dispersed.

To evaluate opportunities for assessing penicillin allergies among patients presenting to dental clinics.

Retrospective cross-sectional study.

VA dental clinics.

Adult patients with a documented penicillin allergy who received an antibiotic from a dentist between January 1, 2015, and December 31, 2018, were included.

Chart reviews were completed on random samples of 100 patients who received a noncephalosporin antibiotic and 200 patients who received a cephalosporin. Each allergy was categorized by severity. These categories were used to determine patient eligibility for 3 testing groups based on peer-reviewed algorithms: (1) no testing, (2) skin testing, and (3) oral test-dose challenge. Descriptive and bivariate statistics were used to compare facility and patient demographics first between true penicillin allergy, pseudo penicillin allergy, and missing allergy documentation, and between those who received a cephalosporin and those who did not at the dental visit.

Overall, 19% lacked documentation of the nature of allergic reaction, 53% were eligible for skin testing, 27% were eligible for an oral test-dose challenge, and 1% were contraindicated from testing. Male patients and African American patients were less likely to receive a cephalosporin.

Most penicillin-allergic patients in the VA receiving an antibiotic from a dentist are eligible for penicillin skin testing or an oral penicillin challenge. Further research is needed to understand the role of dentists and dental clinics in assessing penicillin allergies.

United States dentists prescribe 10% of all outpatient antibiotics. Assessing appropriateness of antibiotic prescribing has been challenging due to a lack of guidelines for oral infections. In 2019, the American Dental Association (ADA) published clinical practice guidelines (CPG) on the management of acute oral infections. Our objective was to describe baseline national antibiotic prescribing for acute oral infections prior to the release of the ADA CPG and to identify patient-level variables associated with an antibiotic prescription.

Cross-sectional analysis.

We performed an analysis of national VA data from January 1, 2017, to December 31, 2017. We identified cases of acute oral infections using International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Antibiotics prescribed by a dentist within ±7 days of a visit were included. Multivariable logistic regression identified patient-level variables associated with an antibiotic prescription.

Of the 470,039 VA dental visits with oral infections coded, 12% of patient visits with irreversible pulpitis, 17% with apical periodontitis, and 28% with acute apical abscess received antibiotics. Although the median days’ supply was 7, prolonged use of antibiotics was frequent (≥8 days, 42%–49%). Patients with high-risk cardiac conditions, prosthetic joints, and endodontic, implant, and oral and maxillofacial surgery dental procedures were more likely to receive antibiotics.

Most treatments of irreversible pulpitis and apical periodontitis cases were concordant with new ADA guidelines. However, in cases where antibiotics were prescribed, prolonged antibiotic courses >7 days were frequent. These findings demonstrate opportunities for the new ADA guidelines to standardize and improve dental prescribing practices.

To examine rural–urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI).

Observational cohort study.

Using the IBM MarketScan Commercial Database (2010–2015), we identified US commercially insured women aged 18–44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural–urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural–urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural–urban status.

Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10–1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural–urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty.

Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.

To characterize trends in outpatient antibiotic prescriptions in the United States

Retrospective ecological and temporal trend study evaluating outpatient antibiotic prescriptions from 2013 to 2015

National administrative claims data from a pharmacy benefits manager PARTICIPANTS. Prescription pharmacy beneficiaries from Express Scripts Holding Company

Annual and seasonal percent change in antibiotic prescriptions

Approximately 98 million outpatient antibiotic prescriptions were filled by 39 million insurance beneficiaries during the 3-year study period. The most commonly prescribed antibiotics were azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin. No significant changes in individual or overall annual antibiotic prescribing rates were found during the study period. Significant seasonal variation was observed, with antibiotics being 42% more likely to be prescribed during February than September (peak-to-trough ratio [PTTR], 1.42; 95% confidence interval [CI], 1.39–1.61). Similar seasonal trends were found for azithromycin (PTTR, 2.46; 95% CI, 2.44–3.47), amoxicillin (PTTR, 1.52; 95% CI, 1.42–1.89), and amoxicillin/clavulanate (PTTR, 1.78; 95% CI, 1.68–2.29).

This study demonstrates that annual national outpatient antibiotic prescribing practices remained unchanged during our study period. Furthermore, seasonal peaks in antibiotics generally used to treat viral upper respiratory tract infections remained unchanged during cold and influenza season. These results suggest that inappropriate prescribing of antibiotics remains widespread, despite the concurrent release of several guideline-based best practices intended to reduce inappropriate antibiotic consumption; however, further research linking national outpatient antibiotic prescriptions to associated medical conditions is needed to confirm these findings.

Infect Control Hosp Epidemiol 2018;39:584–589