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BackgroundDespite focused initiatives to reduce device-associated infection among hospitalised patients, the practices US hospitals are currently using are unknown. We thus used a national survey to ascertain the use of several established and novel practices to prevent device-associated infections.MethodsWe mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about the use of practices to prevent three common device-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). Using sample weights, we estimated the percentage of hospitals reporting regular use of each practice. We also conducted multivariable regression to determine associations between selected hospital characteristics (eg, perceived support from leadership) and use of CAUTI, CLABSI and VAP prevention practices.ResultsThe response rate was 59%. Several practices are reportedly used in over 90% of US hospitals: aseptic technique during indwelling urethral catheter insertion and maintenance (to prevent CAUTI); maximum sterile barrier precautions during central catheter insertion and alcohol-containing chlorhexidine gluconate for insertion site antisepsis (to prevent CLABSI); and semirecumbent positioning of the patient (to prevent VAP). Antimicrobial devices are used in the minority of hospitals for these three device-associated infections.ConclusionsWe provide an updated snapshot of the practices US hospitals are currently using to prevent device-associated infections. Compared with previous studies using a similar design and questions, we found that the use of recommended practices increased in US hospitals, especially for CAUTI prevention.

ASPs that are integrated with hospital infection prevention programs have an advantage in response efforts to emerging pathogens in that (1) they are likely to have pre-existing infection prevention skills and experience, (2) they are likely to be involved in response efforts early, and (3) they will have access to and influence with key stakeholders. Because ASPs and infection prevention programs share similar technology infrastructure, data, and metrics, program integration has many advantages.2 Response efforts to novel respiratory viruses like SARS-CoV-2/COVID-19 represent an opportunity for programs to formally integrate, to develop cross-coverage capabilities, and to create shared leadership opportunities. Novel respiratory virus outbreaks associated with secondary bacterial pneumonias and acute respiratory distress syndrome (ARDS) provide an opportunity for ASPs to monitor compliance with guideline-concordant therapy; severe COVID-19 cases have been treated with broad-spectrum antibiotics.4 Additionally, ASPs can help in the development of local treatment protocols involving repurposed antivirals; they can monitor and manage drug shortages due to supply chain interruptions5; and they can assist frontline providers with expanded access investigational new drug applications (eINDs) and local institutional review board procedures for investigational agents. The Joint Commission accreditation standard for ASPs includes, when available, an infectious diseases physician, pharmacist, infection preventionist, and other practitioners.6 ASP physician and pharmacy leaders often have specialized infectious diseases training.3 Leveraging these resources for planning and response efforts for emerging pathogens is critical and can strengthen and sustain collaborative relationships.

Inappropriate antifungal use is prevalent and can lead to drug-resistant fungi, expose patients to adverse drug events, and increase healthcare costs. While antimicrobial stewardship programs have traditionally focused on antibiotic use, the need for targeted antifungal stewardship (AFS) intervention has garnered interest in recent years. Despite this, data on AFS in immunocompromised patient populations is limited. This paper will review the current state of AFS in this complex population and explore opportunities for multidisciplinary collaboration.

Hospital epidemiologists, infection preventionists, and antimicrobial stewards are integral to the pandemic workforce. However, regardless of pandemic surge or postsurge conditions, their workload remains high due to constant vigilance for new variants, emerging data, and evolving public health guidance. We describe the factors that have led to burnout and suggest strategies to enhance resilience.

Background Watchful waiting management for acute otitis media (AOM), where an antibiotic is used only if the child’s symptoms worsen or do not improve over the subsequent 2–3 days, is an effective approach to reduce antibiotic exposure for children with AOM. However, studies to compare the effectiveness of interventions to promote watchful waiting are lacking. The objective of this study is to compare the effectiveness and implementation outcomes of two pragmatic, patient-centered interventions designed to facilitate use of watchful waiting in clinical practice. Methods This will be a cluster-randomized trial utilizing a hybrid implementation-effectiveness design. Thirty-three primary care or urgent care clinics will be randomized to one of two interventions: a health systems-level intervention alone or a health systems-level intervention combined with use of a shared decision-making aid. The health systems-level intervention will include engagement of a clinician champion at each clinic, changes to electronic health record antibiotic orders to facilitate delayed antibiotic prescriptions as part of a watchful waiting strategy, quarterly feedback reports detailing clinicians’ use of watchful waiting individually and compared with peers, and virtual learning sessions for clinicians. The hybrid intervention will include the health systems-level intervention plus a shared decision-making aid designed to inform decision-making between parents and clinicians with best available evidence. The primary outcomes will be whether an antibiotic was ultimately taken by the child and parent satisfaction with their child’s care. We will explore the differences in implementation effectiveness by patient population served, clinic type, clinical setting, and organization. The fidelity, acceptability, and perceived appropriateness of the interventions among different clinician types, patient populations, and clinical settings will be compared. We will also conduct formative qualitative interviews and surveys with clinicians and administrators, focus groups and surveys of parents of patients with AOM, and engagement of two stakeholder advisory councils to further inform the interventions. Discussion This study will compare the effectiveness of two pragmatic interventions to promote use of watchful waiting for children with AOM to reduce antibiotic exposure and increase parent satisfaction, thus informing national antibiotic stewardship policy development. Clinical trial registration NCT06034080.

IntroductionAntimicrobial stewardship (AMS) is an important strategy to control antimicrobial resistance. Resources are available to provide guidance for design and implementation of AMS programmes, however these may have limited applicability in resource-limited settings including those in Asia. This scoping review aims to identify context-specific domains and items for the development of a healthcare facility (HCF)-level tool to guide AMS implementation in Asia.Methods and analysisThis review is the first step in a larger project to assess AMS implementation, needs and gaps in Asia. We will employ a deductive qualitative approach to identify locally appropriate domains and items of AMS implementation guided by Nilsen and Bernhardsson’s contextual dimensions. This process is also informed by discussions from a technical advisory group coordinated by the US Centers for Disease Control and Prevention to develop an AMS HCF-level assessment tool for low-income and middle-income countries. We will review English-language documents that discuss HCF-level implementation, including those describing frameworks, components/elements or recommendations for design, implementation or assessment globally and specific to Asia. We have performed the search in August–September 2021 including general electronic databases (MEDLINE, Embase, Web of Science and Google Scholar), region-specific databases, national action plans, grey literature sources and reference lists to identify eligible documents. Country-specific documents will be restricted to countries in three subregions: South Asia, East Asia and Southeast Asia. Codes and themes will be derived through a content analysis, classified following the predefined context dimensions and used for developing domains and items of the assessment tool.Ethics and disseminationResults from this review will feed into our stepwise process for developing a context-specific HCF-level assessment tool for AMS programmes to assess the implementation status, identify intervention opportunities and monitor progress over time. The process will be done in consultation with local stakeholders, the end-users of the generated knowledge.

Antimicrobial resistance is a well-known global health threat that has higher prevalence in the refugee population. Although guidance has been provided by the World Health Organization and Centers for Disease Control and Prevention on implementing antimicrobial stewardship in lower- and middle-income countries, as well as by the United Nations Refugee Agency on other infection prevention and control efforts, no specific guidance exists for implementation of stewardship in this population. We highlight challenges specific to this population, review recent studies of interest within this space, and propose a research agenda to help move stewardship forward in the refugee population. We advocate for the importance of this issue, particularly given recent current events of geopolitical volatility that render this population more vulnerable, in the setting of its already well-known numerous health challenges.

By conservative estimates, 700,000 deaths this year will be attributable globally to antimicrobial-resistant bacteria, and this number will rise to 10 million deaths by 2050 if trends in antimicrobial resistance do not change.1 Reversing trends in antimicrobial resistance could have the biggest impact in India, which has the highest infectious disease burden in the world.2 Recent India-wide estimates of Escherichia coli resistance demonstrate 77% resistance to third-generation cephalosporins, 84% resistance to fluoroquinolones, and up to 59% resistance to carbapenems for Klebsiella pneumoniae isolates.3 The concept of antimicrobial stewardship can be hard to reconcile in this setting—particularly with overwhelming barriers including inadequate sanitation, unrestricted access to antibiotics in the community, antibiotic use in agriculture, and antibiograms that warn of a post-antibiotic era. Applying a tiered framework like the Centers for Disease Control and Prevention (CDC) Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings points out how deploying antimicrobial stewardship in India necessitates revision of constructs that have been used commonly in the United States due to the vastly different healthcare infrastructure.4,5 In this issue of Infection Control and Hospital Epidemiology, Rupali et al6 describe incorporating stewardship principles into infectious disease consultation in a South Indian hospital.6 They focused on the intensive care unit and found that 73.3% of antibiotic prescriptions were inappropriate, indicating that an effective inpatient antimicrobial stewardship program would make substantial impact. Selected Contributing Barriers to Antimicrobial Stewardship in India and Tactics that May Help Barriers Proposed Tactics Unregulated antibiotic use in the community National policy change (eg, the Red Line Campaign) Few existing hospital antimicrobial stewardship programs Build stewardship into hospital accreditation standards Lack of infectious diseases (ID)–trained pharmacists and ID physicians Build capacity for infectious diseases fellowship programs and construct infectious disease pharmacy training programs in large academic centers/pharmacy schools; involve medical microbiologists Lack of empowerment of pharmacists Socioadaptive tactics, employing multidisciplinary stewardship teams Disconnected process for inpatients obtaining antibiotics (eg, families will often buy antibiotics from a separate pharmacy while patient is inpatient) Engage insurance and pharmacy stakeholders in cost-related stewardship interventions (eg, narrow-spectrum antibiotics should be priced lower than broad-spectrum antibiotics) Author for correspondence:

Hypervirulent strains of Klebsiella pneumoniae are associated with abscess formation, commonly hepatic, and metastatic spread, even in healthy patients. We describe a case of this clinical syndrome, genotypic and phenotypic features of the isolate, and briefly review epidemiology, clinical manifestations, and pathogenesis of this underappreciated syndrome.

Objective:Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis.Design:Retrospective cohort study.Participants:All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019–June 30th, 2020.Methods:Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5–10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration.Results:Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non–first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]).Conclusions:First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.