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Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Background Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs. Methods An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs. Results One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions. Conclusions Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.

Antimicrobial resistance (AMR), frequently considered a major global public health threat, requires a comprehensive understanding of its emergence, mechanisms, advances, and implications. AMR’s epidemiological landscape is characterized by its widespread prevalence and constantly evolving patterns, with multidrug-resistant organisms (MDROs) creating new challenges every day. The most common mechanisms underlying AMR (i.e., genetic mutations, horizontal gene transfer, and selective pressure) contribute to the emergence and dissemination of new resistant strains. Therefore, mitigation strategies (e.g., antibiotic stewardship programs—ASPs—and infection prevention and control strategies—IPCs) emphasize the importance of responsible antimicrobial use and surveillance. A One Health approach (i.e., the interconnectedness of human, animal, and environmental health) highlights the necessity for interdisciplinary collaboration and holistic strategies in combating AMR. Advancements in novel therapeutics (e.g., alternative antimicrobial agents and vaccines) offer promising avenues in addressing AMR challenges. Policy interventions at the international and national levels also promote ASPs aiming to regulate antimicrobial use. Despite all of the observed progress, AMR remains a pressing concern, demanding sustained efforts to address emerging threats and promote antimicrobial sustainability. Future research must prioritize innovative approaches and address the complex socioecological dynamics underlying AMR. This manuscript is a comprehensive resource for researchers, policymakers, and healthcare professionals seeking to navigate the complex AMR landscape and develop effective strategies for its mitigation.

Purpose of ReviewAn unconfirmed penicillin allergy is known to confer significant risk to patients. Only a small minority of patients labeled with penicillin allergy will be confirmed to be hypersensitive with the current reference standard test, an oral amoxicillin therapeutic dose challenge. Skin testing has been recommended prior to oral challenges to reduce the risk of severe acute challenge reactions. The rate of severe acute anaphylactic reactions with oral amoxicillin is currently extremely low. Unfortunately, penicillin skin testing, as commonly performed, has a high rate of false positive results.Recent FindingsEncouraging skin testing in all individuals with an unconfirmed penicillin allergy, prior to a confirmatory oral challenge, would be technically difficult, make testing all individuals with an unconfirmed penicillin allergy very unlikely, and ultimately increase the risk to patients because of suboptimal antibiotic use. Most patients, who are appropriate candidates for a direct oral amoxicillin challenge, to confirm current penicillin tolerance, can be safely identified by their clinical histories. Higher risk individuals, those with a history of anaphylaxis or other acute onset potentially IgE-mediated reaction such as hives within 6 h of the first dose of the last course of a penicillin, may benefit from properly performed puncture and intradermal skin testing, using commercially available penicilloyl-polylysine, prior to an oral challenge, if skin test negative.SummaryDirect oral amoxicillin challenges in low-risk individuals are well accepted by patients and a safe and effective part of penicillin allergy delabeling.

Background The appropriate use of Piperacillin/Tazobactam (Pip/Taz), including the correct dose, escalating and or de-escalation according to the microbiological culture is essential to reduce the antibiotic resistance. Resistant to antimicrobials in a major global problem and contributes significantly to morbidity, mortality and cost of care. Guidelines exists to ensure appropriate use of Pip/Taz. Antibiotics Stewardship guidelines ( https://apps.who.int/iris/bitstream/handle/10665/329404/9789241515481-eng.pdf ) provides a detailed recommendation with regards to initiation, monitoring and escalation and de-escalation based on final culture results. Appling such guidelines ensures a more proper utilization of the empiric uses of antibiotics used in the hospital-based setting. Use of Pip/Taz in cases of suspected infection postoperatively is common practice in the cardiac surgery ward where this study was conducted. Methods This was a prospective cohort study involving all patients who were admitted to the cardiac surgery unit of a tertiary care center. All patient prescribed at least 1 day of Pip/Taz as an empirical therapy were included and prospectively observed. We aimed to evaluate the use of Pip/Taz and its appropriateness based on Antibiotics Stewardship guidelines (ASG). Any deviation from the guidelines in initiation, escalation, de-escalation based on culture and sensitivity results was considered inappropriate use. Four patients died (1.3%) early as result of complications for surgery but included in the analysis. The study was conducted from October 2017 to October 2018. Results Of the 300 patients who received Pip/Taz Cultures were done in 250 patients (83%). The overall appropriate use of Pip/Taz was seen in 166 patients (55.3%). Conclusion The empirical use of Pip/Taz in the surgical cardiac unit was largely inappropriate and not entirely driven by the culture test results. Interventions are needed to optimize the use of Pip/Taz including appropriate culture and sensitivity driven use and timely de-escalation or de-escalation when indicated. This will prevent emergence of resistance and reduce the patient toxicity and financial costs.

Increased antibiotic use and antibiotic homogeneity cause selective pressure. This study investigated the correlation between antibiotic diversity and antimicrobial resistance (AMR) in Gram-negative organisms. The days of therapy/100 patient-days (DOT) for four broad-spectrum antibiotic classes were evaluated for 2015–2022. The antibiotic heterogeneity index (AHI) for the equal use of four classes (25%) and the modified AHI for the equal use of three classes (30%), excluding fluoroquinolones (10%), were measured (target: 1.0). Quarterly antibiotic use markers and the resistance rates against ≥2 anti-Pseudomonas antibiotics were compared. The DOT value was 9.94, and the relative DOT were 34.8% for carbapenems, 32.1% for piperacillin/tazobactam, 24.3% for fourth generation cephalosporins/ceftazidime/aztreonam, and 8.9% for fluoroquinolones. Although no correlation was found between the total DOT and the resistance rate for any bacterium, a significant negative correlation was found between the heterogeneity indices and resistance rates for Pseudomonas aeruginosa and Klebsiella pneumoniae. The significant cutoffs that discriminate the risk of resistance were 0.756 for the AHI and 0.889 for the modified AHI for K. pneumoniae. Antibiotic diversity is more important in preventing AMR than overall antibiotic use. The ideal ratio of broad-spectrum antibiotics should be studied for diversified use to prevent AMR.

Introduction: This study aims to evaluate the efficacy of a new antimicrobial stewardship program (ASP) on surgical antibiotic prophylaxis (SP) and antibiotics in discharge prescriptions used as a continuation of SP. Methodology: The study included elective patients with clean and clean-contaminated wounds. The accuracy of the assigned SP was evaluated according to international guidelines. Primary outcome measures comprised appropriateness of prophylactic antibiotic indication, correct timing of initial dose, discontinuation of SP within 24 hours, and antibiotic prescription at discharge. A secondary outcome measure was to determine whether the effect of ASP was sustained long-term. Results: The total compliance rate for all stages of SP increased from 8% to 52.1% after the intervention (p < 0.05). When analyzed according to individual SP components, it was found that although ASP did not change first dose timing rates, it did affect the rates of prophylactic antibiotic indication, discontinuation of SP within 24 hours and antibiotic prescription at discharge, with statistical significance (p < 0.05). In addition, ASP continued to increase its effectiveness throughout the 3rd year. Conclusions: Based on the findings of our study, it seems clear that the modified ASP introduced in our general surgery clinic can be used effectively and simply; in addition, this ASP increases its efficacy with time.

In 2014, the Centers for Disease Control and Prevention (CDC) released the Core Elements of Hospital Antibiotic Stewardship Programs (ASPs) and began monitoring uptake through the National Healthcare Safety Network (NHSN) Annual Hospital Survey. In 2019, CDC updated the Core Elements and in 2022 released the Priorities for Hospital Core Element Implementation. We describe Core Element uptake from 2014 to 2021, provide a snapshot of specific ASP practices in acute care hospitals in 2021, and describe how we plan to monitor stewardship moving forward. We used the NHSN Annual Hospital Survey to summarize facility demographics and ASP practices and to monitor uptake of Core Elements. Questions have been updated over time, so not all data could be compared across years. Uptake of all 7 Core Elements increased from 41% in 2014 to 95% in 2021. Uptake of all 6 Priority Elements was 10% in 2021, though 46% of hospitals met 4 or 5 of the possible 6 elements. Antibiotic stewardship was specifically listed in a contract or job description for about 60% of program leaders. The percentage of physician-pharmacist co-led programs rose from 23% to 64%. Seventy-six percent of hospitals reported implementing audit with feedback interventions. With nearly all acute care hospitals reporting uptake of the 7 Core Elements in 2021, and with more evidence for which ASP practices are most effective, the Priorities for Hospital Core Element Implementation were released in 2022 to help enhance the quality and impact of existing ASPs.

Irrational use of antibiotics and antibiotic resistance are one of the major problems encountered in healthcare services. Antibiotic stewardship programs (ASPs) have been one of the most successful attempts in hospitals to control antibiotic resistance. Pharmacists are the core health professionals in ASPs. This study aimed to examine the effect of clinical pharmacist-led ASPs on antibiotic consumption with meta-analysis. ScienceDirect, PubMed, MEDLINE and Cochrane databases were searched for relevant studies. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline was used to identify studies for the review. Methodological quality was assessed using Newcastle-Ottawa scale (NOS) and National Heart, Lung and Blood Institute (NHLBI) pre-post comparison studies quality tool. The R (version 4.0.3.) and metafor packages (version 2.1-0) were used for a random-effects metaanalysis. After pharmacist intervention, the pooled rational use of antibiotics was determined as 0.28 (28% improvement, I2=98.26; 95% CI 0.15-0.41). The pooled duration of therapy data was determined as 0.41 (41% reduction, I2=96.30%; 95% CI 0.54-0.29) in favor of the group with the pharmacist’s intervention. As a result of this study, it was determined that clinical pharmacists took part in the evaluation of the patient, regulation of the treatment, follow-up of the patient after treatment, and education in ASPs. These findings can contribute to improving the role of the pharmacist in ASPs and rational antibiotic use, thereby controlling antibiotic resistance.