To summarize available literature and highlight research gaps pertaining to the role of a pharmacist in providing antimicrobial stewardship (AMS) interventions for antibiotics at transitions of care (TOC) from inpatient hospital settings to home.

Scoping review.

This scoping review follows the Arksey and O’Malley methodological framework. The literature search was conducted using the MEDLINE (OVID) database.

The MEDLINE (OVID) search returned 45 results. Of these, 26 were excluded during title and abstract screening and 11 were excluded after full-text review. Overall, eight studies were included in this scoping review. In six of the studies, AMS interventions were pharmacist-led. In two studies, they were led by an AMS team which included a pharmacist. Six of the studies used a similar intervention where a pharmacist led the review of antibiotics prior to patient discharge and made recommendations to change therapy where appropriate. The details of how these interventions were carried out vary between studies.

Overall, all studies included in this scoping review concluded that pharmacists have a role in providing AMS interventions at TOC. This scoping review summarized available literature pertaining to the role of the pharmacist in providing AMS interventions for antibiotics at TOC. Research gaps that were highlighted are optimal level of AMS training for pharmacists providing AMS interventions, optimal workflow, ideal method of communication to the prescriber, and quality improvement metrics.

Inpatient antibiotic use increased during the early phases of the COVID-19 pandemic. We sought to determine whether these changes persisted in persons with and without COVID-19 infection.

Retrospective cohort analysis.

108 Veterans Affairs (VA) facilities.

Persons receiving acute inpatient care from January 2016 to October 2022.

Data on antibacterial use, patient days present, and COVID-19 care were extracted from the VA Corporate Data Warehouse. Days of therapy (DOT) per 1000 days present (DP) were calculated and stratified by Centers for Disease Control and Prevention-defined antibiotic classes.

Antibiotic use increased from 534 DOT/1000 DP in 11/2019–2/2020 to 588 DOT/1000 DP in 3/2020–4/2020. Subsequently, antibiotic use decreased such that total DOT/1000 DP was 2% less in 2020 as a whole than in 2019. Driven by treatment for community acquired pneumonia, antibiotic use was 30% higher in persons with COVID-19 than in uninfected persons in 3/2020–4/2020, but only 4% higher for the remainder of 2020. In 2022 system-wide antibiotic use was 9% less in persons with COVID-19; however, antibiotic use remained higher in persons with COVID-19 in 25% of facilities.

Although antibiotic use increased during the early phases of the COVID-19 pandemic, overall use subsequently decreased to below previous baseline levels and, in 2022, was less in persons with COVID-19 than in persons without COVID-19. However, further work needs to be done to address variances across facilities and to determine whether current levels of antibiotic use in persons with COVID-19 are justified.

This cross-sectional study aims to determine the mortality trends in patients with SARS-CoV-2 infection during the pandemic in Flint, MI.

Records from 1,663 consecutive adult patients (≥18 years of age) with confirmed SARS-CoV-2 infection, admitted and discharged from our facility from 03/2020 through 02/2022, were abstracted and analyzed. Multivariable logistic regression analysis was performed to examine the association between study explanatory variables (ie, sex, age, co-morbidities, etc.) and the primary study outcome (ie, mortality).

During the 2-year study period, the overall crude 90-day mortality rate was 16.1% (267/1663), being lowest in the period 5 (Table 1). Male sex, older age, certain co-morbidities, supplemental oxygenation use, and lack of immunization were associated with mortality. Therapeutics such as remdesivir and steroids were not associated with improved survival.

Despite substantial changes in supportive care, management and circulating variants, SARS-CoV-2 carried a significant mortality risk. Vaccination coverage in this high-risk study sample was low, at only 12%. Public health efforts should be focused at overcoming the barriers to vaccine acceptance in this high-risk unique population.

The primary objective was to determine the rate of clinical actions taken post-discharge on updated microbiology results by an ID pharmacist-led team. Secondary objectives were to describe the microbiology results requiring intervention, characterize interventions by type and severity, and determine time from result to clinical review.

Retrospective cohort study.

Four hospitals within Mayo Clinic, including two large academic centers and two Mayo Clinic Health System sites.

Adult patients at four sites within Mayo Clinic from 1/1/2019 to 2/28/2023. Eligible patients had a hospitalization with an ID consult and an updated microbiology result reported after discharge.

Pharmacists reviewed a report of selected patients with microbiology tests that resulted post-discharge within the last 24–96 hours. Interventions were recorded electronically in real-time by the pharmacist. Of those patient encounters with an intervention, a sample of 200 patient encounters was randomly selected for detailed chart abstraction.

A total of 6,792 encounters with at least one microbiology result reviewed post-discharge were identified. Of these encounters, 1977 (29%) had at least one resulting intervention. Median time from test update to clinical review was 27.2 hours (IQR 21.6–69.6). The highest severity ratings, in which failure to intervene may have resulted in patient harm, were assigned to the intervention in 28% of cases.

For patients seen by an inpatient ID consult service, a post-hospital discharge microbiology result review process performed by ID-trained pharmacists effectively addressed abnormal results during the transition of care. Similar processes may be considered at other institutions.

Patients receiving hematopoietic stem cell transplants (HSCT) are at increased risk for Clostridioides difficile infection (CDI). The purpose of this study was to assess the effectiveness of oral vancomycin prophylaxis (OVP) for CDI in HSCT patients.

Single-center, retrospective cohort.

Tertiary care academic medical center in New Jersey.

Patients ≥18 years old during admission for the HSCT were included. Patients who were admitted <72 hours or who had an active CDI prior to HSCT day 0 were excluded.

Medical records of patients admitted between January 2015 and August 2022 to undergo an allogeneic or autologous HSCT were reviewed. The primary end point was the incidence of in-hospital CDI. Secondary end points included the incidence of vancomycin-resistant enterococci (VRE) bloodstream infections, VRE isolated from any clinical culture, gram-negative bloodstream infections, hospital survival, and hospital length of stay. Exploratory end points, including 1-year survival, relapse, and incidence of graft-versus-host disease, were also collected.

A total of 156 HSCT patients were included. There was 1 case of CDI (1 of 81, 1.23%) in the OVP group compared to 8 CDI cases (8 of 75, 10.67%) in the no OVP group (P = .0147). There were no significant (P > .05) between-group differences in incidence of gram-negative bloodstream infections, hospital survival, and length of stay. There were zero clinical cultures positive for VRE.

In-hospital incidence of CDI in HSCT patients was significantly decreased with OVP. Randomized controlled trials are needed in this high-risk population to assess the efficacy and risks of OVP for CDI.

The aim of this study was to assess the clinical value of urinary tract infections (UTIs) guideline algorithms and the role of nonspecific symptoms to support clinical decision-making in nursing home residents.

In a preplanned secondary analysis of a cross-sectional study including nursing home residents with a presumed UTI, 2 prediction models were used in a decision curve analysis (DCA): (1) guideline-based and (2) extended: nonspecific symptom(s) added to the guideline model. The stringent outcome definition for “true UTIs” included symptom improvement during adequate antimicrobial therapy, based on susceptibility test results. The outcome of a DCA is the Net Benefit to quantify the performance of the prediction models, visualized in a decision curve.

Dutch nursing homes (n = 13).

Nursing home residents with a presumed UTI.

Of the 180 residents with a presumed UTI, 43 fulfilled the definition of “true UTI” (23.9%). The Net Benefit of the guideline-based model was low and the corresponding threshold range was small (21%–28%). The extended model improved the prediction of UTIs. However, the clinical usefulness of the extended model was still limited to a small threshold range (10%–28%).

The clinical usefulness of the current guideline-based algorithm to diagnose UTI in nursing home residents seems limited, and adding nonspecific symptoms does not further improve decision-making due to the small threshold probability. Given the poor performance of the guideline-based model, refinement of the guidelines may be required.

Dutch trial registry: NTR6467; date of first registration, 25/05/2017.

The acceptability of an electronic HH monitoring system (EHHMS) was evaluated among hospital staff members.

An electronic HH monitoring system was implemented in June 2020 at a large, academic medical center. An interdisciplinary team developed a cross-sectional survey to gather staff perceptions of the EHHMS.

The survey was conducted at a public, tertiary acute care hospital.

The survey included current employees and staff. 1,273 participants responded. The mean age was 44.9 years (SD = 13.5). Most of the samples were female (71%) and non-Hispanic white (83%).

A survey was conducted between June and July 2021. Responses were analyzed using Stata statistical software. Multiple logistic regression models were constructed to examine factors associated with negative perceptions of the EHHMS and its radiofrequency identification (RFID) badge. Supporting qualitative analyses were performed using Atlas.ti version 9.

Three-quarters (75%) of respondents reported neutral to negative perceptions of the EHHMS and its associated badge. Respondents reported limited influence on HH practices. Age, campus location, length of employment, job role, and opinion on data sharing were associated with negative perceptions of the EHHMS and RFID badge. Position in a direct patient care role was associated with negative perceptions of the RFID badge.

Perceptions of the EHHMS aligned with previous research. Identified associations provide opportunities for targeted education, outreach, and intervention to increase acceptability and uptake. Lack of acceptance is explained by poorly perceived ease of use and usefulness, as well as challenges in implementation.

The aim of this study was to determine if oral beta-lactam therapy is non-inferior to alternative therapy at discharge following inpatient treatment with an IV cephalosporin for acute pyelonephritis.

Institutional Review Board (IRB)-approved, multicenter, retrospective, non-inferiority cohort (15% non-inferiority margin).

Six hospitals within two healthcare systems.

Hospitalized patients admitted to the medical floor with acute pyelonephritis without urologic abnormalities who received cefazolin or ceftriaxone followed by step-down therapy.

Patients were discharged with either an oral beta-lactam or an oral alternative agent (ie, fluoroquinolone or trimethoprim-sulfamethoxazole) to complete therapy. The primary objective was treatment failure defined as a composite of hospital readmission or an ED visit for a urinary cause within 30 days of discharge of the index hospitalization. Data were extracted manually from the electronic medical record.

A total of 211 patients were included; 122 received an oral beta-lactam and 89 received an oral alternative agent at discharge. There was no difference in 30-day treatment failure between the two groups (4.9% vs 5.6% for oral beta-lactams vs oral alternatives, respectively. Absolute difference = 0.7%; 95% CI -5.4% to 6.8%; P = .82). The median length of hospital stay, number of patients treated with intravenous ceftriaxone, duration of IV therapy, and median duration of oral therapy were no different between groups.

In non-ICU patients admitted for pyelonephritis without urologic abnormalities, oral beta-lactams were non-inferior to oral alternatives for step-down therapy. In finding non-inferiority between the regimens, we show the feasibility of administering oral beta-lactams to complete therapy for acute pyelonephritis.

We aimed to assess risk of COVID-19 infection & seroprotection status in healthcare workers (HCWs) in both hospital and community settings following an intensive vaccination drive in India.

Tertiary Care Hospital

We surveyed COVID-19 exposure risk, personal protective equipment (PPE) compliance, vaccination status, mental health & COVID-19 infection rate across different HCW cadres. Elecsys® test for COVID-19 spike (Anti-SARS-CoV-2S; ACOVs) and nucleocapsid (Anti-SARS-CoV-2; ACOV) responses following vaccination and/or COVID-19 infection were measured in a stratified sample of 386 HCW.

We enrolled 945 HCWs (60.6% male, age 35.9 ± 9.8 years, 352 nurses, 211 doctors, 248 paramedics & 134 support staff). Hospital PPE compliance was 90.8%. Vaccination coverage was 891/945 (94.3%). ACOVs neutralizing antibody was reactive in 381/386 (98.7%). ACOVs titer (U/ml) was higher in the post-COVID-19 infection group (N =269; 242.1 ± 35.7 U/ml) than in the post-vaccine or never infected subgroup (N = 115, 204.1 ± 81.3 U/ml). RT PCR + COVID-19 infections were documented in 224/945 (23.7%) and 6 HCWs had disease of moderate severity, with no deaths. However, 232/386 (60.1%) of HCWs tested positive for nucleocapsid ACOV antibody, suggesting undocumented or subclinical COVID-19 infection. On multivariate logistic regression, only female gender [aOR 1.79, 95% CI 1.07–3.0, P = .025] and COVID-19 family contact [aOR 5.1, 95% CI 3.84–9.5, P < .001] were predictors of risk of developing COVID-19 infection, independent of association with patient-related exposure.

Our HCWs were PPE compliant and vaccine motivated, with immunization coverage of 94.3% and seroprotection rate of 98.7%. There was no relationship between HCW COVID-19 infection to exposure characteristics in the hospital. Vaccination reduced disease severity and prevented death in HCW.

This study aimed to investigate the contamination status of hospital sinks with carbapenemase-producing Enterobacterales (CPE), the efficacy of daily cleaning with sodium hypochlorite, and the relationships between CPEs isolated from contaminated sinks and patients.

Pre/postintervention surveys of the CPE-contaminated sinks.

Hospital wards including pediatric intensive care unit in a children’s hospital.

Consenting CPE-colonized patients admitted between November 2018 and June 2021 in our hospital.

Environmental culture of 180 sinks from nine wards in our hospital was performed three times with an interval of 2 years (2019, 2021, 2023). Molecular typing of the isolated strains from the sinks and patients was performed. After the first surveillance culture, we initiated daily disinfection of the sinks using sodium hypochlorite.

Before the intervention, we detected 30 CPE-positive sinks in 2019. After the intervention with sodium hypochlorite, we observed a substantial decline in the number of sinks contaminated with CPE; 13 in 2021 and 6 in 2023. However, the intervention did not significantly reduce the number of CPE-contaminated sinks used for the disposal of nutrition-rich substances. The CPE isolates from the patients and those from the sinks of the wards or floors where they were admitted tended to have similar pulse-field gel electrophoresis patterns.

Contaminated sinks could be reservoirs of disseminating CPE to the patients. Daily disinfection of sinks with sodium hypochlorite may be effective in eliminating CPE, although the effect could be weaker in sinks with a greater risk of contact with nutrition-rich substances.

To describe the epidemiology of healthcare-associated Clostridioides difficile infection (HA-CDI) in two Québec hospitals in Canada following the 2003 epidemic and to evaluate the impact of antibiotic stewardship on the incidence of HA-CDI and the NAP1/027 strain.

Time-series analysis.

Two Canadian tertiary care hospitals based in Montréal, Québec.

Patients with a positive assay for toxigenic C. difficile were identified through infection control surveillance. All cases of HA-CDI, defined as symptoms occurring after 72 hours of hospital admission or within 4 weeks of hospitalization, were included.

The incidence of HA-CDI and antibiotic utilization from 2003 to 2020 were analyzed with available C. difficile isolates. The impact of antibiotic utilization on HA-CDI incidence was estimated by a dynamic regression time-series model. Antibiotic utilization and the proportion of NAP1/027 strains were compared biannually for available isolates from 2010 to 2020.

The incidence of HA-CDI decreased between 2003 and 2020 at both hospitals from 26.5 cases per 10,000 patient-days in 2003 to 4.9 cases per 10,000 patient-days in 2020 respectively. Over the study period, there were an increase in the utilization of third-generation cephalosporins and a decrease in usage of fluoroquinolones and clindamycin. A decrease in fluoroquinolone utilization was associated with a significant decrease in HA-CDI incidence as well as decrease in the NAP1/027 strain by approximately 80% in both hospitals.

Decreased utilization of fluoroquinolones in two Québec hospitals was associated with a decrease in the incidence of HA-CDI and a genotype shift from NAP1/027 to non-NAP1/027 strains.

To investigate whether empiric carbapenem therapy, compared to empiric non-carbapenem therapy, was associated with improved clinical outcomes among hospitalized, non-intensive care unit (ICU) patients with extended-spectrum β-lactamase (ESBL)-producing Enterobacterales infections.

We performed a retrospective cohort study of adult, non-ICU patients admitted with ESBL-producing Enterobacterales infections. Primary outcome was time to clinical stability from the first empiric antibiotic dose. Secondary outcomes were early clinical response and 30-day all-cause hospital readmission. We used multivariate regression methods to examine time to clinical stability.

Of the 142 patients, 59 (42%) received empiric carbapenems and 83 (58%) received empiric non-carbapenems, most commonly ceftriaxone (49/83, 59%). Median age was 59 years. The most common infection source was urinary (71%). The carbapenem group had a higher proportion of patients who received antibiotics within 6 months of admission (55% vs 28%, P < .01) and history of ESBL (57% vs 17%, P < .01). There were no significant differences in hours until clinical stability between the carbapenem and non-carbapenem groups (22 (IQR: 0, 85) vs 19 (IQR: 0, 69), P = .54). Early clinical response (88% vs 90%, P = .79) and 30-day all-cause hospital readmission (17% vs 8%, P = .13) were similar between groups.

Among hospitalized non-ICU patients with ESBL-producing Enterobacterales infection, we found no difference in time to clinical stability after the first empiric antibiotic dose between those receiving carbapenems and those who did not. Our data suggest that empiric carbapenem use may not be an important driver of clinical response in patients with less severe ESBL-producing Enterobacterales infection.

Prior studies evaluating the impact of discontinuation of contact precautions (DcCP) on methicillin-resistant Staphylococcus aureus (MRSA) outcomes have characterized all healthcare-associated infections (HAIs) rather than those likely preventable by contact precautions. We aimed to analyze the impact of DcCP on the rate of MRSA HAI including transmission events identified through whole genome sequencing (WGS) surveillance.

Quasi experimental interrupted time series.

Acute care medical center.

Inpatients.

The effect of DcCP (use of gowns and gloves) for encounters among patients with MRSA carriage was evaluated using time series analysis of MRSA HAI rates from January 2019 through December 2022, compared to WGS-defined attributable transmission events before and after DcCP in December 2020.

The MRSA HAI rate was 4.22/10,000 patient days before and 2.98/10,000 patient days after DcCP (incidence rate ratio [IRR] 0.71 [95% confidence interval 0.56–0.89]) with a significant immediate decrease (P = .001). There were 7 WGS-defined attributable transmission events before and 11 events after DcCP (incident rate ratio 0.90 [95% confidence interval 0.30–2.55]).

DcCP did not result in an increase in MRSA HAI or, in WGS-defined attributable transmission events. Comprehensive analyses of the effect of transmission prevention measures should include outcomes specifically measuring transmission-associated HAI.

Clostridioides difficile infection (CDI) is a common, healthcare-associated infection. However, in Japan, testing for CDI is infrequent, suggesting that its incidence may be underestimated. This study aimed to examine the implementation of a multifaceted, diagnostic stewardship (DS) for CDI in a small Japanese hospital during the coronavirus 2019 pandemic.

Before-after study.

A small Japanese community hospital.

Healthcare workers including physicians, nurses, and pharmacists.

A multifaceted intervention including (1) the addition of CD testing criteria to the hospital guidelines; (2) provision of a tutorial on CD testing to physicians, nurses, and pharmacists; (3) assessment by clinical pharmacists and nurses of the need for CD testing in patients with nosocomial diarrhea and issuance of recommendations for CD testing to physicians; (4) reporting of data on the CD testing rate and CDI incidence in the study center.

The CD testing rate increased before the pandemic (+0.16/10,000 patient-days (PD); P = .28), decreased significantly during the pandemic (−0.79/10,000 PD; P = .02), and then increased significantly immediately after the implementation of the intervention (+29.6/10,000 PD; P < .01). Similarly, the CDI incidence increased significantly before the pandemic (+0.26/10,000 PD; P = .02) and decreased significantly during the pandemic (−0.49/10,000 PD; P = .01). Implementation of the intervention resulted in an immediate and significant increase in the CDI incidence (+6.2/10,000 PD; P < .01).

Multifaceted DS involving multidisciplinary specialists was effective in improving CD testing, suggesting that appropriate testing can contribute to diagnosing CDI accurately.