Computerized clinical decision support (CDS) assists healthcare professionals in making decisions to improve patient care. In the realms of antimicrobial stewardship (ASP) and infection prevention (IP) programs, CDS interventions can play a crucial role in optimizing antibiotic prescribing practices, reducing healthcare-associated infections, and promoting diagnostic stewardship when optimally designed. This primer article aims to provide ASP and IP professionals with a practical framework for the development, design, and evaluation of CDS interventions.

Large academic medical center design: Established frameworks of CDS evaluation, “Five Rights” of CDS and the “Ten Commandments of Effective Clinical Decision Support”, were applied to two real-world examples of CDS tools, a Vancomycin Best Practice Advisory and a Clostridioides Difficile order panel, to demonstrate a structured approach to developing and enhancing the functionality of ASP/IP CDS interventions to promote efficacy and reduce unintended consequences of CDS.

By outlining a structured approach for the development and evaluation of CDS interventions, with focus on end user engagement, efficiency and feasibility, ASP and IP professionals can leverage CDS to enhance IP/ASP quality improvement initiatives aimed to improve antibiotic utilization, diagnostic stewardship, and adherence to IP protocols.

During the past several decades, enterococci are emerging as an important cause of healthcare-associated infections. They have developed resistance to various antimicrobials previously used for the treatment of urinary tract infections (UTIs). This study was aimed to determine the prevalence of Enterococcus species among urinary tract-infected patients in a tertiary care hospital, in Karnataka, India.

We have analyzed 4341 culture-positive urine samples received by microbiology laboratory during the year 2021. The bacterial identification was done by matrix-assisted laser desorption ionization-time of flight mass spectrometry. The antibiotic sensitivity was tested by automated VITEK-2® COMPACT (bioMérieux) system.

Among 4341 culture-positive samples, Enterococcal species were isolated from 159 samples. A total of 64.7% of the isolates were identified as Enterococcus faecalis and 28.3% of the strains as Enterococcus faecium. All the enterococci were sensitive to linezolid, teicoplanin, and vancomycin, whereas 59.1%, 30.9%, and 23.3% of the strains exhibited resistance to high-level gentamicin, benzylpenicillin, and nitrofurantoin, respectively. 33.67 % of the isolates were identified as multidrug-resistant (MDR) strains as they exhibited resistance to high-level gentamicin, benzylpenicillin, and nitrofurantoin.

Our study shows the prevalence of Enterococcus faecalis and high-level gentamicin-resistant enterococcal strains. The MDR pattern of enterococci requires careful consideration of antimicrobial therapy to treat UTIs. The reserved drugs such as linezolid, vancomycin, and teicoplanin should be cautiously used for the treatment of enterococcal UTI.

To develop a symptom assessment tool to assist health care providers with discussing bowel habits in a sensitive and accurate method.

Pre and Post education survey.

180 bed academically affiliated Veterans Affairs Hospital.

Nurses, nursing assistants and physicians who participated in a brief educational session.

A Bowel Habits Assessment Tool (BHAT) was developed to assist health care providers in learning skills to assess patient bowel habits accurately. The BHAT was introduced at educational sessions. An anonymous pre and post survey employing a 5-point Likert scale was administered to participants.

Pre-educational session survey results for Question 1 (Q1) “I am comfortable discussing patient’s bowel habits included: 4.6% strongly disagreed or somewhat disagreed, 3% neither agreed nor disagreed, 20% somewhat agreed and 72.3% strongly agreed. After the BHAT education, 100% (n=65) of participants strongly agreed or somewhat agreed that they were comfortable discussing patient’s bowel habits. Q1 pre/post mean difference 0.25 (CI 0.06539 - 0.4269, p = 0.0084). On the pre-survey, only 34% of participants strongly agreed that they were aware of tools to help discuss patients’ bowel habits. This increased to 77% after the BHAT educational session. (Q2). Q2 pre/post mean difference 1.02 (CI 0.7366 - 1.294, p <0.0001).

The BHAT improved clinicians’ comfort level discussing patient’s bowel habits. Health care providers found the BHAT useful and related to their work. This tool shows promise in improving providers’ comfort discussing bowel habits and diagnosing Clostridioides difficile in a timely manner.

To assess the effectiveness of a 3-question decision-support tool to guide the diagnosis and treatment of urinary tract infections (UTIs) in acute care hospitalized patients as an antibiotic and diagnostic stewardship initiative.

Retrospective cohort study.

Four acute care hospitals within the same health system in Miami, FL.

124, admitted from the emergency department and hospitalized adult patients, treated with antibiotics for the indication of a UTI between March and April 2023.

We developed a 3-step clinical decision-support tool (CDST) to evaluate the appropriateness of urine cultures and antibiotic treatment. The tool’s recommendations when deciding to prescribe antibiotics were compared with the actual need for treatment throughout the hospitalization, up to the time of patient discharge.

Overall, 31% of antibiotics prescribed for UTIs were inappropriate and met the criteria for asymptomatic bacteriuria (ASB) based on the CDST. Prospective implementation of the decision-support tool could potentially reduce antibiotic use by 33.6%, corresponding to 265 days of unnecessary therapy. The sensitivity and specificity of the tool were calculated to be 98.6% and 100%, respectively, indicating high accuracy in identifying the need for antibiotic treatment. Urinalysis alone was insufficient to differentiate between symptomatic UTIs and ASB, with leukocyturia present in 95.3% of UTI cases and 94.6% of ASB cases (P = 0.87).

Implementing a 3-question CDST may reduce unnecessary laboratory work-up and treatment for ASB improving the diagnostic and antimicrobial stewardship of UTIs.

To describe the use of plasma next-generation sequencing (NGS) and determine if it provided additional information from routine tests or lead to change in antimicrobial management.

This retrospective cohort study evaluated patients with a NGS test performed who were admitted to a hospital health system in the greater Houston area between May 2022 and May 2023.

In total, 143 NGS tests were ordered in the span of one year for 135 unique patients. Most patients were ≥ 18 years (74.1%), White/Caucasian (43.7%), male (61.5%), and immunocompetent (54.1%). Eight patients had repeat tests during the study period, four being after an initial rejected test, and the rest being greater than 7 days from the initial test.

Of the 139 NGS tests performed, 56 (40%) were positive. When compared to routine testing, 49 (35%) were negative when routine testing was negative, 15 (11%) positive were concordant with routine testing, 29 (21%) positive were discordant from routine testing, 17 (12%) negative while routine testing was positive, and 29 (21%) were positive while routine testing was negative. Documented changes in antimicrobial due to NGS occurred after 16 (13.6%) tests, with the majority of these changes occurring in immunocompromised patients (14/16 [88%]).

NGS provided additional data when compared to routine testing but rarely resulted in antimicrobial changes. The majority of changes occurred in immunocompromised patients. Diagnostic stewardship is a vital component for this type of NGS testing and others in which guidelines do not exist.

Antimicrobial stewardship programs are very essential in addressing the problem of drug-resistant infections. The WHO Access, Watch, and Reserve (AWaRe) classification of antibiotics is essential in monitoring the rational use of antibiotics. Therefore, this study evaluated the awareness of the WHO AWaRe classification of antibiotics among pharmacy professionals in Zambia.

This cross-sectional study was conducted among 239 pharmacy professionals practicing in both private and public facilities in Zambia. A questionnaire was used to collect data which was subsequently analyzed using IBM SPSS version 23.0.

Of the 239 participants, 63% were male and most were pharmacists employed in the public sector. This study found that 58% of the pharmacy professionals were aware of the AWaRe classification of antibiotics. Consequently, only 36% of the participants agreed that they implemented the AWaRe framework of antibiotics in their healthcare facilities. Most of the participants (74%) agreed that implementing the AWaRe tool can promote the rational use of antibiotics and 98% of the participants were willing to learn more about the AWaRe tool through training or meetings.

This study found a low awareness of the WHO AWaRe classification of antibiotics among pharmacy professionals. Our study further revealed that very few pharmacy professionals agreed that they had implemented the WHO AWaRe tool in their healthcare facilities. Hence, there is a need to strengthen antimicrobial stewardship programs by implementing the AWaRe framework and other recommended guidelines for monitoring the rational use of antibiotics.

To estimate incidence and healthcare costs and mortality associated with Clostridioides difficile infection (CDI) among adults <65 years old.

Retrospective cohort study.

First CDI episodes among commercially insured US patients 18–64 years old were identified from a large claims database. CDI+ patients were propensity score−matched (PSM) 1:1 with CDI− controls using clinically relevant variables including comorbidities.

Annual CDI incidence was calculated by age group and year (2015−2019). Healthcare utilization, costs, and mortality were analyzed by age group, acquisition (healthcare and community), and hospitalization status by calculating CDI-excess costs and mortality as the difference between PSM CDI+ and CDI− individuals.

In 50–64- and 18–49-year-olds, respective CDI incidence per 100,000 person-years decreased from 217 and 113 cases in 2015 to 167 and 87 cases in 2019. Most cases (76.5%–86.9%) were community-associated. The costs and mortality analyses included 6,332 matched CDI+/− 50–64-year-olds and 6,667 CDI+/− 18–49-year-olds. Among 50–64-year-olds, mean 2-month healthcare and patients’ out-of-pocket costs were $11,634 and $573 higher, respectively, in the CDI+ versus CDI− group. Among 18–49-year-olds, 2-month costs were $7,826 and $642 higher. Healthcare costs were higher for healthcare- versus community-associated CDI. At the 12-month follow-up, mortality was significantly higher in the CDI+ versus CDI− groups for both 50–64-year-olds (4.2% vs 2.0%; P < .001) and 18–49-year-olds (1.2% vs 0.6%; P < .001). Mortality rates were higher for hospitalized versus nonhospitalized CDI+ patients.

Prevention of CDI among adults 18–64 years old may significantly reduce costs and mortality.

To determine if implementing stewardship pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) nasal surveillance increases use of the test and reduces the inappropriate use of vancomycin for MRSA coverage in patients with pneumonia.

Retrospective pre-/post-intervention study.

Large teaching acute care hospital.

Adult patients receiving vancomycin therapy for treatment of pneumonia.

A stewardship pharmacist ran a report of admitted patients receiving vancomycin and reviewed the patients’ records. If the patient’s indication was pneumonia and a MRSA nasal swab had not been ordered, the pharmacist contacted the patient’s provider and requested an order for it. Upon receipt of a negative MRSA nasal swab result, the pharmacist recommended discontinuation of vancomycin if appropriate.

The control group was four weeks prior to the stewardship intervention, where there was no dedicated stewardship pharmacist reviewing MRSA swab utilization. The primary outcome was percentage of patients who had a MRSA swab ordered. Secondary outcomes included percentage of patients who had vancomycin appropriately de-escalated based on MRSA nasal swab results and length of vancomycin therapy.

Percentage of swabs ordered increased from 36.1% (22/61) to 83.7% (41/49) with pharmacist intervention (P < 0.0001). The rate of vancomycin de-escalation following a negative MRSA swab increased from 19.7% (12/61) to 61.2% (30/49) with pharmacist intervention (P < 0.0001).

The results suggest implementing a pharmacist driven MRSA nasal surveillance program into practice could increase the number of MRSA nasal swabs ordered and promote timely de-escalation of vancomycin in patients with pneumonia.

Examine the relationship between patients’ race and prescriber antibiotic choice while accounting for differences in underlying illness and infection severity.

Retrospective cohort analysis.

Acute care facilities within an academic healthcare system.

Adult inpatients from January 2019 through June 2022 discharged from the Hospital Medicine Service with an ICD-10 Code for Pneumonia.

We describe variability in days of therapy of antimicrobials with activity against Pseudomonas aeruginosa (anti-Pseudomonas agents) or against MRSA (anti-MRSA agents), by patient’s race and ethnicity. We estimated the likelihood of receipt of any anti-Pseudomonas agents by race and modeled the effect of race on rate of use, adjusting for age, severity, and indication.

5,820 patients with 6,700 encounters were included. After adjusting for broad indication, severity, underlying illness, and age, use of anti-Pseudomonas agents were less likely among non-Hispanic Black patients than other race groups, although this effect was limited to younger patients (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.29, 0.70), and not older ones (aOR 0.98; 95% CI 0.85, 1.13); use of anti-MRSA agents were similar between groups. Among patients receiving any anti-Pseudomonas agents, Black patients received them for relatively lower proportion of their inpatient stay (incidence rate ratio 0.91; 95% CI 0.87, 0.96).

We found difference in use of anti-Pseudomonas agents between non-Hispanic Black patients and other patients that could not be easily explained by indications or underlying illness, suggesting unmeasured factors may be playing a role in treatment decisions.