The Critical Role of the Staff Nurse in Antimicrobial Stewardship—Unrecognized, but Already There
TL;DR: An operational analysis of inpatient admissions evaluates staff nurses' nursing stewardship activities and analyzes the potential benefits of nurses' formal education about, and inclusion into, ASPs.
Abstract: An essential participant in antimicrobial stewardship who has been unrecognized and underutilized is the "staff nurse." Although the role of staff nurses has not formally been recognized in guidelines for implementing and operating antimicrobial stewardship programs (ASPs) or defined in the medical literature, they have always performed numerous functions that are integral to successful antimicrobial stewardship. Nurses are antibiotic first responders, central communicators, coordinators of care, as well as 24-hour monitors of patient status, safety, and response to antibiotic therapy. An operational analysis of inpatient admissions evaluates these nursing stewardship activities and analyzes the potential benefits of nurses' formal education about, and inclusion into, ASPs.
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TL;DR: This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports and guidance in the preanalytic phase.
Abstract: Antimicrobial stewardship is a bundle of integrated interventions employed to optimize the use of antimicrobials in health care settings. While infectious-disease-trained physicians, with clinical pharmacists, are considered the main leaders of antimicrobial stewardship programs, clinical microbiologists can play a key role in these programs. This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports, guidance in the preanalytic phase, rapid diagnostic test availability, provider education, and alert and surveillance systems. In reviewing this material, we emphasize how the rapid, and especially the recent, evolution of clinical microbiology has reinforced the importance of clinical microbiologists' collaboration with antimicrobial stewardship programs.
147 citations
Cites background from "The Critical Role of the Staff Nurs..."
...Thus, the role of nursing in accurate and standardized specimen collection should be emphasized (43, 103, 104)....
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TL;DR: In this article, a group of experts in infectious diseases/clinical microbiology and wound management, after thoroughly reviewing the available literature and holding teleconferences, jointly produced a guidance document aimed at providing clinicians an understanding of: the basic principles of why AMS is important in caring for patients with infected wounds; who should be involved in AMS; and how to conduct AMS for patients having infected wounds.
Abstract: Background With the growing global problem of antibiotic resistance it is crucial that clinicians use antibiotics wisely, which largely means following the principles of antimicrobial stewardship (AMS). Treatment of various types of wounds is one of the more common reasons for prescribing antibiotics. Objectives This guidance document is aimed at providing clinicians an understanding of: the basic principles of why AMS is important in caring for patients with infected wounds; who should be involved in AMS; and how to conduct AMS for patients with infected wounds. Methods We assembled a group of experts in infectious diseases/clinical microbiology (from the British Society for Antimicrobial Chemotherapy) and wound management (from the European Wound Management Association) who, after thoroughly reviewing the available literature and holding teleconferences, jointly produced this guidance document. Results All open wounds will be colonized with bacteria, but antibiotic therapy is only required for those that are clinically infected. Therapy is usually empirical to start, but definitive therapy should be based on results of appropriately collected specimens for culture. When prescribed, it should be as narrowly focused, and administered for the shortest duration, as possible. AMS teams should be interdisciplinary, especially including specialists in infection and pharmacy, with input from administrative personnel, the treating clinicians and their patients. Conclusions Available evidence is limited, but suggests that applying principles of AMS to the care of patients with wounds should help to reduce the unnecessary use of systemic or topical antibiotic therapy and ensure the safest and most clinically effective therapy for infected wounds.
103 citations
TL;DR: The attitudes of nurses and infection preventionists toward 5 nurse‐driven antibiotic stewardship practices were explored, and three practices were perceived most favorably: questioning the necessity of urinary cultures, ensuring proper culturing techniques, and encouraging the prompt transition from IV to PO antibiotics.
76 citations
TL;DR: The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aims to improve antibiotic prescribing practices by combining adaptive change theories and evidence-based diagnostic and treatment practices to accomplish meaningful and sustained change.
Abstract: Antibiotics save countless lives, but can also cause significant harm including antibiotic-associated adverse events, Clostridium difficile (also known as Clostridioides difficile) infections, increasing antibiotic resistance, and changes to the microbiome (the implications of changes to the microbiome are only beginning to be understood).1 Antibiotic stewardship programs have become increasingly commonplace in hospitals in the United States and around the world, but these programs almost always rely heavily on restrictive practices (eg, requiring approval before prescribing certain antibiotics) or persuasive practices (eg, discussions with clinicians regarding the continued need for antibiotics).2 Although these approaches have had success in improving antibiotic use,2 they depend on external motivators, and their ability to influence how clinicians will prescribe antibiotics in the absence of an antibiotic stewardship program–driven intervention is questionable. Some conceptual frameworks have been shown to assist clinicians with recognizing problems and guiding them through a logical sequence of questions and potential solutions (eg, patient care handoffs between clinicians).3 Similar low-cost, straightforward approaches have been successfully used to improve adherence with hand hygiene guidelines4 and central line insertion practices.5 A structured approach emphasizing the 4 critical time points of antibiotic prescribing may improve antibiotic decision making by clinicians and communication surrounding antibiotic decisions among health care practitioners (eg, nurses, pharmacists). The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use aims to improve antibiotic prescribing practices by combining adaptive change theories and evidence-based diagnostic and treatment practices to accomplish meaningful and sustained change.6 A core feature of the AHRQ safety program is training clinicians to incorporate the 4 moments of antibiotic decision making into their thought process when prescribing antibiotics. The 4 moments framework provides an easy-to-remember, structured approach to improve antibiotic prescribing that could be used in the acute care setting (Table).
73 citations
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TL;DR: A review of the literature on quality assessment of medical care can be found in this article, where the authors focus almost exclusively on the evaluation of the medical care process at the level of physician-patient interaction.
Abstract: This p aper i s a n a ttempt t o d escribe a nd evaluate current methods for assessing the quality of medical care and to suggest some directions for further study. It is concerned with methods rather than findings, and with an evaluation of methodology in general, rather than a detailed critique of methods in specific studies. This is not an exhaustive review of the pertinent literature. Certain key studies, of course, have been included. Other papers have been selected only as illustrative examples. Those omitted are not, for that reason, less worthy of note. This paper deals almost exclusively with the evaluation of the medical care process at the level of physician-patient interaction. It excludes, therefore, processes primarily related to the effective delivery of medical care at the community level. Moreover, this paper is not concerned with the administrative aspects of quality control. Many of the studies reviewed here have arisen out of the urgent need to evaluate and control the quality of care in organized programs of medical care. Nevertheless, these studies will be discussed only in terms of their contribution to methods of assessment and not in terms of their broader social goals. The author has remained, by and large, in the familiar territory of care provided by physicians and has avoided incursions into other types of
5,020 citations
TL;DR: This research presents a meta-analysis of 125 cases of central giant cell apoptosis, a type of cell death that is known as a “cell death” and which has been associated with Parkinson’s disease for more than 40 years.
Abstract: Timothy H. Dellit, Robert C. Owens, John E. McGowan, Jr., Dale N. Gerding, Robert A. Weinstein, John P. Burke, W. Charles Huskins, David L. Paterson, Neil O. Fishman, Christopher F. Carpenter, P. J. Brennan, Marianne Billeter, and Thomas M. Hooton Harborview Medical Center and the University of Washington, Seattle; Maine Medical Center, Portland; Emory University, Atlanta, Georgia; Hines Veterans Affairs Hospital and Loyola University Stritch School of Medicine, Hines, and Stroger (Cook County) Hospital and Rush University Medical Center, Chicago, Illinois; University of Utah, Salt Lake City; Mayo Clinic College of Medicine, Rochester, Minnesota; University of Pittsburgh Medical Center, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; William Beaumont Hospital, Royal Oak, Michigan; Ochsner Health System, New Orleans, Louisiana; and University of Miami, Miami, Florida
2,831 citations
TL;DR: If the antimicrobial resistance crisis is to be addressed, a concerted, grassroots effort led by the medical community will be required and could mean a literal return to the preantibiotic era for many types of infections.
Abstract: The ongoing explosion of antibiotic-resistant infections continues to plague global and US health care. Meanwhile, an equally alarming decline has occurred in the research and development of new antibiotics to deal with the threat. In response to this microbial “perfect storm,” in 2001, the federal Interagency Task Force on Antimicrobial Resistance released the “Action Plan to Combat Antimicrobial Resistance; Part 1: Domestic” to strengthen the response in the United States. The Infectious Diseases Society of America (IDSA) followed in 2004 with its own report, “Bad Bugs, No Drugs: As Antibiotic Discovery Stagnates, A Public Health Crisis Brews,” which proposed incentives to reinvigorate pharmaceutical investment in antibiotic research and development. The IDSA’s subsequent lobbying efforts led to the introduction of promising legislation in the 109th US Congress (January 2005–December 2006). Unfortunately, the legislation was not enacted. During the 110th Congress, the IDSA has continued to work with congressional leaders on promising legislation to address antibiotic-resistant infection. Nevertheless, despite intensive public relations and lobbying efforts, it remains unclear whether sufficiently robust legislation will be enacted. In the meantime, microbes continue to become more resistant, the antibiotic pipeline continues to diminish, and the majority of the public remains unaware of this critical situation. The result of insufficient federal funding; insufficient surveillance, prevention, and control; insufficient research and development activities; misguided regulation of antibiotics in agriculture and, in particular, for food animals; and insufficient overall coordination of US (and international) efforts could mean a literal return to the preantibiotic era for many types of infections. If we are to address the antimicrobial resistance crisis, a concerted, grassroots effort led by the medical community will be required.
1,523 citations
"The Critical Role of the Staff Nurs..." refers background in this paper
...use, pharmaceutical industry retreat from new antibiotic development [2], and spread of antibiotic resistant organisms [3], combined with rapid, accessible international travel [4] has captured the attention of healthcare professionals, national...
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Journal Article•
1,347 citations
Additional excerpts
...ceptance of antimicrobial stewardship, and outcomes [41]....
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TL;DR: In this article, the authors found that patients with penicillin "allergy" history spend significantly more time in the hospital and are exposed to significantly more antibiotics previously associated with C difficile and vancomycin-resistant Enterococcus (VRE).
Abstract: Background Penicillin is the most common drug "allergy" noted at hospital admission, although it is often inaccurate. Objective We sought to determine total hospital days, antibiotic exposures, and the prevalence rates of Clostridium difficile , methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) in patients with and without penicillin "allergy" at hospital admission. Methods We performed a retrospective, matched cohort study of subjects admitted to Kaiser Foundation hospitals in Southern California during 2010 through 2012. Results It was possible to match 51,582 (99.6% of all possible cases) unique hospitalized subjects with penicillin "allergy" to 2 unique discharge diagnosis category–matched, sex-matched, age-matched, and date of admission–matched control subjects each. Cases with penicillin "allergy" averaged 0.59 (9.9%; 95% CI, 0.47-0.71) more total hospital days during 20.1 ± 10.5 months of follow-up compared with control subjects. Cases were treated with significantly more fluoroquinolones, clindamycin, and vancomycin ( P C difficile , 14.1% (95% CI, 7.1% to 21.6%) more MRSA, and 30.1% (95% CI, 12.5% to 50.4%) more VRE infections than expected compared with control subjects. Conclusions A penicillin "allergy" history, although often inaccurate, is not a benign finding at hospital admission. Subjects with a penicillin "allergy" history spend significantly more time in the hospital. Subjects with a penicillin "allergy" history are exposed to significantly more antibiotics previously associated with C difficile and VRE. Drug "allergies" in general, but most those notably to penicillin, are associated with increased hospital use and increased C difficile , MRSA, and VRE prevalence.
572 citations