Background: The role of follow up blood cultures (FUBC) in the management of gram-negative bloodstream infection (GN-BSI) remains controversial. This retrospective cohort study examines the association between obtaining FUBC and mortality in GN-BSI. Methods: Hospitalized adults with community-onset GN-BSI at Prisma Health-Midlands hospitals in South Carolina, USA from January 1, 2010 to June 30, 2015 were identified. Patients who died or were discharged from hospital within 72 h were excluded to minimize impact of survival and selection biases on results, respectively. Multivariate Cox proportional hazards regression was used to examine association between obtaining FUBC and 28-day all-cause mortality after adjustment for the propensity to obtain FUBC. Findings: Among 766 patients with GN-BSI, 219 (28.6%) had FUBC obtained and 15 of 219 (6.8%) FUBC were persistently positive. Overall, median age was 67 years, 438 (57%) were women, 457 (60%) had urinary source of infection, and 426 (56%) had BSI due to Escherichia coli. Mortality was significantly lower in patients who had FUBC obtained than in those who did not have FUBC (6.3% vs. 11.7%, log-rank p = 0.03). Obtaining FUBC was independently associated with reduced mortality (hazards ratio 0.47, 95% confidence intervals: 0.23À0.87; p = 0.02) after adjustments for age, chronic comorbidities, acute severity of illness, appropriateness of empirical antimicrobial therapy, and propensity to obtain FUBC. Interpretation: Improved survival in hospitalized patients with GN-BSI who had FUBC is consistent with the results of recent publications from Italy and North Carolina supporting utilization of FUBC in management of GN-BSI. Funding: This study had no funding source.

For decades, the performance of antimicrobial stewardship programs (ASPs) has been measured by incidence rates of hospital-onset Clostridioides difficile and other infections due to multidrug-resistant bacteria. However, these represent indirect and nonspecific ASP metrics. They are often confounded by factors beyond an ASP’s control, such as changes in diagnostic testing methods or algorithms and the potential of patient-to-patient transmission. Whereas these metrics remain useful for global assessment of healthcare systems, antimicrobial use represents a direct metric that separates the performance of an ASP from other safety and quality teams within an institution. The evolution of electronic medical records and healthcare informatics has made measurements of antimicrobial use a reality. The US Centers for Disease Control and Prevention’s initiative for reporting antimicrobial use and standardized antimicrobial administration ratio in hospitals is highly welcomed. Ultimately, ASPs should be evaluated based on what they do best and what they can control, that is, antimicrobial use within their own institution. This narrative review critically appraises existing stewardship metrics and advocates for adopting antimicrobial use as the primary performance measure. It proposes novel formulas to adjust antimicrobial use based on quality of care and microbiological burden at each institution to allow for meaningful inter-network and inter-facility comparisons.

This retrospective cohort study examined the impact of the pandemic on antimicrobial use (AU) in South Carolina hospitals. AU in days of therapy (DOT) per 1000 days-present was evaluated in 17 hospitals in South Carolina. Matched-pairs mean difference was used to compare AU during the pandemic (March-June 2020) to that during the same months in 2019 in hospitals that did and did not admit patients with COVID-19. There was a 6.6% increase in overall AU in the 7 hospitals admitting patients with COVID-19 (from 530.9 to 565.8; mean difference: 34.9 DOT/1000 days-present, 95% CI: 4.3, 65.6; p=0.03). There was no significant change in overall AU in the remaining 10 hospitals that did not admit patients with COVID-19 (mean difference 6.0 DOT/1000 days-present, 95% CI: -55.5, 67.6; p=0.83). Most of the increase in AU in the 7 hospitals that admitted patients with COVID-19 was observed in broad-spectrum antimicrobial agents. A 16.4% increase was observed in agents predominantly used for hospital-onset infections (from 122.3 to 142.5; mean difference: 20.1 DOT/1000 days-present, 95% CI: 11.1, 29.1, p=0.002). There was also a 9.9% increase in the use of anti-MRSA agents (from 66.7 to 73.3; mean difference: 6.6 DOT/1000 days-present, 95% CI: 2.3, 10.8; p=0.01). COVID-19 pandemic appears to drive overall and broad-spectrum antimicrobial use in South Carolina hospitals admitting patients with COVID-19. Additional antimicrobial stewardship resources are needed to curtail excessive antimicrobial use in hospitals to prevent subsequent increases in antimicrobial resistance and Clostridioides difficile infection rates given the continuing nature of the pandemic.

The standardized antimicrobial administration ratio (SAAR) is a novel antimicrobial stewardship metric that compares actual to expected antimicrobial use (AU). This prospective cohort study examines the utility of SAAR reporting and inter-facility comparisons as a motivational tool to improve overall and broad-spectrum AU within a three-hospital healthcare system. Transparent inter-facility comparisons were deployed during system-wide antimicrobial stewardship meetings beginning in October 2017. Stakeholders were advised to interpret the results to foster competition and incorporate SAAR data into focused antimicrobial stewardship interventions. Student’s t-test was used to compare mean SAARs in the pre- (July 2017 through October 2017) and post-intervention periods (November 2017 through June 2019). The mean pre-intervention SAARs for hospitals A, B, and C were 0.69, 1.09, and 0.60, respectively. Hospital B experienced significant reductions in SAAR for overall AU (from 1.09 to 0.83; p < 0.001), broad-spectrum antimicrobials used for hospital-onset infections (from 1.36 to 0.81; p < 0.001), and agents used for resistant gram-positive infections in the intensive care units (from 1.27 to 0.72; p < 0.001) after the interventions. The alignment of the SAAR across the health-system and sustained reduction in overall and broad-spectrum AU through implementation of inter-facility comparisons demonstrate the utility in the motivational application of this antimicrobial use metric.