How Far We’ve Come, How Far We Have to Go: a Review of Advances in Antimicrobial Stewardship in the Veterans Health Administration

Ramakrishnan, Aditi; Patel, Payal

doi:10.1007/s40506-020-00221-w

“…Similarly, a total of 1227 S. maltophilia isolates were identified between 2009-2012 which increased to 1987 between 2013-2016 from 259 medical centres worldwide enrolled in the SENTRY surveillance programme [21]. The decreasing trend in S. maltophilia cultures we observed may be related to increased infection control and antimicrobial stewardship efforts throughout the VA over the study period [33][34][35]. It is unknown why S. maltophilia cultures decreased in VA hospitals and long-term care facilities and remained stable in outpatient facilities.…”

Section: Discussionmentioning

confidence: 65%

“…The decreasing trend in S. maltophilia cultures we observed may be related to increased infection control and antimicrobial stewardship efforts throughout the VA over the study period [33–35]. It is unknown why S.…”

Section: Discussionmentioning

confidence: 99%

Trends in Stenotrophomonas maltophilia antibiotic resistance rates in the United States Veterans Affairs Health System

Appaneal

¹

,

Lopes

²

,

LaPlante

³

et al. 2022

Journal of Medical Microbiology

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Introduction. Stenotrophomonas maltophilia is an important multidrug-resistant Gram-negative pathogen. While largely a hospital-acquired pathogen, there have been increasing reports of the pathogen in the community. Gap Statement. Trends in S. maltophilia prevalence and resistance rates that include outpatient isolates are unknown. Aim. We described recent trends in prevalence and resistance of S. maltophilia in the national Veterans Affairs (VA) Healthcare system. Methodology. The study identified positive S. maltophilia clinical cultures among VA adult patients from 2010 to 2018 across all VA hospitals, long-term care facilities/units, and outpatient settings. Annual S. maltophilia resistance rates were evaluated. Multidrug resistant (MDR) was defined as resistance to sulfamethoxazole/trimethoprim (SMX/TMP) and minocycline or levofloxacin. Time trends were assessed with regression analyses to estimate annual average percent changes (AAPC) with 95 % confidence intervals using Joinpoint software. Results. Over the 9 year study period, 18 285 S . maltophilia cultures were identified (57 % hospital, 3 % long-term care, 40 % outpatient). The most common source of S. maltophilia cultures were respiratory cultures (34.6 %) followed by urine cultures (30.4 %). In VA hospitals and long-term care facilities, the number of S. maltophilia cultures decreased significantly (by 5.4% and 8.4 % per year respectively). Overall, 3.1 % of isolates were MDR which remained stable over the study period. Resistance to other antibiotics assessed mostly remained stable, except SMX/TMP resistance decreased significantly by 8.5 % (2010, 15 %; 2018, 6 %) per year in VA hospitals. Conclusion. While previous work has recognized S. maltophilia as primarily a nosocomial pathogen, the present study found that 40 % of cultures collected were among outpatients. Between 2010 and 2018, the number of positive S. maltophilia cultures decreased significantly in the national VA Healthcare System. Resistance to SMX/TMP decreased over the study period in VA hospitals and now more closely reflects previously reported resistance rates worldwide (0–10 %). MDR S. maltophilia remained stable and low in the national VA Healthcare System.

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“…In 2007, the VA implemented a methicillin-resistant Staphylococcus aureus (MRSA) infection control bundle among all VA medical centers, and previous work has shown that this initiative may have led to reductions in Gram-negative bacteria through expanded infection control programs and resources [22]. In 2011, the VA established the National Antimicrobial Stewardship Task Force (ASTF) and in 2014 the VA required all of its hospitals to have antimicrobial stewardship programs [23]. Previous work has demonstrated an increase in antimicrobial stewardship in VAMCs over the study period [24].…”

Section: Discussionmentioning

confidence: 99%

National trends in hospital, long-term care and outpatient Acinetobacter baumannii resistance rates

Appaneal

¹

,

O’Neill

²

,

Lopes

³

et al. 2021

Journal of Medical Microbiology

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Introduction. Acinetobacter baumannii is a top-priority pathogen of the World Health Organization (WHO) and the Centers for Disease Control (CDC) due to antibiotic resistance. Gap Statement. Trends in A. baumannii resistance rates that include community isolates are unknown. Aim. Identify trends in A. baumannii resistance rates across the Veterans Affairs (VA) Healthcare System, including isolates from patients treated in hospitals, long-term care facilities and outpatient clinics nationally. Methodology. We included A. baumannii clinical cultures collected from VA patients from 2010 to 2018. Cultures were categorized by location: VA medical centers (VAMCs), long-term care (LTC) units [community living centers (CLCs)], or outpatient. We assessed carbapenem resistance, multidrug resistance (MDR) and extensive drug resistance (XDR). Time trends were assessed with Joinpoint regression. Results. We identified 19 376 A . baumannii cultures (53% VAMCs, 4% CLCs, 43% outpatient). Respiratory cultures were the most common source of carbapenem-resistant (43 %), multidrug-resistant (49 %) and extensively drug-resistant (21 %) isolates. Over the study period, the number of A. baumannii cultures decreased significantly in VAMCs (11.9% per year). In 2018, carbapenem resistance was seen in 28% of VAMC isolates and 36% of CLC isolates, but only 6% of outpatient isolates, while MDR was found in 31% of VAMC isolates and 36% of CLC isolates, but only 8 % of outpatient isolates. Carbapenem-resistant, multidrug-resistant and extensively drug-resistant A. baumannii isolates decreased significantly in VAMCs and outpatient clinics over time (VAMCs: by 4.9, 7.2 and 6.9%; outpatient: by 11.3, 10.5 and 10.2% per year). Resistant phenotypes remained stable in CLCs. Conclusion. In the VA nationally, the prevalence of A. baumannii is decreasing, as is resistance. Carbapenem-resistant and multidrug-resistant A. baumannii remain common in VAMCs and CLCs. The focus of infection control and antimicrobial stewardship efforts to prevent transmission of resistant A. baumannii should be in hospital and LTC settings.

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“…Despite these qualities, prior literature suggests that ASPs have not prioritized APP engagement and outreach for stewardship education and interventions, instead focusing on physician, physician-trainees, pharmacists, and pharmacy-trainees. 7,12 In one survey of NPs at a tertiary care medical center, 66% of respondents reported that they were “not familiar” with the center's ASP and only 17% reported finding ASP interactions “useful” or “very useful.” 13 Few studies exist on stewardship or educational interventions designed specifically for APPs and the potential effect on patient care. One study found that educational sessions with NPs were effective in decreasing the amount of inappropriate antibiotic use in the outpatient pediatric setting; however, no studies have reported experiences in the inpatient setting or with PAs.…”

mentioning

confidence: 99%

A Seat at the Table: Delivering Effective Infectious Diseases and Antimicrobial Stewardship Education to Advanced Practice Providers at an Academic Medical Center

Lee¹,

Stead²

2021

J Contin Educ Health Prof

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Introduction:Antimicrobial Stewardship programs promote appropriate antimicrobial use through different avenues, including education. Advanced Practice Providers (APPs) provide inpatient care in a wide-range of settings. Little is known about the educational needs of APPs at academic medical centers or the effect of educational interventions directed at inpatient APPs on clinical care. Our study looked at the effect of an educational intervention on antimicrobial prescribing by APPs for asymptomatic bacteriuria (ASB) and candiduria (ASC). We also conducted a needs assessment on the opportunities and barriers to continuing medical education.Methods:The educational intervention consisted of in-person interactive learning accompanied by an online video. Pre-intervention and postintervention surveys included an educational needs assessment and knowledge acquisition assessment. A retrospective chart review of adult inpatients admitted to the APP services with bacteriuria or candiduria during the 3 months pre-intervention and postintervention was performed.Results:Our needs assessment revealed several barriers to APP-focused education including no protected time for learning, and curricula predominantly directed at the Graduate Medical Education level. Engaged APPs had improved knowledge scores, but the proportion of treated ASB or ASC episodes did not differ between the pre-intervention and postintervention.Discussion:Although our educational intervention did not change prescribing patterns, the intervention increased knowledge around ASB and ASC. The potential hierarchical structure of interprofessional care teams may be a barrier to changing antimicrobial prescribing. Our study identified the possibility of a hidden curriculum at academic medical centers that does not prioritize APP educational needs.

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How Far We’ve Come, How Far We Have to Go: a Review of Advances in Antimicrobial Stewardship in the Veterans Health Administration

Cited by 7 publications

References 32 publications

Trends in Stenotrophomonas maltophilia antibiotic resistance rates in the United States Veterans Affairs Health System

Trends in Stenotrophomonas maltophilia antibiotic resistance rates in the United States Veterans Affairs Health System

National trends in hospital, long-term care and outpatient Acinetobacter baumannii resistance rates

A Seat at the Table: Delivering Effective Infectious Diseases and Antimicrobial Stewardship Education to Advanced Practice Providers at an Academic Medical Center

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