Infectious Disease Clinics of North America

Immunocompromised (IC) patients are high risk for complications due to a high rate of antibiotic exposure. Antimicrobial stewardship interventions targeted to IC patients can be challenging due to limited data in this population and a high risk of severe infection-related outcomes. Here, the authors review immunocompromised antimicrobial stewardship barriers, metrics, and opportunities for antimicrobial use and testing optimization. Last, the authors highlight future steps in the field.

Antimicrobial Stewardship Programs (ASP) improve individual patient outcomes and clinical care processes while reducing antimicrobial-associated adverse events, optimizing operational priorities, and providing institutional cost savings. ASP composition, resources required, and priority focuses are influenced by myriad factors. Despite robust evidence and broad national support, individual ASPs still face challenges in obtaining appropriate resources. Though understanding the current landscape of ASP resource allocation, factors influencing staffing needs, and strategies required to obtain desired resources is important, acceptance of recommended staffing levels and appropriate ASP resource allocation are much needed to facilitate ASP sustainability and growth across the complex and diverse health care continuum...

Given the complexity and nuance needed to make antimicrobial prescribing decisions, metrics aiming to assess these decisions can be complex in method, require resource investment for measurement, and demand thoughtfulness in how to use data for program implementation and messaging to key partners. Antimicrobial stewardship programs today use several metrics of antimicrobial use in parallel with other clinical data for a multitude of purposes and audiences. Here, we discuss goals for inpatient stewardship metrics, current metrics used by stewardship programs locally and nationally, and future directions for antimicrobial use metric development...

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Tele-antimicrobial stewardship programs (tele-ASPs) use technology and remote access to resources and clinical expertise to expand antimicrobial services within and outside of health systems. Models of tele-ASPs are workforce multiplying and workforce extending, depending on how they are structured. Building rapport and strong interpersonal networks are essential for successful ASPs. The available evidence suggests that an optimal model for tele-ASP includes hands-on involvement from remote infectious disease (ID) expertise with implementation by local pharmacists...

Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings...

Antimicrobial stewardship programs (ASPs) demonstrated poise and resilience in assisting with COVID-19 efforts across the globe, harnessing expertise in diagnostic stewardship, therapeutics, protocol development, and use of technology to rapidly expand their scope through strategic collaborations, dissemination of content expertise, and numerous contributions to the body of knowledge on COVID-19. Lessons learned from pandemic response should be used to advance the mission of ASPs and secure a "seat at the table" as health systems continue to expand and adapt to future public health crises...

Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.

Antimicrobial stewardship interventions have historically been siloed in different care settings; recently, a need for stewardship interventions at care transitions has arisen as inappropriate prescribing at care transitions may result in patient harm. There are several care areas that should be considered for optimizing antibiotic prescribing. Interventions can be difficult to implement as they often require the efforts of a multidisciplinary team and are resource intensive. Antimicrobial stewardship programs should prioritize interventions at transitions of care to improve prescribing and patient outcomes...

Little is known about how social determinants of health may impact antimicrobial prescribing among racial and ethnic minority populations, different age groups and genders, and across geographic regions. The factors that influence antimicrobial prescribing are complex, but evidence suggests that demographic and socioeconomic factors do influence prescribing patterns. This review describes the inequities observed in antimicrobial use and prescribing that have been heretofore published, with a focus on differences observed by race and ethnicity, age, gender, and geographic region of the United States...

There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.

Antibiotic stewardship has seen transformative change over the past decade. Antibiotic stewardship infrastructure has grown significantly across the spectrum of health care in hospitals, nursing homes, and ambulatory settings, and issues related to improving antibiotic use have become central to high-level policy discussions, regulations, and legislation. Herein we review important events and developments in stewardship across the spectrum of care with a focus on (1) infrastructure and implementation, (2) requirement and regulation, and (3) measurement of antibiotic use and other outcomes...

Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges...

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Recently, there have been significant advances in the diagnosis and management of invasive fungal infections. Compared with traditional fungal diagnostics, molecular assays promise improved sensitivity and specificity, the ability to test a range of samples (including noninvasive samples, ie, blood), the detection of genetic mutations associated with antifungal resistance, and the potential for a faster turnaround time. Antifungals in late-stage clinical development include agents with novel mechanisms of action (olorofim and fosmanogepix) and new members of existing classes with distinct advantages over existing antifungals in toxicity, drug-drug interactions, and dosing convenience (oteseconazole, opelconazole, rezafungin, ibrexafungerp, encochleated amphotericin B)...

Pediatric solid organ transplant (SOT) recipients are at risk for infection following transplantation. Data from adult SOT recipients are often used to guide prevention and treatment of infections associated with organ transplantation in children. This article highlights key recent pediatric SOT-specific publications for an array of infectious complications of organ transplantation. Attention is given to areas of need for future study.

Herein, we review the current knowledge of donor-derived disease and current US Organ Procurement and Transplantation Network policies to minimize the risk. During the process, we also consider actions to further mitigate the risk of donor-derived disease. The overarching goal is to provide an infectious disease perspective on the complex decision of organ acceptance for transplant programs and candidates.

Although antimicrobial stewardship programs have excelled over the past decade, uptake and application of these programs to special populations such as solid organ transplant recipients have lagged. Here, we review the value of antimicrobial stewardship for transplant centers and highlight data supporting interventions that are ripe for adoption. In addition, we review the design of antimicrobial stewardship initiatives, targets for both syndromic and system-based interventions.

This review describes the epidemiology and risk factors of tuberculosis (TB) in solid organ transplant recipients. We discuss the pre-transplant screening for risk of TB and management of latent TB in this population. We also discuss the challenges of management of TB and other difficult to treat mycobacteria such as Mycobacterium abscessus and Mycobacterium avium complex. The drugs for the management of these infections include rifamycins which have significant drug interactions with immunosuppressants and must be monitored closely...

Using organs from donors with treatable infections is a strategy to increase the quality and number of organs for transplantation. For HIV, pilot studies of kidney and liver transplantation from donors with HIV to recipients with HIV demonstrate excellent early outcomes. However, the number of donors and transplants per year remains lower than projected due to several barriers. For HCV, the use of organs from donors with HCV has expanded to recipients without HCV due to safe, effective direct-acting antivirals for HCV, which are well-tolerated in transplant recipients...