Abstract Objectives: To determine trends and predictors of cefdinir use for common pediatric infections in the United States. Design: Retrospective cohort study, 2016–2023. Setting: U.S. outpatient encounters (ambulatory, emergency department, urgent care) included in the Medicaid MarketScan database. Patients: Children aged 0–18 years diagnosed with bacterial rhinosinusitis, pharyngitis, urinary tract infection (UTI), acute otitis media (AOM), or community-acquired pneumonia (CAP). Methods: We assessed cefdinir prescription rates by diagnosis and year, comparing to other commonly administered antibiotics. We used logistic regression to identify demographic predictors of cefdinir use. Results: Among 7,346,547 encounters, most common diagnoses were AOM (36.9%) and bacterial pharyngitis (36.2%). Patients were predominantly non-Hispanic White (53.0%), 1–5 years-old (41.1%), and seen in ambulatory settings (75.3%). Cefdinir was prescribed in 10.4% of encounters, ranking among the top prescribed antibiotics. After an initial increase, use declined post-2020 to 7.6%. In children 1–18 years-old, younger age was uniformly associated with higher odds of cefdinir prescription across all diagnoses. This pattern was inconsistent among infants <1 years-old across diagnoses but persisted for UTI, with ORs of 9.38 (95% CI, 8.91–9.88) for <1 years-old and 5.91 (95% CI, 5.76–6.06) for 1–5 years-old versus 15–18 years-old patients. NH Black patients and those seen in urgent care or the emergency department were less likely to receive cefdinir. Conclusions: Despite a small decline in use since 2020, cefdinir use remains substantial, especially among young children with UTI. Continued efforts to reduce inappropriate use and promote antibiotic stewardship are warranted.
Abstract Objective: To compare maternal and neonatal outcomes between mono-infections and co-infections of the reproductive tract in pregnancy due to bacteria and Trichomonas. Methods: We conducted searches across MedLine, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane CENTRAL, Web of Science, Scopus, and Embase. Searches from database inception to August 5, 2024, for studies that compared reproductive tract bacterial and Trichomonas mono-infections and co-infections in pregnancy with regards to maternal and/or neonatal outcomes. Two independent investigators analyzed each study. Random-effect models were used to estimate pooled odds ratios (ORs) with 95% confidence intervals (CIs), and heterogeneity was assessed using the I 2 statistic. The Downs and Black scale was used to assess study quality and risk of bias. Results: Among 1,436 publications, nine studies met inclusion criteria. Mono-infections and co-infections showed no significant differences in delivery before the 34 th week of gestation (OR 0.66, 95% CI 0.36–1.22), gestational hypertension (OR 1.30, 95% CI 0.72–2.33), preterm premature rupture of membranes (OR 0.89, 95% CI 0.50–1.58), or Apgar score < 7 at five minutes (OR 0.53, 95% CI 0.20–1.36). The analysis of birth before the 37 th week rate (five studies) showed an advantage for the mono-infections group (OR 0.83, 95% CI 0.78–0.89). Mono-infections showed lower rates of neonatal death (OR 0.83, 95% CI 0.78–0.89) and intensive care unit admission (OR 0.16, 95% CI 0.03–0.86). Conclusions: Reproductive tract non-viral co-infections may exacerbate adverse neonatal outcomes compared to mono-infections. Future studies are needed to establish a more robust correlation between infections numbers and pregnancy outcomes.
Abstract Objective: To evaluate the implementation and effectiveness of handshake antimicrobial stewardship interventions for surgical antibiotic prophylaxis at a quaternary hospital in Ghana. Design: Retrospective cross-sectional secondary data analysis. Setting: Quaternary referral hospital in Accra, Ghana. Participants: Adult surgical encounters (n = 227) with complete antimicrobial stewardship documentation between June and September 2024. Methods: We analyzed antimicrobial stewardship audit records to assess recommendation acceptance, implementation, antibiotic selection concordance, and duration patterns. Outcomes were stratified by surgical service and procedure urgency. Descriptive statistics were used. Results: Of 227 encounters, 109 (48.0%) required stewardship recommendations, of which 78 (71.6%) were verbally accepted. However, only 39 (50.0% of accepted recommendations) were implemented. Implementation failures were primarily due to patient discharge (19.3%) and prescriber unavailability (16.5%). Duration optimization accounted for 76.1% of interventions. Overall, 43.2% of encounters exceeded the recommended prophylaxis duration (>24 hours). Emergency procedures had lower acceptance and higher missed opportunity rates compared to elective cases. Conclusions: Handshake stewardship demonstrated moderate acceptance but limited implementation. Execution failures were primarily associated with specific operational bottlenecks, including patient discharge and prescriber unavailability, which were exacerbated in emergency and high-volume surgical services. These findings suggest that in resource-limited settings, stewardship models must incorporate asynchronous communication and automated system safeguards (e.g., stop orders) to overcome workflow barriers.
Abstract Introduction: Antimicrobial resistance (AMR) continues to rise owing to inappropriate antimicrobial use. In many countries, especially where patients cannot afford repetitive physician consultations, patients self-prescribe antimicrobials even for self-limiting infections like pharyngitis. Well-trained pharmacists capable of effectively managing pharyngitis through clinical decision-making scores (CDS) like Centor/McIsaac score can aid antimicrobial stewardship programs (ASP). The main aim of the current study was to train pharmacists to apply validated clinical decision criteria (Centor/McIsaac) for the differential assessment of pharyngitis, promote guideline-based antimicrobial dispensing, and evaluate the effectiveness of training. Methods: A cross-sectional, interventional study using a combination of convenience sampling and snowball sampling techniques was conducted among pharmacists and clinical pharmacy trainees in Pakistan. Educational material was developed through extensive literature search, and training sessions were conducted at community pharmacies and academic institutes. Knowledge was assessed before and after the training sessions using a self-developed, validated, structured questionnaire. Results: Of the 288 participants, majority of the practicing pharmacists at community pharmacies were younger than 30 years of age with an experience of less than 3 years. Most participants demonstrated poor baseline knowledge which imporved significantly following the training intervention, highlighting its effectiveness in enhancing the knowledge, beliefs, and perceptions of AMR and AMS. Discussion: Microteaching-based continuing professional development interventions can support the clinical competencies of pharmacists. These findings highlight the potential of such training interventions to improve infection management and antimicrobial stewardship and underscore the need for similar tailored programs for other clinical conditions.
Abstract Objective: To evaluate the knowledge, attitudes, and behaviors regarding AMR and antimicrobial use among Irish university students and to inform the development of tailored educational interventions. Design: Cross-sectional online survey. Setting: Two Irish universities, 2022. Participants: University students aged 18–25 years (N = 239). Methods: A questionnaire incorporating validated items adapted from the World Health Organisation (WHO) and European Union (EU) barometer survey instruments was administer online. Data were analyzed using descriptive statistics, ANOVA, and principal component analysis. Results: A total 239 students participated (73% female). Mean scores were high for knowledge 77.9% (SD 17.8) and attitudes 74.0% (SD 8.9) with no significant differences by gender, discipline, or health status. However, 18% reported using antibiotics without prescription, while 39%–44% of students demonstrated misconceptions across several statements relating to the use of antibiotics for non-bacterial conditions. Awareness of public AMR campaigns was low (27% “Resist” and 18% European Antibiotic Awareness Day). Principal component analysis identified four attitudinal dimensions: responsible use and preventive behavior, global and collective awareness, innovation and policy solutions, and perceived helplessness and reliance on experts. Conclusions: Although students demonstrated generally high knowledge and positive attitudes towards AMR, important misconceptions and inappropriate antibiotic behaviors remained. The identified attitudinal dimensions suggest that educational interventions should extend beyond knowledge acquisition to address behavioral and attitudinal factors that support responsible antibiotic use and antimicrobial stewardship.
Abstract Objective: Antimicrobial stewardship programs (ASPs) are difficult to implement in hospitals with limited access to infectious disease (ID) specialists. Electronic consultation–based tele-stewardship may offer a scalable solution; however, evidence regarding its implementation and impact remains limited. This study evaluated the impact of an eConsult-based remote antimicrobial stewardship program on antimicrobial consumption and resistance patterns. Design: Single-center retrospective observational study. Setting: A 500-bed tertiary care hospital without on-site ID specialists. Patients: In total, 27,863 patients were hospitalized. Interventions: An asynchronous eConsult-based tele-stewardship program using the ExpertTWIN system was implemented in February 2025. Data from February 2024 to January 2026 were analyzed using a Bayesian structural time-series model. Results: During the intervention period, 145 cases were reviewed. Carbapenem use decreased; use of antipseudomonal and narrow-spectrum agents showed evidence of increases, whereas use of anti-MRSA agents and total oral and intravenous antimicrobial use showed evidence of reductions. The incidences of carbapenem-resistant Pseudomonas aeruginosa, two-drug-resistant P. aeruginosa, and MRSA showed evidence of reductions, whereas third-generation cephalosporin-resistant Escherichia coli increased. Culture specimen submission showed evidence of an increase. There was no clear evidence of reductions in all-cause in-hospital mortality or length of stay. Total antimicrobial costs were unchanged. Conclusions: The eConsult-based tele-stewardship program reduced carbapenem use and was associated with favorable changes in several antimicrobial-use, resistance, and diagnostic measures, although third-generation cephalosporin-resistant E. coli increased. No clear changes in clinical outcomes were observed. This model may offer a practical and scalable ASP strategy for hospitals without on-site ID specialists.
Abstract Objective: To investigate clinicians’ rationale for low-value ordering of urine cultures (UC). Design: Qualitative descriptive study. Setting: A public tertiary acute hospital in New Zealand. Participants: Doctors and nurses working in the Emergency Department, General Medicine, and General Surgery. Methods: In-depth structured interviews were conducted with 18 doctors and 8 nurses. We analyzed the data using inductive thematic analysis focused on exploring the behavioral and psycho-socio-cultural influences behind ordering of low-value UC. Results: We generated four main themes encompassing patient and non-patient factors behind low-value testing. (1) In the grey zone: described patient presentations which were considered clinically ambiguous, such as undifferentiated infectious symptoms, delirium, communication challenges, and catheters. (2) The pressure to act: illustrated how the fear of uncertainty and expectations of patients and families, colleagues, healthcare systems, and hierarchies impacted clinician decision-making and defensive testing practices. (3) It depends on who you talk to: highlighted how inconsistent knowledge, communication, and perceptions of harm between individuals, services, and professions contributed to unnecessary tests. And (4) It’s just how we do things here: reflected dogma and inertia behind institutional conditions and a culture of over-testing. An additional theme, (5) Solutions to change the culture, explored participants ideas to improve UC ordering behaviors. Conclusion: Diagnostic stewardship interventions to reduce low-value UC requests must address the multiple, often compounding, patient and non-patient factors that influence clinicians’ behavior.
Abstract Objective: To evaluate the effect that discontinuing contact precautions for children with methicillin-resistant Staphylococcus aureus (MRSA) had on MRSA healthcare-associated infections (HAIs). Design: Retrospective, nonrandomized, observational, quasi-experimental study. Setting: A large pediatric healthcare system including two tertiary children’s hospitals with level 4 neonatal intensive care units (NICUs). Patients: Hospitalized children. Methods: Contact precautions for children infected or colonized with MRSA was discontinued in October 2018. Prospective surveillance for MRSA HAIs was performed using standard definitions. Control charts monitored changes in annual MRSA HAI rates from 2014 to 2025. In March 2024, active surveillance cultures for MRSA were initiated in NICU A primarily for antibiotic stewardship purposes. MRSA nasal cultures were obtained upon admission and repeated every two weeks unless a patient was positive for MRSA. Healthcare-associated (HA) conversion was defined as a positive MRSA culture after one or more negative surveillance cultures. Results: Annual MRSA HAI rates/1000 patient days decreased for the System, Hospital A and Hospital B. Rates remained stable for NICU A and NICU B. Between March 2024 and December 2025, there were 1904 MRSA surveillance cultures from 682 patients in NICU A. Thirty-seven patients (5.4%) had a positive MRSA surveillance culture. HA conversion occurred in 21 patients (3.1%). Conclusion: After seven years, discontinuing contact precautions for MRSA did not result in increased MRSA HAI rates in a large pediatric healthcare system. NICU MRSA HAI rates remained stable, and HA conversion of MRSA was low.
To improve adult vaccinations rates, we implemented a Virtual Vaccine (ViVa) clinic that provided concise vaccine recommendations for patients with an upcoming primary care visit. Among Veterans ≥50, 36% of patients reviewed by the ViVa clinic received ≥1 of the recommended vaccines, compared to 23% of those in control groups.
Analytics of antimicrobial stewardship applications (ASApp) from two pediatric hospitals over 24 months revealed an average of 4922 monthly sessions. A survey of users reported use in all clinical areas with 30% exclusively in outpatient settings. Overall, >70% reported using the recommendations and almost all self-reported an impact on practice.
Antibiotic overuse at hospital discharge is common and often overlooked. We conducted interviews with 91 clinicians across 9 Veterans Health Administration hospitals to assess perceptions of a metric comparing discharge antibiotic-prescribing. Clinicians found the metric valid and meaningful, but successful implementation will require more granular contextual data and quality-improvement framing.
Infection prevention and antimicrobial stewardship (IP/ASP) leaders serve as content experts within their health systems, yet they rarely have direct managerial authority over the personnel and budgets needed to implement change. Success in these roles depends not only on clinical and scientific expertise but also on the ability to persuade: to secure buy-in from frontline clinicians, nursing leadership, hospital administrators, and other stakeholders. Despite the importance of persuasion to these roles, most IP/ASP leaders receive no formal training in influence or negotiation. This review synthesizes evidence from social psychology, behavioral science, and organizational leadership to provide IP/ASP leaders with a practical framework for effective persuasion. Key topics include building relational power, framing and contrast, credibility, concreteness, social proof, urgency, and consistency. Each principle is illustrated with examples drawn directly from IP/ASP practice. Applied ethically and strategically, these techniques can greatly enhance a leader’s impact on patient safety, institutional culture, and program success.
In this retrospective study, fungal blood cultures rarely detected fungal pathogens not found in paired standard blood cultures, with added findings in only 0.4% of cases. Given the low diagnostic yield and high cost, results support reserving fungal blood cultures for select high-risk patients to improve diagnostic stewardship.
Abstract Background: Ralstonia species are environmental Gram-negative bacilli increasingly linked to healthcare-associated bloodstream infection (BSI) outbreaks from contaminated medical solutions. We describe an outbreak of Ralstonia mannitolilytica BSI in which the source was identified and withdrawn within 24 hours. Methods: Following an unusual cluster of R. mannitolilytica blood cultures on 29 September 2024 at a 700-bed tertiary-care hospital in Oman, we conducted a multidisciplinary investigation including chart review, hospitalwide surveillance, environmental and product sampling, antimicrobial susceptibility testing, and pulsed-field gel electrophoresis (PFGE) of clinical and product isolates. Results: Between 29 September and 8 October 2024, 21 patients met the case definition (median age 9 yr; 62% pediatric; 62% male; 95% immunocompromised; 86% with central venous access). Newly introduced pre-filled 10 mL 0.9% sodium chloride vials from a single manufacturer yielded R. mannitolilytica with concordant clinical and product antimicrobial susceptibility profiles. PFGE of 18 clinical isolates and one product isolate demonstrated 100% genetic relatedness, confirming a single-clone outbreak. The implicated product was withdrawn within 24 hours of cluster recognition. Thirteen of 21 patients had their central catheters removed; all received intravenous trimethoprim–sulfamethoxazole. Two patients experienced bacteremia recurrence after initial line retention; no outbreak-related deaths occurred. Conclusions: Prefilled saline vials can serve as the source of clonal R. mannitolilytica BSI outbreaks in immunocompromised patients. Laboratory-driven cluster detection, multidisciplinary coordination, and rapid product suspension enabled source identification within 24 hours and limited outbreak size and severity. Vigilance after introduction of new pharmaceutical products and prompt catheter removal in catheter-associated Ralstonia BSI are essential.
In over 380,000 U.S. veterans from 2014 to 2024 with a listed penicillin allergy, we report the characteristics and potential antimicrobial stewardship implications of 2781 veterans that could have undergone direct removal of the penicillin allergy label based on the receipt of a penicillin-class antibiotic since the index allergy listing.
Abstract Objective: To evaluate outcomes in patients with ceftriaxone-non-susceptible, non-extended-spectrum beta-lactamases (ESBL), Enterobacterales bacteremia treated with carbapenem and non-carbapenem treatment options. Methods: This pilot retrospective chart review evaluated adult patients admitted between January 2021 and November 2024 with a bacteremia caused by a non-ESBL, ceftriaxone-non-susceptible, piperacillin/tazobactam-sensitive, cefepime-sensitive, Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Proteus mirabilis. Patients were stratified into 3 groups depending on the administered targeted treatment (cefepime or piperacillin/tazobactam vs carbapenem vs other). Results: Of the 76 patients who were screened, 40 patients were analyzed. There were 28 patients in the cefepime or piperacillin/tazobactam group, 8 patients in the carbapenem group, and 4 patients in the other antibiotics group. The median age of the cohort was 77 years, most patients were female, and 30% of patients were in septic shock. The most common source of infection was genitourinary (63%). Thirty-day mortality was 3.8% in the cefepime or piperacillin/tazobactam group, 14.3% in the carbapenem group, and 0% in the other antibiotic group (P = .611). There was no significant difference in any of the secondary outcomes. Conclusions: In this pilot retrospective chart review, there was no difference between carbapenem and non-carbapenem treatment for ceftriaxone-non-susceptible, non-ESBL Enterobacterales bacteremia. Better understanding of the resistance mechanisms and collaboration with other healthcare systems to increase sample size may help assess optimal treatment of these organisms.
Abstract Objective: To evaluate antibiotic prescribing knowledge and confidence before versus after deployment of a web-based clinical decision support tool at an academic dental center. Design: Pre and post survey instrument. Setting: Academic dental center in the United States. Patients: Dental students, residents, and faculty. Methods: Participants completed a series of seven clinical vignettes assessing their antibiotic prescribing knowledge and confidence using 5-point Likert scale questions pre (2022) and post (2025) deployment of a web-based educational tool. The survey questions included content about antibiotic prophylaxis and treatment for dental infections. Mean Likert scale responses were compared before and after deployment of the tool. The responses were analyzed individually, pooled, and stratified by training level. Sensitivity analyses were conducted comparing results between tool users and non-users. Results: Two hundred and thirteen participants completed the pretool deployment survey, and 116 participants completed the post survey. Respondents were slightly less likely to prescribe antibiotics after having access to the tool (median pooled 5-point Likert Scale score 2.55 vs 2.67; P = .07). However, antibiotic prescribing confidence did not change significantly (median pooled score 3.37 vs 3.24; P = .21). Stratified results showed substantial variability based on individual vignette. Self-reported users of the tool (n = 37) demonstrated no differences in knowledge versus non-users (n = 97; P = .76) but did demonstrate a trend toward more confidence in their decisions (P = .07). Conclusions: Uptake of a web-based antibiotic prescribing tool was low overall and was not associated with any change in antibiotic prescribing knowledge and confidence. Additional interventions are needed to improve tool use in dental settings.
Abstract Background: Management of shigellosis is increasingly complicated by antimicrobial resistance, yet susceptibility testing is rarely performed, and the role of broad-spectrum empiric therapy in hospitalized adults remains unclear. Methods: We conducted a multi-center retrospective cohort study of adults hospitalized with stool-confirmed Shigella spp. from October 2023 to August 2024 across five hospitals in the Portland metropolitan area. The primary outcome was time from antibiotic initiation to symptom resolution (less than 3 stools in 24 h) and the secondary outcome was length of hospital stay. Results: Of 45 patients included in the outcome analyses, 29 (64%) received carbapenems and 16 (36%) received non-carbapenem antibiotics. Median time from antibiotic initiation to symptom resolution was 18 hours (IQR 9–37) in the carbapenem group and 29 hours (IQR 15–36) in the non-carbapenem group, with no significant difference between groups (P = .89). The median length of hospital stay was significantly longer in the carbapenem group, at 5.4 days (IQR 3.6–8.3), compared with 3.9 days (IQR 2.6–4.4) in the non-carbapenem group (P = .02). Only 26% of patients had susceptibility testing ordered. Conclusions: Carbapenem use was not associated with faster symptom resolution and was associated with significantly longer hospitalization. Susceptibility testing was underutilized and may be essential to guide local empiric and targeted therapy decisions.
