Attitudes generally positive on stewardship
Stach LM, Hedican EB, Herigon JC. Clinicians’ Attitudes Towards an Antimicrobial Stewardship Program at a Children’s Hospital Pediatr Infect Dis Soc 2012;1:190-197.
In an attempt to preserve antibiotic efficacy and stem the rise of drug-resistant bacteria, there is an urgent call for antibiotic stewardship programs (ASP) across the health care continuum. Infection preventionists and healthcare epidemiologists may play pivotal roles in these evolving programs, particularly through prompt detection of MDROs and promoting compliance with infection control precautions. But how well are these new collaboratives going to be received by physicians that value their clinical autonomy? Very well, overall, according to this survey of clinician attitudes toward ASPs.
“Our investigation found positive attitudes towards our prospective-audit-with-feedback ASP among pediatricians directly impacted at our institution,” the authors concluded. “Clinicians believed that the ASP improved the quality of care for hospitalized children, with minimal negative impact on clinical decision-making and autonomy.”
An electronic survey was administered to clinicians two years after the implementation to assess their attitudes toward the ASP. There were 205 of 365 participants (56%) that responded. Of these, 80% (160 of 199) had never worked with an ASP before the intervention. Respondents agreed that the ASP decreased the improper use of antibiotics (162 of 194, 84%), improved the quality of care of hospitalized children (159 of 194, 82%), and provided knowledge and education about appropriate antibiotic use (177 of 194, 91%).
“The most common negative feeling was the removal of prescriber autonomy (11%, 22 of 194),” the authors reported. “We identified that 6% (12 of 194) felt the ASP interfered with clinical decision-making and that 5% (9 of 194) of our respondents thought the program was threatening when providing recommendations.
Only 3% (2 of 75) of the residents and fellows vs 7% (7 of 96) of the attending physicians felt the ASP was threatening. Because communication was a core value of the ASP team, the researchers tried to use the best mechanisms to provide information and recommendations to clinicians.
“We found that 61% (116 of 189) did not have a preference on whether the ID physician or pharmacist delivered the ASP recommendation,” they noted. “However, 23% (44 of 189) preferred the physician alone and 15% (29 of 189) preferred both the physician and pharmacist. Among attending physicians, most (71 of 96, 74%) felt that it was acceptable to be informed of recommendations through residents or nurse practitioners.”
This study documents that a prospective ASP can successfully decrease the use of broad-spectrum antibiotics in a tertiary care children’s hospital. The magnitude of decrease was comparable to that observed among adult institutions. The clinician’s compliance with recommendations using this type of ASP was very high, providing insight to the potential benefit of using a prospective-audit-with-feedback over other strategies such as requiring preauthorization. There were substantial positive feelings among clinicians with this approach, with the vast majority believing that the ASP improved the quality of care for hospitalized children. Also, the clinicians reported minimal negative impact, such as a sense of interference with clinical decision-making and threatened autonomy.
This report illustrates that the five steps to successfully implement a prospective-audit-with-feedback antibiotic stewardship program are:
(1) developing the ASP team;
(2) determining the stewardship strategies and antimicrobials to monitor;
(3) establishing a method of identifying patients;
(4) designing an evaluation of the program;
(5) implementing the program.
Norovirus a threat to frail paients
Bok K, Green KKY. Norovirus gastroenteritis in immunocompromised patients. New Eng J Med 2012; 367:2126-2132
Norovirus has become a scourge, particularly in closed populations like those in hospitals and on cruise ships. There is another aspect of the disease profile of this emerging virus, namely its ability to cause unexpected severe illness in immunosuppressed patients. Two investigators from the Calicivirus Section at the NIH have done an exceptional job of summarizing the mechanisms, scope and treatment of norovirus gastroenteritis in immunosuppressed patients. Vigilant hand hygiene, of course, is the best method to prevent transmission and protect these patients. Here are other major points in the paper:
- Norovirus infection can include symptoms of fever, diarrhea, projectile vomiting, and mimic graft versus host disease in transplant patients.
- Noroviruses have a small RNA genome that can mutate readily. There are six major geno groups, labeled GI-GVI.
- The genome has only 2 structural proteins along with 7 nonstructural proteins. VP1 is the major structural protein, VP2 the minor one.
- As compared to the disease in immunocompetent hosts, in the immunocompromised host the disease last for years and shedding of the virus may be indefinite.
- Disease is usually self-limited in the immunocompetent, but little therapy may available for the more severe illness in the immunocompromised host.
- Infection in the immunocompromised host can cause malnutrition, dehydration and worsen the underlying immunocompromising illness.
- There are several assays available in the clinical microbiology laboratory including those based on RT-PCR, but not all labs will offer these tests. More study is required to understand the utility of the different diagnostic assays.
- Immunocompromised patients may have a diverse population of mutating noroviruses, including many so called “low-frequency variants” in chronic infection.
- New studies will be necessary to determine when and how new strains are introduced to currently infected immunocompromised patients.
- Both T-cell and B-cell responses seem necessary for adequate immune surveillance and viral clearance. Increasing CD4 cell count in HIV patients improved symptoms.
- Commonly used antiviral agents do not allow viral clearance. Some success with improving symptoms has been reported with nitazoxanide, an anti-protozoal drug.
- In one study 80% of surfaces in a children’s unit were contaminated with 21 different noroviruses.
- Norovirus testing should result more often from the consideration of this infection in immunosuppressed patients with acute and chronic diarrhea.
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