Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.

Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P  = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.

Background Safe hospital discharge on parenteral antibiotic therapy is challenging for people who inject drugs (PWID) admitted with serious bacterial infections (SBI). We describe a Comprehensive Care of Drug Addiction and Infection (CCDAI) program involving a partnership between Intermountain Healthcare hospitals and a detoxification facility (DF) to provide simultaneous drug recovery assistance and parenteral antibiotic therapy (DRA-OPAT). Methods The CCDAI program was evaluated using a pre-post study design. We compared outcomes in PWID hospitalized with SBI during a 1-year post-implementation period (2018) with similar patients from a historical control period (2017), identified by propensity modeling and manual review. Results Eighty-seven patients were candidates for the CCDAI program in the implementation period. 35 participants (40.2%) enrolled in DRA-OPAT and discharged to the DF; 16 (45.7%) completed the full OPAT duration. Fifty-one patients with similar characteristics were identified as a pre-implementation control group. Median length of stay (LOS) was reduced from 22.9 days (IQI 9.8-42.7) to 10.6 days (IQI 6-17.4) after program implementation, p&lt;0.0001. Total median cost decreased from $39,220.90 (IQI $23,300.71-$82,506.66) pre-implementation vs $27,592.39 (IQI $18,509.45-48,369.11) post-implementation, p&lt;0.0001. 90-day readmission rates were similar (23.5% vs 24.1%), p=0.8. At 1-year follow-up, all-cause mortality was 7.1% in the pre-implementation group vs 1.2% post-implementation, p=0.06. Conclusion Partnerships between hospitals and community resources hold promise for providing resource efficient OPAT and drug recovery assistance. We observed significant reductions in length of stay and cost without increases in readmission rates; 1-year mortality may have been improved. Further study is needed to optimize benefits of the program.

Narrative Abstract The optimal management of bacteriuria/pyuria of clinically undetermined significance (BPCUS) is unknown. Among 220 emergency department patients prescribed antibiotics for BPCUS, we found frequent readmissions, which were mitigated by outpatient follow-up visits. Observation and follow-up for an unknown diagnosis should be emphasized over antibiotics due to high likelihood of readmissions.

Highlights Clostridium botulinum and related organisms are emerging pathogens in intravenous drug users. Non-toxigenic Clostridia can cause invasive infections in the absence of clinical botulism. Black tar heroin can predispose to Clostridial infections.