Survey of physician and pharmacist steward perceptions of their antibiotic stewardship programs

ObjectiveTo examine how individual steward characteristics (eg, steward role, sex, and specialized training) are associated with their views of antimicrobial stewardship program (ASP) implementation at their institution.DesignDescriptive survey from a mixed-methods study.SettingTwo large national healthcare systems; the Veterans' Health Administration (VA) (n = 134 hospitals) and Intermountain Healthcare (IHC; n = 20 hospitals).ParticipantsWe sent the survey to 329 antibiotic stewards serving in 154 hospitals; 152 were physicians and 177 were pharmacists. In total, 118 pharmacists and 64 physicians from 126 hospitals responded.MethodsThe survey was grounded in constructs of the Consolidated Framework for Implementation Research, and it assessed stewards' views on the development and implementation of antibiotic stewardship programs (ASPs) at their institutions We then examined differences in stewards' views by demographic factors.ResultsRegardless of individual factors, stewards agreed that the ASP added value to their institution and was advantageous to patient care. Stewards also reported high levels of collegiality and self-efficacy. Stewards who had specialized training or those volunteered for the role were less likely to think that the ASP was implemented due to a mandate. Similarly volunteers and those with specialized training felt that they had authority in the antibiotic decisions made in their facility.ConclusionsGiven the importance of ASPs, it may be beneficial for healthcare institutions to recruit and train individuals with a true interest in stewardship

Survival and dispersal of a defined cohort of Irish cattle

An understanding of livestock movement is critical to effective disease prevention, control and prediction. However, livestock movement in Ireland has not yet been quantified. This study has sought to define the survival and dispersal of a defined cohort of cattle born in Co. Kerry during 2000. The cohort was observed for a maximum of four years, from January 1, 2000 to December 31, 2004. Beef and dairy animals moved an average 1.31 and 0.83 times, respectively. At study end, 18.8% of the beef animals remained alive on Irish farms, including 6.7% at the farm-of-birth, compared with 48.6% and 27.7% for dairy animals respectively. Beef animals werae dispersed to all Irish counties, but mainly to Cork, Limerick, Tipperary and Galway. Dairy animals mainly moved to Cork, Limerick, and Tipperary, with less animals going to Galway, Meath and Kilkenny. The four-year survival probability was 0.07 (male beef animals), 0.25 (male dairy), 0.38 (female beef), and 0.72 (female dairy). Although there was considerable dispersal, the number of moves per animal was less than expected

Multicenter Evaluation of a Novel Surveillance Paradigm for Complications of Mechanical Ventilation

Ventilator-associated pneumonia (VAP) surveillance is time consuming, subjective, inaccurate, and inconsistently predicts outcomes. Shifting surveillance from pneumonia in particular to complications in general might circumvent the VAP definition's subjectivity and inaccuracy, facilitate electronic assessment, make interfacility comparisons more meaningful, and encourage broader prevention strategies. We therefore evaluated a novel surveillance paradigm for ventilator-associated complications (VAC) defined by sustained increases in patients' ventilator settings after a period of stable or decreasing support.We assessed 600 mechanically ventilated medical and surgical patients from three hospitals. Each hospital contributed 100 randomly selected patients ventilated 2-7 days and 100 patients ventilated >7 days. All patients were independently assessed for VAP and for VAC. We compared incidence-density, duration of mechanical ventilation, intensive care and hospital lengths of stay, hospital mortality, and time required for surveillance for VAP and for VAC. A subset of patients with VAP and VAC were independently reviewed by a physician to determine possible etiology.Of 597 evaluable patients, 9.3% had VAP (8.8 per 1,000 ventilator days) and 23% had VAC (21.2 per 1,000 ventilator days). Compared to matched controls, both VAP and VAC prolonged days to extubation (5.8, 95% CI 4.2-8.0 and 6.0, 95% CI 5.1-7.1 respectively), days to intensive care discharge (5.7, 95% CI 4.2-7.7 and 5.0, 95% CI 4.1-5.9), and days to hospital discharge (4.7, 95% CI 2.6-7.5 and 3.0, 95% CI 2.1-4.0). VAC was associated with increased mortality (OR 2.0, 95% CI 1.3-3.2) but VAP was not (OR 1.1, 95% CI 0.5-2.4). VAC assessment was faster (mean 1.8 versus 39 minutes per patient). Both VAP and VAC events were predominantly attributable to pneumonia, pulmonary edema, ARDS, and atelectasis.Screening ventilator settings for VAC captures a similar set of complications to traditional VAP surveillance but is faster, more objective, and a superior predictor of outcomes

A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs.

ObjectiveTo examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers.DesignQualitative semistructured interviews.SettingThe study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare.ParticipantsWe interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders.MethodsInterviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR.ResultsWe identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff.ConclusionFurther understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles

Genetic Parameter estimates for Milkability Traits and their Relationship with Somatic Cell Score in South African Holstein Cattle

Milkability is an important functional trait, which is directly related to milking costs and udder health. There are no milkability traits incorporated in the South African dairy cattle breeding objectives and genetic parameter estimates for these traits are not available in this population. The main objective of the study was, therefore, to estimate the genetic parameters for milkability traits and its correlation with somatic cell scores in South African Holstein cattle. Data consisted of production and milkability records of 2719 Holstein cows, from ten herds, collected from 2016 to 2018. Genetic parameters were estimated by a multi-trait animal model using the Restricted Maximum Likelihood (REML) procedure. Means for milking time (MT), average milk flow (AMF), maximum milk flow (MMF) and somatic cell score (SCS) were 5.20 min, 1.91 kg/min, 2.99 kg/min and 2.06, respectively. The heritability estimates were low to moderate from 0.19±0.07, 0.24±0.06, 0.36±0.11 and 0.41±0.12 respectively for SCS, AMF, MT and MMF. The genetic correlations were significant (P<0.05) among the three milkability traits ranged from -0.31±0.05 between AMF and MT to 0.85±0.02 between AMF and MMF. Positive genetic correlations were observed between AMF and MMF, while the correlations for MT with the remaining milkability traits were negative. Genetic correlations of SCS with AMF, MMF and MT were -0.13±0.04, 0.13±0.04 and -0.25±0.12, respectively. The mean estimated breeding value (EBV) was estimated using cattle birth dates and there was an increase in AMF of 0.0001 kg/min EBV per year on cattle born during the period 2002 to 2014. Maximum milk flow also showed an increasing genetic trend of 0.0003 kg/min per year over the same period. On the other hand, the genetic trend for MT was undesirable, as it increased by 0.0003 kg/min per year. The moderate to high heritability estimates for milkability traits showed that selection for improvement was possible in South African Holstein cattle. High genetic correlation between AMF and MMF implied that these two may be regarded as the same trait. Milking time can contribute towards improving the accuracy of estimating EBVs for SCS in a multi-trait analysis, and vice versa, due to the moderate correlation between the two traits. The marginal genetic trend in milkability traits may be an interrelated response to selection of other traits already under selection in the population such as SCS. Results of the current study provided a basis for including milkability traits of South African Holstein cattle in the breeding objectives