Innovation Concept: The Orange Book (OB) identifies drugs approved on the basis of safety and effectiveness by the FDA and serves as the gold standard reference for correct pharmacological therapies. It ties in closely with Choosing Wisely Canada (CWC) modelling good stewardship in antimicrobial prescriptions. The book focuses on passive didactic learning instead of active learning, which was shown to have a greater influence on prescribing behaviour. Educational video games, a form of active learning, have been shown to improve clinical skills in medical training. Contagion is a role-playing video game providing an active way of teaching antimicrobial components of the OB and CWC guidelines. Method: Phase I of Contagion was qualitatively tested on students and physicians at McMaster University for teaching effectiveness, applicability to real-life scenarios, and enjoyability. Post-game play 12 participants scored different aspects of the game on a Likert scale. Curriculum, Tool, or Material: The player is a rural physician treating infections in various communities. Each round, the player is given a crate of antibiotics. As communities are infected, the player is provided with clinical symptoms the patients present with. The player must identify the pathology and then correctly treat the communities. The player can treat empirically or order tests to identify the infectious organism. The player strategically navigates which communities to treat as there are limited actions per turn and the player must prevent communities from dying or infecting neighboring regions. Communities tend to build antibiotic resistance over time making first-line treatments unviable, thus careful strategizing and stewardship is essential. Active learning will occur when players are tasked with finding the correct answer to different presentations. After each turn, players will learn about the infecting organism, its phenotypes, and common infectious symptoms. This is considered passive learning. Conclusion: Contagion was well-received by physicians and medical students as an active learning tool to teach the OB and CWC guidelines. On preliminary user testing Contagion scored 5 in effectiveness in teaching treatments and 4.6 in teaching stewardship. An objective of this project is to perform large scale testing across schools to demonstrate the effectiveness of the learning components of the game. We hope to eventually create a tool that can be incorporated in continuing medical education for physicians.

Livestock producers are encouraged to reduce the use of antibiotics belonging to classes of medical importance to humans. We conducted a scoping review on non-antibiotic interventions in the form of products or management practices that could potentially reduce the need for antibiotics in beef and veal animals living under intensive production conditions. Our objectives were to systematically describe the research on this broad topic, identify specific topics that could feasibly support systematic reviews, and identify knowledge gaps. Multiple databases were searched. Two reviewers independently screened and charted the data. From the 13,598 articles screened, 722 relevant articles were charted. The number of relevant articles increased steadily from 1990. The Western European research was dominated by veal production studies whereas the North American research was dominated by beef production studies. The interventions and outcomes measured were diverse. The four most frequent interventions included non-antibiotic feed additives, vaccinations, breed type, and feed type. The four most frequent outcomes were indices of immunity, non-specific morbidity, respiratory disease, and mortality. There were seven topic areas evaluated in clinical trials that may share enough commonality to support systemic reviews. There was a dearth of studies in which interventions were compared to antibiotic comparison groups.

Introduction: It is assumed that sexual assault cases presenting at Emergency Departments (ED) are frequently lost to follow-up and should be considered an eligible population for presumptive antimicrobial treatment of sexual transmitted infections (STIs) at initial assessment without lab confirmation. With the growing burden of antibiotic resistance, antimicrobial stewardship guidelines caution against this practice. Among sexual assault cases, our study evaluated STI prevalence, follow-up and retention patterns, and described the prevalence of STI presumptive treatment. Methods: The Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital is the only program in Ottawa offering emergency and forensic care for survivors of sexual assault and domestic violence. Descriptive statistics were used to summarize information on demographics, clinical presentation, STI testing and results using data from the SAPACP case registry (January 1 - December 31, 2015). Results: Among the 406 patients seen by the SAPACP, there were 262 (64.5%) sexual assault cases that were included in this analysis. STI testing was completed for 209 (79.8%) patients at the initial visit, 90 (43.1%) completed via urine nucleic acid testing (NAAT), 140 (67.0%) via culture swab and 20 (9.6%) via both. Laboratory results detected no cases of gonorrhea, 8 (3.8%) cases of chlamydia, 33(15.8%) cases of bacterial vaginosis (BV), 17 (8.1%) cases of yeast vaginitis and 16 (7.7%) indeterminate testing results. Antimicrobial STI presumptive treatment was given to 12 (5.7%) patients at the time of their initial visit prior to lab confirmation. Patient follow-up occurred in 172 (82.3%) patients, with all chlamydia cases treated. Of the 37 (17.7%) patients lost to follow up, 9 were positive for BV, 1 was positive for yeast and 10 were indeterminate, all of which may be underlying vaginal flora. Follow up testing/test of cure was completed in 91 (52.9%) of patients, with 4 (2.3%) positive results, all of which were BV. Conclusion: In our ED, up to 15.8% of sexual assault patients had at least one laboratory confirmed STI and over 80% of all patients returned for follow-up. Our results show that it is safe and effective to only treat STI screen positive cases at follow-up, reducing the frequency of presumptive antimicrobial STI treatment. Benefits of this strategy include decreased patient side effects, cost savings and better antimicrobial stewardship.

Introduction: The Toronto Central Local Health Integration Network released new antimicrobial guidelines for the treatment of community acquired pneumonia (CAP) in August 2013. These deemphasized antimicrobial coverage for atypical organisms and use amoxicillin-clavulanic acid (AMC) as first-line for low risk CAP. The purpose of this study was to assess physician adherence to these guidelines in St. Michael’s Hospital (SMH) Emergency Department (ED). Methods: A retrospective chart review was conducted from April 1 to May 31 in 2013, 2014 and 2015. All adult patients who were discharged home from the ED with a diagnosis of pneumonia were included. Severity of pneumonia was graded based on the CRB-65 score as per the CAP guidelines. Primary outcome was type of antibiotic prescribed by the ED physician. Data was analyzed using simple descriptive statistics. Results: There were a total of 141 patients analyzed during the study period (N=46 in 2013, N=59 in 2014, N=36 in 2015). Demographics and relevant comorbidities were similar across the years: age (2013: median=53 years, range 20-92 years; 2014: 56, 21-83; 2015: 54, 20-81); preexisting lung disease (30%, 27%, 25% respectively); HIV positive status (9%, 7%, 17%). CRB-65 score was: low risk (0 points)=70% in 2013, 66% in 2014, 75% in 2015; intermediate risk (1-2 points)=30%, 34%, 25%; high risk (3-4 points)=0% in all years. Percentage of patients discharged home with a documented prescription was 83%, 85%, and 94% respectively. In 2013, patients received azithromycin (AZM) (n=17, 43% of antibiotic prescriptions that year); levofloxacin (LVX) (n=10, 25%); AMC (n=5, 13%); clarithromycin (CLR) (n=5, 13%); trimethoprim-sulfamethoxazole (SXT) (n=2, 5%); doxycycline (DOX) (n=1, 3%). In 2014: AMC (n=26, 51%); AZM (n=12, 24%); LVX (n=9, 18%); CLR (n=2, 4%); DOX (n=1, 2%); erythromycin (ERY) (n=1, 2%). In 2015: AMC (n=17, 47%); AZM (n=12, 33%); LVX (n=4, 11%); CLR (n=1, 3%); SXT (n=1, 3%); DOX (n=1, 3%). Number of return ED visits within 2 weeks were: n=16 (35%); n=11 (19%); and n=10 (28%) respectively. Conclusion: The results of this study show that there has been a change in antibiotic prescribing practices in the SMH ED since dissemination of the CAP guidelines, with AMC accounting for nearly half of antibiotic prescriptions. Further antimicrobial stewardship efforts will focus on evaluating factors influencing prescribing practices.

The objective of this study was to evaluate the impact of restricting high-risk antibiotics on methicillin-resistant Staphylococcus aureus (MRSA) incidence rates in a hospital setting. A secondary objective was to assess the impact of reducing fluoroquinolone use in the primary-care setting on MRSA incidence in the community. This was an interventional, retrospective, ecological investigation in both hospital and community (January 2006 to June 2010). Segmented regression analysis of interrupted time-series was employed to evaluate the intervention. The restriction of high-risk antibiotics was associated with a significant change in hospital MRSA incidence trend (coefficient = −0·00561, P = 0·0057). Analysis showed that the intervention relating to reducing fluoroquinolone use in the community was associated with a significant trend change in MRSA incidence in community (coefficient = −0·00004, P = 0·0299). The reduction in high-risk antibiotic use and fluoroquinolone use contributed to both a reduction in incidence rates of MRSA in hospital and community (primary-care) settings.