{'fraction_non_alphanumeric': 0.018569589998161426, 'fraction_numerical': 0.005791505791505791, 'mean_word_length': 5.872394188250158, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Antimicrobial stewardship programs in solid‐organ transplant recipients in Switzerland

Abstract Introduction Antimicrobial stewardship programs (ASPs) are essential for minimizing the emergence of antimicrobial resistance, while improving patient outcomes. The current status of ASP in the field of organ transplantation in Switzerland has not been well characterized. Methods We describe in this article the current status of ASP and discuss challenges and opportunities of implementing ASP dedicated to solid‐organ transplant (SOT) recipients in Switzerland. Results ASP have been implemented in the Swiss healthcare system over the last years, although specific strategies for SOT recipients are mostly based on transplant infectious diseases (TID) consultations rather than structured institutional interventions. Even so, there is a unique opportunity for developing a successful ASP in Switzerland that also specifically addresses areas of practice relevant to SOT recipients. This is due to the existent network of TID specialists in close collaboration with transplant physicians, the small number of centers involved in the care of transplant recipients, and the development of the Swiss Transplant Cohort Study (STCS), a prospective nationwide cohort of SOT recipients in Switzerland. The STCS can identify actual challenges through the updated reports on the epidemiology on transplant infections, accurately monitor the impact of potential antimicrobial stewardship interventions, and represent an opportunity for nesting of pragmatic randomized controlled trials to address key questions about optimized antibiotic use for SOT recipients. Conclusions Although ASP in SOT recipients rely more on specific TID consultations than in general antimicrobial stewardship teams, we identified several opportunities for the implementation of a successful ASP in Switzerland.


ORGAN TRANSPLANTATION IN SWITZERLAND
In Switzerland (population of 8.6 million inhabitants), organ transplantation is performed in five University Hospitals (Basel, Bern, Geneva, Lausanne, and Zurich) and one Cantonal Hospital (St. Gallen), comprising six kidney, three liver, three heart, two lung, and two pancreas transplant programs. 1

EPIDEMIOLOGY OF TRANSPLANT-INFECTIOUS DISEASES IN SWITZERLAND
The epidemiology and outcomes of transplant infections have been characterized in detail in several publications of the STCS. Some studies have described the general epidemiology of infection in all patients included in the cohort, 4 whereas others have focused on a specific type of pathogen (e.g., cytomegalovirus and other herpesviruses, 5,6 Aspergillus, 7 Clostridioides difficile 8 ) or on a specific syndrome (e.g., food-borne infection, 9 urinary tract infection 10 ). In addition to the scientific value, these publications have a pivotal role in quantifying the burden of disease associated with infection, in describing local trends on the epidemiology of specific infections, and in identifying potential unexpected infectious diseases concerns in a particular center. 11 Given the updated annual reports generated by the STCS, these potential concerns can be identified and addressed in a real-time matter.
The most comprehensive data on the epidemiology of transplant infection in Switzerland has been summarized by van Delden et al. 4 This study collected more than 3500 clinically significant infections

ANTIMICROBIAL USE IN SOT RECIPIENTS
The preventive and therapeutic strategies against infectious diseases in Switzerland vary according to organ and transplant center.

CONTEXT OF ANTIMICROBIAL STEWARDSHIP IN SWITZERLAND
Antimicrobial stewardship is defined as a coherent set of activities adapted to a specific context that encourage the judicious use of antimicrobials. 14 Although the minimization of the emergence of antimicrobial resistance is a key goal of antimicrobial stewardship, it is also considered essential to improve patient outcomes. 15 Structured and consistent approaches to improving the use of antimicrobials are especially important for patients at high risk of invasive and difficult-to-treat infections, and more targeted utilization of antimicrobials has not been found to be associated with adverse outcomes in hemato-oncological patients. 16,17 ASP for SOT recipients are challenging due to the added diagnostic and therapeutic uncertainties in this group compared to other patients receiving antimicrobial treatments. 18 Switzerland, like many other countries, has several interrelated national strategies in place that address antimicrobial stewardship.
The Strategy on Antibiotic Resistance (StAR) represents the Swiss National Action Plan on antimicrobial resistance. 19 It takes a One Health approach, with all aspects of antimicrobial stewardship, such as availability of guidelines and strengthened surveillance, at the core of the response to antimicrobial resistance in the human sector. A relevant related national strategy is the NOSO strategy, which addresses the prevention and management of healthcare-associated infections in acute care facilities in Switzerland. 20 The cross section of a focus on healthcare-associated infections and optimized antimicrobial use in acute care facilities is an obvious area of synergy between these two strategies.
The Swiss healthcare system is highly devolved, with much of the strategic and operational decision-making about healthcare taking place at the cantonal (regional) level. 21

CURRENT STATE OF ANTIMICROBIAL STEWARDSHIP IN SWITZERLAND
To provide a common framework for delivering antimicrobial stewardship in Swiss acute care facilities, including for at-risk groups such as SOT patients, SwissASP has published guidance on areas of action to be considered by healthcare facilities while reviewing the structural and implementation maturity of antimicrobial stewardship activities at their site. In a subsequent phase, an integrated approach toward monitoring of antimicrobial stewardship in acute care facilities, consisting, for example, of antimicrobial use surveillance, assessment of antimicrobial stewardship maturity, and tracking of nationally agreed quality indicators, will be developed. All monitoring approaches will include the possibility of monitoring site performance over time and benchmarking.
In a survey conducted at the initiation of the SwissASP activities, only a minority of responding hospitals indicated that a written strategy document or policy was in place for antimicrobial stewardship (21/63, 33% and 14/63, 22%, respectively). 23 Instead, healthcare facilities were relying on antimicrobial treatment recommendations focusing on specific indications, surgical antibiotic prophylaxis, guidance on the avoidance of unnecessary broader-spectrum antimicrobials, and duration of treatment. 23 Approaches to the review of antimicrobial therapy based on clinical and diagnostic information, therapeutic drug monitoring, antifungal and antiviral treatment, and appropriate documentation around antimicrobial therapy were addressed only infrequently by hospital guidelines. 23 Many of these aspects would be particularly relevant in a vulnerable patient group, such as SOT recipients.

ANTIMICROBIAL STEWARDSHIP FOR SOT RECIPIENTS
As mentioned, only six centers in Switzerland are considered primary SOT facilities. The leading infectious diseases physicians at those centers were approached to gather information on the current state of implementation of antimicrobial stewardship for SOT recipients (Table 1)  Abbreviations: AS, antimicrobial stewardship; ID, infectious diseases; IV, intravenous; SOT, solid-organ transplant. a Note that the following activities were not reported as in use for SOT recipients in any of the responding centers: antimicrobial cycling, antimicrobial order forms, automatic alerts for unnecessarily duplicative therapy, and closed formulary.

OPPORTUNITIES AND CHALLENGES FOR ANTIMICROBIAL STEWARDSHIP FOR SOT RECIPIENTS
The reported activities in the Swiss transplant centers, including restrictions on antimicrobials and reliance on guidelines, and a focus on recommendations in the area of overlap between infectious diseases consults and antimicrobial stewardship (such as dose optimization, de-escalation and intravenous to oral conversions), align with those known to be predominantly applied as part of antimicrobial stew-ardship for SOT recipients in other countries. 24 The challenges of antimicrobial stewardship relate to the lack of robust evidence for key aspects of infection management in immunosuppressed patients, including SOT recipients. 24 As an example, the duration of treatment for certain infections is often less well defined than in immunocompetent patients, making it difficult to use time-sensitive stop orders. 25 Thus, improvement of antimicrobial prescriptions is mostly based on specific transplant-infectious diseases consultations rather than on institutional general rules for antimicrobial stewardship. This close involvement of infectious diseases specialist in the care of SOT recipients in Switzerland represents an opportunity for the development of ASPs specifically for this population. Engagement of SOT centers in an early stage of the development of SwissASP could mean that needs of SOT (and also stem-cell transplant) recipients can be specifically addressed, for example, through a small working group within the platform that can be consulted on aspects relevant to these patient groups. Additionally, the small number of centers involved could work toward nationally aligned guidance on antimicrobial stewardship for SOT patients, including on use of diagnostics and prophylaxis. Specific interventions where more robust evidence is available for SOT recipients could be implemented initially, based also on local epidemiology and in collaboration with transplant specialists. Examples of targeted interventions can be a comprehensive program for reducing antibiotic use in kidney transplant recipients with asymptomatic bacteriuria, 26 shortening the duration of antibiotic therapy for urinary tract infection, 27 or apply standardized preventive strategies against invasive fungal infections in lung transplant recipients. In parallel, some challenges exist on the development of a successful stewardship program specifically for SOT recipients in Switzerland, mainly due to the highly devolved nature of the Swiss healthcare system, which means that any resource implications must be negotiated at a cantonal level.

CONCLUSIONS
In Switzerland, there is a unique opportunity for developing a successful ASP that also specifically addresses areas of practice relevant to SOT recipients. First, the implementation of such ASPs is a priority for the Swiss healthcare system, for which the structure and expertise in a national level is already in place, as previously mentioned.