Impact of Two Different Antimicrobial Stewardship Methods on Frequency of Streamlining Antimicrobial Agents in Patients with Bacteremia

2016 ◽  
Vol 38 (1) ◽  
pp. 89-95 ◽  
Author(s):  
Jennifer Lukaszewicz Bushen ◽  
Jimish M. Mehta ◽  
Keith W. Hamilton ◽  
Shawn Binkley ◽  
Daniel R. Timko ◽  
...  
Keyword(s):  
Emergency Department ◽  
Antimicrobial Stewardship ◽  
Medical Service ◽  
Antimicrobial Agents ◽  
Academic Medical Center ◽  
Prior Authorization ◽  
Prospective Audit ◽  
Gram Negative ◽  
Gram Negative Bacteremia ◽  
Audit Period

OBJECTIVETo assess the likelihood of antimicrobial streamlining between 2 antimicrobial stewardship methods.DESIGNRetrospective cohort study.SETTINGLarge academic medical center.METHODSFrequency and time to antimicrobial streamlining were compared during a prior authorization and a prospective audit period. Streamlining was defined as an antimicrobial change to a narrower agent if available or to a broader agent if the isolate was resistant to empiric therapy. Patients included were ≥18 years old with monomicrobial bacteremia with S. aureus, Enterococcus spp., or any aerobic Gram-negative organism.RESULTSA total of 665 cases of bacteremia met inclusion criteria. Frequency of streamlining was similar between periods for all cases of bacteremia (audit vs restriction: 60.7% vs 53.2%; P=.12), S. aureus bacteremia (73.2% vs 76.9%; P=.671), and Enterococcus bacteremia (81.6% vs 71.9%; P=.335). Compared to restriction, the audit period was associated with an increased frequency of streamlining for cases of Gram-negative bacteremia (51.4% vs 35.6%; odds ratio [OR], 1.85; 95% confidence interval [CI], 1.06–3.25), those on the medical service (67.9% vs 53.1%; OR, 1.86; 95% CI, 1.09–3.16), and those admitted through the emergency department (71.6% vs 51.4%; OR, 2.32; 95% CI, 1.24–4.34). Characteristics associated with increased streamlining included: absence of β-lactam allergy (P<.001), Gram-negative bacteremia (P<.001), admission through the emergency department (P=.001), and admission to a medical service (P=.011).CONCLUSIONSCompared with prior authorization, prospective audit increased antimicrobial streamlining for cases of Gram-negative bacteremia, those admitted through the emergency department, and those admitted to a medical but not surgical service.Infect Control Hosp Epidemiol 2016:1–7

scholarly journals Comparison of Prior Authorization and Prospective Audit with Feedback for Antimicrobial Stewardship

2014 ◽  
Vol 35 (9) ◽  
pp. 1092-1099 ◽  
Author(s):  
Jimish M. Mehta ◽  
Kevin Haynes ◽  
E. Paul Wileyto ◽  
Jeffrey S. Gerber ◽  
Daniel R. Timko ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Broad Spectrum ◽  
Academic Medical Center ◽  
Antimicrobial Use ◽  
Prior Authorization ◽  
Antimicrobial Consumption ◽  
Prospective Audit ◽  
Gram Negative ◽  
Stewardship Program ◽  
Days Of Therapy

(See the commentary by Van Schooneveld and Rupp, on pages1100–1102.)ObjectiveAlthough prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center.DesignQuasi-experimental study.MethodsWe compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS).ResultsIn total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (−9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (−4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively).ConclusionsSignificant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.Infect Control Hosp Epidemiol 2014;35(9):1092-1099

scholarly journals 183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S98-S98
Author(s):  
Hannah Kafisheh ◽  
Matthew Hinton ◽  
Amanda Binkley ◽  
Christo Cimino ◽  
Christopher Edwards
Keyword(s):  
Emergency Department ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Positive Culture ◽  
Culture Result ◽  
Academic Medical ◽  
Positive Culture Result ◽  
Therapy Modification

Abstract Background Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI). Methods This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed. Results A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p &lt; 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p &lt; 0.01). Conclusion The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA. Disclosures All Authors: No reported disclosures

scholarly journals Evaluation of the impact of the Accelerate Pheno™ system on time to result for differing antimicrobial stewardship intervention models in patients with gram-negative bloodstream infections

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Gerald Elliott ◽  
Michael Malczynski ◽  
Viktorjia O. Barr ◽  
Doaa Aljefri ◽  
David Martin ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Bloodstream Infections ◽  
Standard Of Care ◽  
Resistance Mechanisms ◽  
Gram Negative ◽  
Intervention Models ◽  
Gram Negative Bacteremia ◽  
Potential Impact ◽  
Potential Clinical Impact ◽  
The Impact

Abstract Background Initiating early effective antimicrobial therapy is the most important intervention demonstrated to decrease mortality in patients with gram-negative bacteremia with sepsis. Rapid MIC-based susceptibility results make it possible to optimize antimicrobial use through both escalation and de-escalation. Method We prospectively evaluated the performance of the Accelerate Pheno™ system (AXDX) for identification and susceptibility testing of gram-negative species and compared the time to result between AXDX and routine standard of care (SOC) using 82 patient samples and 18 challenge organisms with various confirmed resistance mechanisms. The potential impact of AXDX on time to antimicrobial optimization was investigated with various simulated antimicrobial stewardship (ASTEW) intervention models. Results The overall positive and negative percent agreement of AXDX for identification were 100 and 99.9%, respectively. Compared to VITEK® 2, the overall essential agreement was 96.1% and categorical agreement was 95.4%. No very major or major errors were detected. AXDX reduced the time to identification by an average of 11.8 h and time to susceptibility by an average of 36.7 h. In 27 patients evaluated for potential clinical impact of AXDX on antimicrobial optimization, 18 (67%) patients could potentially have had therapy optimized sooner with an average of 18.1 h reduction in time to optimal therapy. Conclusion Utilization of AXDX coupled with simulated ASTEW intervention notification substantially shortened the time to potential antimicrobial optimization in this cohort of patients with gram-negative bacteremia. This improvement in time occurred when ASTEW support was limited to an 8-h coverage model.

scholarly journals 519. Multidrug-resistant Gram-Negative Bacteremia in Pediatric Patients: Is It Time to Change to Empiric Meropenem?

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S250-S250
Author(s):  
Kanokporn Mongkolrattanothai ◽  
Leslie Stach ◽  
Regina Orbach
Keyword(s):  
Antimicrobial Agents ◽  
Pediatric Patients ◽  
Multidrug Resistant ◽  
Suspected Sepsis ◽  
In Vitro Susceptibility ◽  
Gram Negative ◽  
Gram Negative Bacteremia ◽  
Delayed Initiation ◽  
Poor Outcomes

Abstract Background The rise of antimicrobial resistance among gram-negative (GN) pathogens has been dramatic nationally. Delayed initiation of active antimicrobial agents has been associated with poor outcomes. We aimed at evaluating the prevalence and treatment of multi-drug-resistant gram-negative (MDR-GN) bacteremia in our pediatric patients. Methods All episodes of GN bacteremia from 2017–2018 at our institution were retrospectively reviewed. GN defined as MDR in our study were carbapenem-resistant organisms (CRO), extended-spectrum β-lactamase (ESBL) producers, and GN that were resistant to cefepime and ≥2 classes of non-cephalosporin antimicrobial agents. Stenotrophomonas maltophilia was excluded. Ineffective empirical treatment (IET) is defined as an initial antibiotic regimen that is not active against the identified pathogen[s] based on in vitro susceptibility testing results. Results A total of 292 episodes of GN bacteremia were identified and 6 S. maltophilia were excluded. Of these, 29 bacteremic episodes in 26 patients were caused by MDR-GN organisms including 18 ESBL, 7 CRO, 1 ESBL and CRO, 3 non-ESBL/non-CRO cefepime-resistant MDR-GN. None of the CRO had carbapenemase genes detected. However, there was a patient with multiple sites of infection simultaneously with non-NDM CR Acinetobacter bacteremia and NDM-mediated CR-Klebsiella ventriculitis. The annual rate of MDR-GN bacteremia increased from 8% in 2017 to 12% in 2018. Almost half (48%) of episodes were community onset. Among these, all but one had underlying medical conditions with hospital exposure and most patients had central venous devices at the time of infection. 52% (15/29) episodes of MDR-GN bacteremia had IET. Despite IET, 47% (7/15) had negative blood cultures prior to initiation of effective therapy (6 ESBL and 1 P. aeruginosa). Various antibiotic regimens were used for CRO therapy as shown in Table 1. Conclusion In our institution, MDR-GN infection is increasing. As such, empiric meropenem is currently recommended in BMT or neutropenic patients with suspected sepsis. However, empiric meropenem must be used judiciously as its widely use will lead to more selection of MDR pathogens. It is essential to continue monitoring of these MDR-GN to guide appropriate empiric regimens. Disclosures All authors: No reported disclosures.

scholarly journals 227Evaluation of Antimicrobial Stewardship in an Academic Medical Center Emergency Department (ED)

2014 ◽  
Vol 1 (suppl_1) ◽  
pp. S99-S99
Author(s):  
Jennifer Anthone ◽  
Barry Nakaoka ◽  
Renuga Vivekanandan ◽  
Krysta Baack ◽  
John Horne ◽  
...  
Keyword(s):  
Emergency Department ◽  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical

Automated Alerts Coupled with Antimicrobial Stewardship Intervention Lead to Decreases in Length of Stay in Patients with Gram-Negative Bacteremia

2014 ◽  
Vol 35 (2) ◽  
pp. 132-138 ◽  
Author(s):  
Jason M. Pogue ◽  
Ryan P. Mynatt ◽  
Dror Marchaim ◽  
Jing J. Zhao ◽  
Viktorija O. Barr ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Blood Culture ◽  
Antimicrobial Stewardship ◽  
Positive Blood Culture ◽  
Medical Center ◽  
Intervention Group ◽  
Gram Negative ◽  
Gram Negative Bacteremia ◽  
Appropriate Therapy ◽  
The Impact

Objective.To assess the impact of active alerting of positive blood culture data coupled with stewardship intervention on time to appropriate therapy, length of stay, and mortality in patients with gram-negative bacteremia.Design.Quasi-experimental retrospective cohort study in patients with gram-negative bacteremia at the Detroit Medical Center from 2009 to 2011.Setting.Three hospitals (1 community, 2 academic) with active antimicrobial stewardship programs within the Detroit Medical Center.Patients.All patients with monomicrobial gram-negative bacteremia during the study period.Intervention.Active alerting of positive blood culture data coupled with stewardship intervention (2010-2011) compared with patients who received no formalized stewardship intervention (2009).Results.Active alerting and intervention led to a decreased time to appropriate therapy (8 [interquartile range (IQR), 2-24] vs 14 [IQR, 2-35] hours; P = .014) in patients with gram-negative bacteremia. After controlling for differences between groups, being in the intervention arm was associated with an independent reduction in length of stay (odds ratio [OR], 0.73 [95% confidence interval (CI), 0.62-0.86]), correlating to a median attributable decrease in length of stay of 2.2 days. Additionally, multivariate modeling of patients who were not on appropriate antimicrobial therapy at the time of initial culture positivity showed that patients in the intervention group had a significant reduction in both length of stay (OR, 0.76 [95% CI, 0.66-0.86]) and infection-related mortality (OR, 0.24 [95% CI, 0.08-0.76]).Conclusions.Active alerting coupled with stewardship intervention in patients with gram-negative bacteremia positively impacted time to appropriate therapy, length of stay, and mortality and should be a target of antimicrobial stewardship programs.

Impact of antimicrobial stewardship and rapid microarray testing on patients with Gram-negative bacteremia

2017 ◽  
Vol 36 (10) ◽  
pp. 1879-1887 ◽  
Author(s):  
K. R. Rivard ◽  
V. Athans ◽  
S. W. Lam ◽  
S. M. Gordon ◽  
G. W. Procop ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Gram Negative ◽  
Gram Negative Bacteremia
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