Prolonged antimicrobial prophylaxis following cardiac device procedures increases preventable harm: insights from the VA CART program

2018 ◽  
Vol 39 (9) ◽  
pp. 1030-1036 ◽  
Author(s):  
Archana Asundi ◽  
Maggie Stanislawski ◽  
Payal Mehta ◽  
Anna E. Barón ◽  
Howard Gold ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Cardiac Electrophysiology ◽  
Electronic Device ◽  
Antimicrobial Prophylaxis ◽  
Secondary Outcome ◽  
Antimicrobial Use ◽  
Cardiac Device ◽  
Increased Risk ◽  
Preventable Harm ◽  
The Impact

AbstractBackgroundThe rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to quantify the harms associated with this approach.ObjectiveTo measure the association between Clostridium difficile infection (CDI), acute kidney injury (AKI) and receipt of prolonged postprocedural antimicrobials.MethodsCIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) database during fiscal years 2008–2016 were included. The primary outcome was 90-day incidence of CDI and the secondary outcome was the 7-day incidence of AKI. The primary exposure measure was duration of postprocedural antimicrobial therapy. Associations were measured using Cox-proportional hazards and binomial regression.ResultsProlonged postprocedural antimicrobial therapy was identified following 3,331 of 6,497 CIED procedures (51.3%), and the median duration of prophylaxis was 5 days. Prolonged postprocedural antimicrobial use was associated with increased risk of CDI (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.54–5.46). Of the 27 patients who developed CDI, 11 subsequently died. Postprocedural antimicrobial use with ≥2 antimicrobials was associated with an increased risk of AKI (OR, 4.16; 95% CI, 2.50–6.90). The impact was particularly significant when one of the dual agents prescribed was vancomycin (adjusted OR, 8.41; 95% CI, 5.53–12.79).ConclusionsProlonged antimicrobial prophylaxis following CIED procedures increases preventable harm; this practice should be discouraged in procedural settings such as the cardiac electrophysiology laboratory.

Cardiac Electrophysiology Laboratories: A Potential Target for Antimicrobial Stewardship and Quality Improvement?

2016 ◽  
Vol 37 (9) ◽  
pp. 1005-1011 ◽  
Author(s):  
Westyn Branch-Elliman ◽  
Maggie Stanislawski ◽  
Judith Strymish ◽  
Anna E. Barón ◽  
Kalpana Gupta ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Cardiac Electrophysiology ◽  
Electronic Device ◽  
Antimicrobial Use ◽  
Cardiac Device ◽  
Potential Target ◽  
Procedural Volume ◽  
Improvement Programs

BACKGROUNDInfections following cardiovascular implantable electronic device (CIED) procedures, including pacemaker and implantable cardioverter–defibrillators, are devastating and costly. Preimplantation prophylactic antimicrobials are effective for reducing postprocedural infections. However, routine postprocedural antimicrobials are not associated with improved outcomes, and they may be harmful. Thus, we sought to characterize antimicrobial use patterns following CIED procedures.DESIGNAll patients who underwent CIED procedures from October 1, 2007 to September 30, 2013 and had procedural information entered into the VA Clinical Assessment Reporting and Tracking (CART) software program were included in this study. All antibiotic prescriptions lasting more than 24 hours following device implantation or revision were identified using pharmacy databases, and postprocedural antibiotic use lasting more than 24 hours was characterized.RESULTSIn total, 3,712 CIED procedures were performed at 34 VA facilities on 3,570 patients with a mean age of 71.7 years (standard deviation [SD], 11.1 years), 98.4% of whom were male. Postprocedural antibiotics >24 hours were prescribed following 1,579 of 3,712 CIED procedures (42.5%). The median duration of therapy was 5 days (interquartile range [IQR], 3–7 days). The most commonly prescribed antibiotic was cephalexin (1,152 of 1,579; 72.9%), followed by doxycycline (118 of 1,579; 7.47%) and ciprofloxacin (93 of 1,579; 5.9%). Vancomycin was used in 73 of 1,579 prescriptions (4.62%). Among the highest quartile of procedural volume, prescribing practices varied considerably, ranging from 3.2% to 77.6%.CONCLUSIONSNearly 1 in 2 patients received prolonged postprocedural antimicrobial therapy following CIED procedures, and the rate of postprocedural antimicrobial therapy use varied considerably by facility. Given the lack of demonstrated benefit of routine prolonged antimicrobial therapy following CIED procedures, antimicrobial use following cardiac device interventions may be a potential target for quality improvement programs and antimicrobial stewardship.Infect Control Hosp Epidemiol 2016;37:1005–1011

Reducing Broad Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation (ECMO): Reduce AMMO Study

2021 ◽  
Author(s):  
Aditya Shah ◽  
Priya Sampathkumar ◽  
Ryan W Stevens ◽  
John K Bohman ◽  
Brian D Lahr ◽  
...  
Keyword(s):  
Time Series ◽  
Extracorporeal Membrane Oxygenation ◽  
Broad Spectrum ◽  
Antimicrobial Prophylaxis ◽  
Current Evidence ◽  
Antimicrobial Use ◽  
Infection Rates ◽  
Interrupted Time Series Analysis ◽  
Membrane Oxygenation ◽  
The Impact

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across three time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol. Study design and Methods In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and NHSN reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we re-evaluated the same metrics. Results Our study population included 338 ICU patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates. Conclusion Our final protocol significantly reduces broad spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience.

Influence of Estimated Fetal Weight on Labor Management

2019 ◽  
Vol 37 (03) ◽  
pp. 252-257
Author(s):  
Elisa T. Bushman ◽  
Norris Thompson ◽  
Meredith Gray ◽  
Robin Steele ◽  
Sheri M. Jenkins ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Secondary Analysis ◽  
Physical Exam ◽  
Fetal Weight ◽  
Secondary Outcome ◽  
Labor Management ◽  
Increased Risk ◽  
Tertiary Center ◽  
The Impact ◽  
Estimated Fetal Weight

Abstract Objective Prior studies suggest knowledge of estimated fetal weight (EFW), particularly by ultrasound (US), increases the risk for cesarean delivery. These same studies suggest that concern for macrosomia potentially alters labor management leading to increased rates of cesarean delivery. We aimed to assess if shortened labor management, as a result of suspected macrosomia (≥4,000 g), leads to an increased rate of cesarean delivery. Study Design This is a secondary analysis of a retrospective cohort study at a single tertiary center in 2015 of women with singleton pregnancies ≥36 weeks with documented EFW by US within 3 weeks or physical exam on admission. Women were excluded if an initial cervical exam was ≥6 cm or no attempt was made to labor. In addition, patients were excluded for the diagnosis of hypertension, diabetes, or prior cesarean delivery, as these comorbidities influence the use of US, labor management, and cesarean delivery independent of fetal weight. Patients were classified as EFW of ≥4,000 and <4,000 g. Secondary analysis examined the impact of US within 3 weeks of admission when compared with physical exam at the time of admission. The primary maternal outcomes were duration of labor and cesarean delivery. Duration of labor was evaluated as total time from 4 cm to delivery (with 4-cm dilation being a surrogate marker for active labor), length of time allowed from 4 cm until the first documented cervical change (or delivery), and time in second stage of labor (complete dilation to delivery). Cesarean delivery for arrest of labor was a secondary outcome. Student's t-test, Mann–Whitney U-test, chi-squared test, and Fisher's exact test were used for univariate data analysis as appropriate. Results Of 1,506 patients included, 54 (3.5%) had EFW of ≥4,000 g. Women with EFW of ≥4,000 g had a larger body mass index, higher fetal birth weight, were more likely to be undergoing induction of labor, had a more advanced gestational age, and were more likely to have had an US within 3 weeks of delivery. They were more likely to undergo cesarean delivery (29.6 vs. 9.3%, adjusted odds ratio [AOR]: 2.7, 95% confidence interval [CI]: 1.3–5.5) despite not having shortened labor times. When analyzing this population by method of obtaining EFW, those with EFW based on US rather than external palpation were more likely to undergo cesarean delivery (13.1 vs. 7.9%, AOR: 1.5, 95% CI: 1.01–2.12), again without having shortened labor times. Conclusion EFW of ≥4,000 g and use of US to estimate fetal weight do not appear to shorten labor management despite being associated with an increased risk of cesarean delivery.

Antimicrobial Stewardship by Transitions of Care Pharmacists at Hospital Discharge

2020 ◽  
pp. 001857872095117
Author(s):  
Noah Leja ◽  
Curtis D. Collins ◽  
Janice Duker
Keyword(s):  
High Risk ◽  
Hospital Discharge ◽  
Antimicrobial Therapy ◽  
Treatment Duration ◽  
Descriptive Study ◽  
Pharmacological Therapy ◽  
Transitions Of Care ◽  
Antimicrobial Use ◽  
The Impact ◽  
Hospital Discharge Date

Objectives: This study assessed the impact transitions of care (TOC) pharmacists have on optimizing antimicrobial use for patients at high risk for mortality at hospital discharge. In addition, this study aimed to summarize and categorize the types of interventions made. Methods: This was a retrospective descriptive study that included adult patients 18 years of age or older who were at high risk for readmission and mortality. Participants were selected if they had a hospital discharge date between January 2017 and June 2018, but were excluded if they were discharged to a facility where medications were managed by healthcare employees or if they were hospice eligible. TOC pharmacists identified eligible participants and reviewed their discharge medication lists to optimize pharmacological therapy, contacting the discharging prescriber if therapy changes were identified. The therapy recommendations made by TOC pharmacists were documented in an internal database for further analysis. Results: A total of 1100 patients were analyzed by TOC pharmacists during the studied timeframe and a total of 2066 interventions were made. With respect to study objectives, 298 (14.4%) of the interventions made by TOC pharmacists involved antimicrobial recommendations, affecting 255 (23.2%) patients. Recommendations involving dosing (89, 29.9%), treatment duration (74, 24.8%), and drug interactions (41, 13.8%) were the most frequent types of interventions made. Sixty-six (25.9%) patients received multiple interventions and 240 (80.5%) recommendations were accepted by the provider. Conclusion: An opportunity exists to optimize antimicrobial therapy surrounding the time of hospital discharge.

scholarly journals 622. Evaluation of Vascular Access Device Selection in Patients Discharged on Outpatient Parenteral Antimicrobial Therapy

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S413-S414
Author(s):  
Jessica Hu ◽  
Lauren Dutcher ◽  
Vasilios Athans ◽  
Shawn Binkley ◽  
Justin Harris ◽  
...  
Keyword(s):  
Vascular Access ◽  
Antimicrobial Therapy ◽  
Secondary Outcome ◽  
Patient Specific ◽  
National Guidelines ◽  
Access Device ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
Increased Risk ◽  
Multivariable Regression ◽  
Vascular Access Device

Abstract Background Selection of a vascular access device (VAD) is an important consideration for patients receiving outpatient parenteral antimicrobial therapy (OPAT). Midline catheters (MC) and peripherally inserted central catheters (PICC) are the most commonly placed VADs, with the former recommended by national guidelines to be used for durations no longer than two weeks. These recommendations, however, are based on limited data from heterogeneous populations. As such, we aim to further characterize VAD-associated complications specifically in patients receiving antimicrobials. Methods We conducted a retrospective cohort study that included adult patients discharged on OPAT with a newly inserted MC or PICC between January 2020 and August 2020. Patients with non-OPAT VAD indications were excluded. The primary outcome was the incidence of VAD-associated complications, which was further assessed by type and severity. The secondary outcome was time to complication. Multivariable Poisson regression was used to assess the association between VAD type and incidence of VAD-associated complications. Results A total of 190 encounters from 181 patients were included for analysis. Baseline demographics are detailed in Table 1. Despite a higher number of complications in the PICC group, rates per 1000 VAD days were not significantly different between VAD types (Table 2). Median time to first complication was 17 days in the overall cohort. Multivariable regression analysis showed those with a dermatologic history had a four-fold increased risk for VAD-associated complications (Table 3). VAD type was not independently associated with the risk of developing a complication. Conclusion Our results suggest that the development of VAD-associated complications was strongly associated with patients’ dermatologic history. To our knowledge, dermatologic history has not been previously identified as a risk factor for VAD-associated complications. Thorough assessment of patient-specific risk factors can inform optimal VAD selection for patients discharged on OPAT. Further studies are needed to assess the safety of MC for extended OPAT use. Disclosures All Authors: No reported disclosures

scholarly journals 809. Evaluation of Antimicrobial Prophylaxis Prescribing in Post-operative Neurosurgical Procedures

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S498-S499
Author(s):  
Clarice Resso ◽  
Kelsey Mott ◽  
Jasmine Reber ◽  
Malika N Kheraj
Keyword(s):  
Antimicrobial Therapy ◽  
Adverse Drug Events ◽  
Antimicrobial Prophylaxis ◽  
Surgical Site Infections ◽  
Drug Event ◽  
P Value ◽  
Neurosurgical Procedures ◽  
Prescribing Practices ◽  
Shunt Insertion ◽  
Increased Risk

Abstract Background Due to lack of relevant clinical data or guidelines, duration of post-operative prophylactic antimicrobial therapy for neurosurgical procedures at the Kaiser Permanente Northern California (KPNC) hospitals has varied among patients and is largely based on the clinical judgment of surgeons. Non-standardized perioperative microbial prophylaxis practice has been associated with excessive antimicrobial therapy, increased risk of drug resistance, institutional cost, and adverse drug effects. This study aims to evaluate differences in prescribing practices of post-operative prophylactic antibiotics among neurosurgeons and to observe the incidence of surgical site infections and adverse drug events caused by antimicrobial prophylaxis that are associated with varying durations of post-procedure prophylaxis. Methods A retrospective, observational study of health plan members of KPNC who underwent neurosurgical procedures from 01/01/2011 to 12/31/2019. Prophylactic antimicrobial therapy and duration was identified from medication dispensing and administration records. The study analyzed rates of surgical site infection, post-surgical wound drainage, 60-day mortality, and adverse drug events within 60 days of surgery. Results The cohort consisted of 491 patients. 140 received antibiotics for &gt;24 hours and 351 received antibiotics for ≤24 hours. The most common procedures analyzed in our patient population were VP shunt insertion (70.7%) and craniotomy subdural hematoma evacuation (17.9%). There were more surgical site infections in those who received antibiotics &gt;24 hours (4.3% vs 1.4%, p value= 0.05). Univariate logistic regression model showed receiving antibiotics for ≤ 24 hours significantly decreased chance of composite drug event (odds ratio 0.345, 95% CI 0.172-0.691, p value= 0.003). Conclusion This study demonstrated that antimicrobial prophylaxis for neurosurgical procedures ≤24 hours decreases risk of adverse drug events. The study provides further evidence to support the development of a standardized protocol that recommends short duration of antibiotic prophylaxis for neurosurgical procedures at KPNC. Poster Disclosures All Authors: No reported disclosures

scholarly journals Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases

2017 ◽  
Vol 127 (5) ◽  
pp. 1096-1104 ◽  
Author(s):  
Jian Guan ◽  
Andrea A. Brock ◽  
Michael Karsy ◽  
William T. Couldwell ◽  
Meic H. Schmidt ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Body Mass ◽  
Secondary Outcome ◽  
Neurosurgical Procedures ◽  
Complication Rates ◽  
Increased Risk ◽  
Neurosurgical Patients ◽  
Physical Classification ◽  
The Impact ◽  
Surgery Duration

OBJECTIVEOverlapping surgery—the performance of parts of 2 or more surgical procedures at the same time by a single lead surgeon—has recently come under intense scrutiny, although data on the effects of overlapping procedures on patient outcomes are lacking. The authors examined the impact of overlapping surgery on complication rates in neurosurgical patients.METHODSThe authors conducted a retrospective review of consecutive nonemergent neurosurgical procedures performed during the period from May 12, 2014, to May 12, 2015, by any of 5 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Overlapping surgery was defined as any case in which 2 patients under the care of a single lead surgeon were under anesthesia at the same time for any duration. Information on patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed. Primary outcome was the occurrence of any complication from the beginning of surgery to 30 days after discharge. A secondary outcome was the occurrence of a serious complication—defined as a life-threatening or life-ending event—during this same period.RESULTSOne thousand eighteen patients met the inclusion criteria for the study. Of these patients, 475 (46.7%) underwent overlapping surgery. Two hundred seventy-one patients (26.6%) experienced 1 or more complications, with 134 (13.2%) suffering a serious complication. Fourteen patients in the cohort died, a rate of 1.4%. The overall complication rate was not significantly higher for overlapping cases than for nonoverlapping cases (26.3% vs 26.9%, p = 0.837), nor was the rate of serious complications (14.7% vs 11.8%, p = 0.168). After adjustments for surgery type, surgery duration, body mass index, American Society of Anesthesiologists (ASA) physical classification grade, and intraoperative blood loss, overlapping surgery remained unassociated with overall complications (OR 0.810, 95% CI 0.592–1.109, p = 0.189). Similarly, after adjustments for surgery type, surgery duration, body mass index, ASA grade, and neurological comorbidity, there was no association between overlapping surgery and serious complications (OR 0.979, 95% CI 0.661–1.449, p = 0.915).CONCLUSIONSIn this cohort, patients undergoing overlapping surgery did not have an increased risk for overall complications or serious complications. Although this finding suggests that overlapping surgery can be performed safely within the appropriate framework, further investigation is needed in other specialties and at other institutions.

scholarly journals Balanced forced-diuresis compared to control as a reno-protective approach in cardiac surgery: secondary outcome of a randomized controlled trial, assessment of neutrophil gelatinase-associated lipocalin levels

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Heyman Luckraz ◽  
Ramesh Giri ◽  
Benjamin Wrigley ◽  
Kumaresan Nagarajan ◽  
Eshan Senanayake ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Surgery ◽  
Kidney Injury ◽  
Secondary Outcome ◽  
Control Group ◽  
Neutrophil Gelatinase Associated Lipocalin ◽  
Forced Diuresis ◽  
Increased Risk ◽  
Neutrophil Gelatinase ◽  
The Impact

Abstract Background Neutrophil gelatinase-associated lipocalin (NGAL) is a recognised biomarker for acute kidney injury (AKI).This study investigated the impact of balanced forced-diuresis using RenalGuard® system (RG), in reducing acute kidney injury (AKI) rates and the associated NGAL levels (6-h post-CPB plasma level) post adult cardiac surgery with cardiopulmonary bypass (CPB). Methods Patients included in the study were at high-risk for AKI post cardiac surgery, namely history of diabetes and/or anaemia, e-GFR 20–60 ml/min/1.73 m2, Logistic EuroScore > 5, anticipated CPB time > 120 min. Patients were randomized to either RG (n = 110) or managed as per current practice (control = 110). RIFLE-defined AKI rate (based on serum creatinine level increase) within first 3 days of surgery and 6-h post CPB NGAL levels were the primary and secondary end-points. Results Pre and intra-operative characteristics between the two groups were similar (p > 0.05) including the pre-op NGAL levels, the oxygen delivery (ecDO2i) and the carbon dioxide production (ecVCO2i) during CPB. Patients in the RG group had a significantly lower post-operative RIFLE-defined AKI rate compared to control (10% (11/110) v/s 20.9% (23/110), p = 0.03). Overall, median 6-h post CPB NGAL levels in patients with AKI were significantly higher than those who did not develop AKI (211 vs 150 ng/ml, p < 0.001). Patients managed by balanced forced-diuresis had lower post-operative NGAL levels (146 vs 178 ng/ml, p = 0.09). Using previously reported NGAL cut-off level for AKI (142 ng/ml), binary logistic regression analysis confirmed a beneficial effect of the RG system, with an increased risk of AKI of 2.2 times in the control group (OR 2.2, 95% CI 1.14–4.27, p = 0.02). Conclusions Overall, the 6-h post-CPB plasma NGAL levels were significantly higher in patients who developed AKI. Patients managed with the novel approach of balanced forced-diuresis, provided by the RenalGuard® system, had a lower AKI rate and lower NGAL levels indicating a lesser degree of renal tissue injury. Trial registration ClinicalTrials.gov website, NCT02974946, https://clinicaltrials.gov/ct2/show/NCT02974946.

Development of a Guideline for the Management of Ventilator-Associated Pneumonia Based on Local Microbiologic Findings and Impact of the Guideline on Antimicrobial Use Practices

2008 ◽  
Vol 29 (6) ◽  
pp. 525-533 ◽  
Author(s):  
Timothy H. Dellit ◽  
Jeannie D. Chan ◽  
Shawn J. Skerrett ◽  
Avery B. Nathens
Keyword(s):  
Mortality Rate ◽  
Antimicrobial Therapy ◽  
Late Onset ◽  
Baseline Period ◽  
Antimicrobial Use ◽  
Ventilator Associated Pneumonia ◽  
Definitive Therapy ◽  
All Cause Mortality ◽  
Before And After ◽  
The Impact

Objective.To describe the development of a guideline for the management of ventilator-associated pneumonia (VAP) based on local microbiologic findings and to evaluate the impact of the guideline on antimicrobial use practices.Design.Retrospective comparison of antimicrobial use practices before and after implementation of the guideline.Setting.Intensive care units at Harborview Medical Center, Seattle, Washington, a university-affiliated urban teaching hospital.Patients.A total of 819 patients who received mechanical ventilation and who underwent quantitative bronchoscopy between July 1, 2003, and June 30, 2005, for suspected VAP.Interventions.Implementation of an evidence-based VAP guideline that focused on the use of quantitative bronchoscopy for diagnosis, administration of empirical antimicrobial therapy based on local microbiologic findings and resistance patterns, tailoring definitive antimicrobial therapy on the basis of culture results, and appropriate duration of therapy.Results.During the baseline period, 168 (46.7%) of 360 patients had quantitative cultures that met the diagnostic criteria for VAP, compared with 216 (47.1%) of 459 patients in the period after the guideline was implemented. The pathogens responsible for VAP remained similar between the 2 periods, except that the prevalence of VAP due to carbapenem-resistant Acinetobacter species increased from 1.8% to 15.3% (P < .001), particularly in late-onset VAP. Compared with the baseline period, there was an improvement in antimicrobial use practices after implementation of the guideline: antimicrobial therapy was more frequently tailored on the basis of quantitative culture results (103 [61.3%] of 168 vs 150 [69.4%] of 216 patients; P = .034), there was an increase in the use of appropriate definitive therapy (135 [80.4%] of 168 vs 193 [89.4%] of 216 patients; P = .001), and there wasadecrease in the mean duration oftherapy (12.0vs 10.7days; P = .0014). The all-cause mortality rate was similar in the periods before and after the guideline was implemented (38 [22.6%] of 168 vs 46 [21.3%] of 216 patients; P = .756).Conclusions.Implementation of a guideline for the management of VAP that incorporated the use of quantitative bronchoscopy, the use of empirical therapy based on local microbiologic findings, tailoring of therapy on the basis of culture results, and use of shortened durations of therapy led to significant improvements in antimicrobial use practices without adversely affecting the all-cause mortality rate.

scholarly journals 1101. What Do Electrophysiologists Think about Peri-Procedural Antibiotics? A Qualitative Assessment of Factors Driving Use and Facilitators for Implementing Change

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S391-S391
Author(s):  
Westyn Branch-Elliman ◽  
Rani Elwy ◽  
Kalpana Gupta
Keyword(s):  
Antimicrobial Prophylaxis ◽  
Qualitative Interviews ◽  
Academic Community ◽  
Qualitative Assessment ◽  
Local Culture ◽  
Successful Implementation ◽  
Antimicrobial Use ◽  
Cardiac Device ◽  
Implementing Change ◽  
Formative Evaluations

Abstract Background Prolonged courses of antimicrobials are common following cardiac device procedures, but there are little data to explain drivers of this practice and factors that may facilitate change. Methods We conducted formative evaluations consisting of semi-structured, qualitative interviews with electrophysiologists (EP) to identify perceived barriers to discontinuing post-procedure antimicrobial prophylaxis and factors that may facilitate improvements. A directed content analysis approach was used to map qualitative responses to key factors in the Proctor Implementation Outcomes Framework, with flexibility to allow for new themes to emerge. Interviews ceased after data saturation was reached. Results 13 interviews were conducted with EPs representing diverse US regions (Northeast, Midwest, South, West) and diverse settings of care (academic, community, VA). Responses to questions about antimicrobial use and willingness (or lack thereof) to stop post-procedural antimicrobials most commonly mapped to the acceptability domain; feasibility, fidelity, cost and appropriateness were also frequently identified factors (see figure for exemplary quotes). Themes that emerged during the interview process associated with prolonged antimicrobial prescribing included beliefs and knowledge, local culture and normative behaviors, and organizational structure. There was a strong “cultural inertia” to conform to normative practices within an institution. Reasons for this ranged from reports of streamlining processes for clinical staff to ensure standardized care across all patients and concerns about being perceived as an “outlier.” Infectious diseases staff were important influencers of practice and potential facilitators of improvement. Conclusion Formative evaluations of stakeholders are essential for designing successful implementation interventions to facilitate behavioral change. Local culture appeared to be a major driver of antimicrobial use. The desire to conform to normative behaviors and to promote institutional standardization suggests that strategies to facilitate implementation of antimicrobial stewardship guidelines must include facility-level changes, rather than individual-provider-level interventions. Disclosures All authors: No reported disclosures.

Sign in / Sign up

Export Citation Format

Share Document