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 Effect of Obesity on Clinical Failure of Patients Treated with Beta-Lactams

2021 ◽  
Author(s):  
Nathan A Pinner ◽  
Natalie G Tapley ◽  
Katie E Barber ◽  
Kayla R Stover ◽  
Jamie L Wagner
Keyword(s):  
Treatment Failure ◽  
Clinical Outcomes ◽  
Hospital Length Of Stay ◽  
Source Control ◽  
Definitive Treatment ◽  
Therapeutic Drug ◽  
Obese Patients ◽  
Definitive Therapy ◽  
All Cause Mortality ◽  
The Impact

Abstract Background Altered pharmacokinetics in obese patients raise concerns over worse clinical outcomes. This study assessed whether obese patients receiving a beta-lactam (BL) have worse clinical outcomes compared to non-obese patients and to identify if therapeutic drug monitoring (TDM) may be beneficial. Methods This multi-center, retrospective cohort included hospitalized adults admitted from July 2015-July 2017 treated with a BL as definitive monotherapy against a Gram-negative bacilli for ≥72 hours. Patients were excluded if there was lack of source control or if polymicrobial infections required &gt;1 antibiotic for definitive therapy. Patients were classified based on body mass index (BMI): non-obese (BMI ≤29.9 kg/m 2) and obese (BMI ≥30.0 kg/m 2). The primary outcome was clinical treatment failure, and secondary were hospital length of stay (LOS), inpatient all-cause mortality, and 30-day all-cause readmission. Results There were 257 (43.6%) obese patients and 332 (56.4%) non-obese patients included. The most common infections were urinary (50.9%) and respiratory (31.4%). Definitive treatment was driven by 3 rd generation cephalosporins (46.9%) and cefepime (44.7%). Treatment failure occurred in 131 (51%) obese patients and 109 (32.8%) non-obese patients (p&lt;0.001). Obesity and respiratory source were independently associated with increased likelihood of treatment failure. Obese patients were hospitalized longer than non-obese patients (p=0.002), but no differences were found for all-cause mortality (p=0.117) or infection-related readmission (0=0.112). Conclusions Obese patients treated with BLs have higher rates of treatment failure and longer hospitalization periods than non-obese patients. Future studies are needed to assess the impact of TDM and specific dosing recommendations for targeted infection types.

scholarly journals 216. Are Automatic Antimicrobial Stop Orders an Effective Stewardship Tool for Urinary Tract and Intra-Abdominal Infections?

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S110-S110
Author(s):  
Christina Maguire ◽  
Dusten T Rose ◽  
Theresa Jaso
Keyword(s):  
Urinary Tract ◽  
Antimicrobial Therapy ◽  
Source Control ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Before And After ◽  
The Difference ◽  
Tract Infections ◽  
Length Of Therapy ◽  
The Impact

Abstract Background Automatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI). ASO Outcome Definitions ASO Outcomes Methods This multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site. Results This study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018). Conclusion While implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols. Disclosures All Authors: No reported disclosures

scholarly journals 888. Improving outcomes with revised preoperative universal decolonization protocol

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S479-S479
Author(s):  
Silvia I Gnass
Keyword(s):  
Surgical Procedures ◽  
Baseline Period ◽  
Surgical Team ◽  
Team Members ◽  
Surgical Infection ◽  
Before And After ◽  
Trial Basis ◽  
The Impact ◽  
Before And After Study ◽  
Patient Infection

Abstract Background In order to improve outcomes, including reduced surgical infection rate and costs, a revised universal preoperative decolonization protocol was implemented on a trial basis. Methods In a 12 month before and after study at a public teaching hospital in southern California, an alcohol based nasal antiseptic was introduced in place of nasal povidone iodine (PVI) for all surgical patients pre-operatively, paired with chlorhexidine (CHG) bathing which was already in place. All surgical procedures were included, the most common being cholecystectomy, cesarean section and hip fracture. The alcohol nasal antiseptic was selected to replace the PVI nasal antiseptic based on efficacy, staff preference and cost. At the same time, surgical team members began self-application of the alcohol nasal antiseptic each day prior to surgical procedures. This was not mandatory and compliance was not tracked, though informal feedback and observation revealed most surgical team members were applying the nasal antiseptic prior to cases daily. Results In comparison to the 6 month baseline period where there were 27 SSI in 1188 procedures, during the 6 month study period there were 10 SSI in 1253 procedures, representing a 63% reduction (p=.0162) for all types of procedures. We have observed a reduction of 17 SSIs in 2019, compared to the previous year, during the 6 months period. That means a saving of $589,420 during the same period. Conclusion Preoperative universal decolonization with alcohol based nasal antiseptic in place of nasal PVI, paired with CHG bathing, was effective in reducing SSI rate and associated costs. Further study is needed to measure and assess the impact of surgical team member nasal decolonization on patient infection risk and rate. Disclosures All Authors: No reported disclosures

scholarly journals Developing a Dashboard Software for the ICUs and Studying its Impact on Reducing the Ventilator-Associated Pneumonia

2018 ◽  
Vol 12 (1) ◽  
pp. 42-50
Author(s):  
Mohammad Fathi ◽  
Hamid Moghaddasi ◽  
Azamossadat Hosseini ◽  
Monir Ebrahimi Aghdam
Keyword(s):  
User Satisfaction ◽  
Pilot Project ◽  
Point Of View ◽  
P Value ◽  
Ventilator Associated Pneumonia ◽  
Healthcare Organizations ◽  
Survey Tool ◽  
Usability Assessment ◽  
Before And After ◽  
The Impact

Objective: Ventilator-Associated Pneumonia (VAP), a lung infection developing in patients on a ventilator in Intensive Care Units (ICU), is the second most common nosocomial infection and a leading cause of morbidity and mortality in ICUs. To reduce the incidence rate of VAP complication, many healthcare organizations have already developed certain strategies and guidelines. However, there are still high rates of VAP infections mainly due to: conflicting guidelines from different sources, implementing the guidelines at different times and conditions, different ICU caregivers at different shifts, and of course the human mistakes. Methods: The present study aimed to develop a dashboard to help reducing VAP incidences in ICUs. To achieve the objective of the research, first, the VAP prevention guidelines were compiled. The object-oriented analysis approach was adopted for designing of the dashboard software. To assess the impact of the developed dashboard on the reduction of VAP events, a pilot hospital was selected and a pilot project was prepared. For the dashboard usability assessment based on user satisfaction, a questionnaire was developed as the survey tool. Conclusion: The dashboard was developed and put into operation in a pilot ICU. The results from the t-test (with a probable error of 0.05 percent) indicated a meaningful difference between the number of VAP patients before and after the dashboard implementation with p-value ˂ 0.02. Also, the developed software was evaluated from a usability point of view based on user satisfaction, with health professionals and caregivers of the pilot ICU as the users of the software. The total score was equivalent to 95 percent, falling within the acceptable range of 75-100 percent.

scholarly journals 1826. Impact of Rapid Diagnostics and Ceftazidime–Avibactam on Mortality after Bacteremia Caused by Carbapenem-Resistant Enterobacteriaceae

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S41-S41
Author(s):  
Michael J Satlin ◽  
Liang Chen ◽  
Gregory Weston ◽  
Angela Gomez-Simmonds ◽  
Tanaya Bhowmick ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Blood Culture ◽  
Antimicrobial Therapy ◽  
Statistical Significance ◽  
Diagnostic Methods ◽  
Source Control ◽  
Carbapenem Resistant ◽  
Carbapenemase Gene ◽  
Definitive Therapy ◽  
Carbapenem Resistant Enterobacteriaceae

Abstract Background Patients with bloodstream infections (BSIs) due to carbapenem-resistant Enterobacteriaceae (CRE) have long delays until receipt of appropriate antimicrobial therapy and high mortality rates. Rapid molecular diagnostics and novel therapies, such as ceftazidime–avibactam (CAZ-AVI), offer promise to improve outcomes, but their clinical impact is unclear. Methods We conducted an observational study of patients with CRE BSI from January 2016 to June 2018 at 8 New York and New Jersey medical centers. Patient demographics, comorbidities, clinical presentations, diagnostic methods, and treatments were compared between patients who died within 30 days of BSI onset and survivors. Independent risk factors for mortality were identified using logistic regression. We then compared time to receipt of active antimicrobial therapy between patients whose positive blood culture bottles underwent testing for the Klebsiella pneumoniae carbapenemase gene (blaKPC PCR) and patients where this test was not used. Results We identified 178 patients with CRE BSI (K. pneumoniae: n = 104, 58%; Enterobacter cloacae: n = 26, 15%; Escherichia coli: n = 26, 15%). The 30-day mortality rate was 38%. An increasing Acute Physiology and Chronic Health Evaluation II score (adjusted odds ratio [aOR] 1.06, P = 0.005) was independently associated with increased 30-day mortality; whereas, use of blaKPC PCR (aOR 0.31, P = 0.005), urinary tract source (aOR 0.12, P = 0.001), and source control (aOR 0.25, P = 0.001) were independently associated with survival. Initial targeted therapy with CAZ-AVI was associated with a 28% 30-day mortality rate, compared with a 49% 30-day mortality rate among patients who received a polymyxin or aminoglycoside (P = 0.036). Patients whose blood culture underwent blaKPC PCR were more likely to receive active antimicrobial therapy within 24 hours of BSI onset (42% vs. 28%; P = 0.07) and had a decreased median time until receipt of active therapy (25 hours vs. 46 hours; P = 0.07), although these differences did not achieve statistical significance. Conclusion The use of PCR to rapidly identify blood cultures with blaKPC and definitive therapy with CAZ-AVI instead of polymyxins or aminoglycosides were associated with decreased mortality after CRE bacteremia. Disclosures All Authors: No reported Disclosures.

Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves

2020 ◽  
Vol 41 (8) ◽  
pp. 921-925
Author(s):  
Tara H. Lines ◽  
Whitney J. Nesbitt ◽  
Matthew H. Greene ◽  
George E. Nelson
Keyword(s):  
Staphylococcus Aureus ◽  
Adverse Events ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Safety Net ◽  
Definitive Therapy ◽  
Before And After ◽  
Bundle Compliance ◽  
The Impact ◽  
Major Adverse Events

AbstractObjective:To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation.Design:Retrospective cohort study with descriptive and before-and-after analyses.Setting:Tertiary-care academic medical center.Patients:All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis.Methods:A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre–post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters.Results:Overall, 391 interventions were made in the 20-month period following implementation, including 20 “good saves” avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045).Conclusions:This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.

scholarly journals Out of Sight—Out of Mind: Impact of Cascade Reporting on Antimicrobial Usage

2020 ◽  
Vol 7 (2) ◽  
Author(s):  
Siyun Liao ◽  
Judith Rhodes ◽  
Roman Jandarov ◽  
Zachary DeVore ◽  
Madhuri M Sopirala
Keyword(s):  
Relative Risk ◽  
Positive Culture ◽  
Baseline Period ◽  
Adjusted Relative Risk ◽  
Test Results ◽  
Antibiotic Susceptibilities ◽  
Days Of Therapy ◽  
All Cause Mortality ◽  
Study Population ◽  
The Impact

Abstract Background There is a paucity of data evaluating the strategy of suppressing broader-spectrum antibiotic susceptibilities on utilization. Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary (eg, broader-spectrum, costlier) agents may only be reported if an organism is resistant to primary agents within a particular drug class. Our objective was to evaluate the impact of ceftriaxone-based cascade reporting on utilization of cefepime and clinical outcomes in patients with ceftriaxone-susceptible Escherichia and Klebsiella clinical cultures. Methods We compared post-CR (July 2014–June 2015) with baseline (July 2013–June 2014), evaluating utilization of cefepime, cefazolin, ceftriaxone, ampicillin derivatives, fluoroquinolones, piperacillin/tazobactam, ertapenem, and meropenem; new Clostridium difficile infection; and length of stay (LOS) after the positive culture, 30-day readmission, and in-hospital all-cause mortality. Results Mean days of therapy (DOT) among patients who received any antibiotic for cefepime decreased from 1.229 days during the baseline period to 0.813 days post-CR (adjusted relative risk, 0.668; P &lt; .0001). Mean DOT of ceftriaxone increased from 0.864 days to 0.962 days, with an adjusted relative risk of 1.113 (P = .004). No significant differences were detected in other antibiotics including ertapenem and meropenem, demonstrating the direct association of the decrease in cefepime utilization with CR based on ceftriaxone susceptibility. Average LOS in the study population decreased from 14.139 days to 10.882 days from baseline to post-CR and was found to be statistically significant (P &lt; .0001). Conclusions In conclusion, we demonstrated significant association of decreased cefepime utilization with the implementation of a CR based on ceftriaxone susceptibility. We demonstrated the safety of deescalation, with LOS being significantly lower during the post-CR period than in the baseline period, with no change in in-hospital mortality.

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 The impact of late-onset ventilator-associated pneumonia on mortality in a Saudi-Arabian hospital

Critical Care ◽  
10.1186/cc814 ◽  
2000 ◽  
Vol 4 (Suppl 1) ◽  
pp. P94
Author(s):  
W Djazmati ◽  
GA Oni ◽  
ZA Memish ◽  
G Cunningham ◽  
M Itani ◽  
...  
Keyword(s):  
Late Onset ◽  
Saudi Arabian ◽  
Ventilator Associated Pneumonia ◽  
The Impact

scholarly journals The effect of prior antimicrobial therapy for community acquired infections on the aetiology of early and late onset ventilator-associated pneumonia in a level I trauma intensive care unit

2017 ◽  
Vol 32 (3) ◽  
pp. 91-95
Author(s):  
Yogandree Ramsamy ◽  
David J.J. Muckart
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Antimicrobial Therapy ◽  
Late Onset ◽  
Bacterial Flora ◽  
First Episode ◽  
Ventilator Associated Pneumonia ◽  
Bacterial Isolates ◽  
Prior Therapy ◽  
Hospital Acquired

Background: Ventilator-associated pneumonia (VAP) is the most common hospital acquired infection in patients who require mechanical ventilation. Early VAP is associated with community acquired pathogens whereas late VAP involves hospital flora. Based on this premise, a protocol may be formulated for microbiological surveillance and antimicrobial stewardship within a specific intensive care unit (ICU) to ensure appropriate empiric antimicrobial choice. The bacterial flora in VAP may be affected, however, by antimicrobials prescribed during the ICU stay. Aim: The aim of this study was to determine the effect of prior antimicrobial therapy for community acquired infections on aetiology and the susceptibility of bacterial isolates from the first episode of early or late VAP in a trauma intensive care unit.Methods: Endotracheal aspirates (ETAs) were obtained from patients with suspected early and late VAP. All ETAs were processed and interpreted as per the Clinical and Laboratory Standards Institute (CLSI). Patients were divided into two cohorts: those whose injuries had required antimicrobial therapy for community acquired infections and those who were antimicrobial naïve. The effect of prior antimicrobial therapy on bacterial isolates from the first episode of suspected VAP was compared between the two groups.Results: Of 288 patients admitted to the Trauma ICU between January and December 2014, pneumonia was suspected in 91 (31.6%). Of these, 69 (76%) patients were antimicrobial naïve and 22 (24%) had received prior antimicrobial therapy. Early VAP occurred in 31 (45%) patients in the naïve cohort compared to 3 (12.5%) with prior antimicrobial exposure (p = 0.01). Of the early VAP isolates 25 (81%) in the naïve cohort contained community flora, whereas all isolates in those with prior antimicrobial therapy revealed hospital acquired organisms (p = 0.01). In the antimicrobial naïve cohort with late VAP 27 (71%) patients had community acquired organisms, whereas only 3 (16%) isolates in late VAP in those with prior therapy revealed community acquired flora (p 0.001).Conclusion: Patients who receive prior antimicrobial therapy have a significantly lower incidence of early VAP, but in those who developed either early or late VAP hospital acquired pathogens were more commonly isolated. Knowledge of prior antimicrobial exposure in a patient with early or late VAP will assist in determining the correct empiric antimicrobial choice.

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