scholarly journals Pathogen-Negative Sepsis—An Opportunity for Antimicrobial Stewardship

2019 ◽  
Vol 6 (10) ◽  
Author(s):  
Gabriel C Lockhart ◽  
Jacob Hanin ◽  
Scott T Micek ◽  
Marin H Kollef
Keyword(s):  
Median Duration ◽  
Antimicrobial Stewardship ◽  
Hospitalized Patients ◽  
Interquartile Range ◽  
Common Reason ◽  
Empiric Antibiotics

Abstract Sepsis is a common reason for empiric antibiotics among hospitalized patients. We found that the median duration of empiric antibiotics (interquartile range) was 6 (4–9) days among 1047 survivivors with pathogen-negative sepsis. These findings suggest that patients with pathogen-negative sepsis could represent an important opportunity for antimicrobial stewardship.

scholarly journals 42. A Pharmacist-Led Intervention to Decrease Anaerobic Coverage for Hospitalized Patients with Community-Acquired Pneumonia

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S44-S45
Author(s):  
Maxx O Enzmann ◽  
Courtney M Pagels ◽  
Emily J Perry ◽  
Justin Jones ◽  
Paul Carson
Keyword(s):  
Infectious Diseases ◽  
Antimicrobial Stewardship ◽  
Community Acquired Pneumonia ◽  
Lung Abscess ◽  
American Thoracic Society ◽  
Hospitalized Patients ◽  
Guidance Document ◽  
Antibiotic Exposure ◽  
Antibiotic Regimen ◽  
Days Of Therapy

Abstract Background Community-acquired pneumonia (CAP) is frequently mis-categorized as aspiration pneumonia, prompting the addition of anaerobic coverage to the antibiotic regimen. In our institution, this usually takes the form of adding metronidazole to ceftriaxone. The 2019 American Thoracic Society and Infectious Diseases Society of America CAP guidelines recommend anaerobic coverage only for hospitalized patients with a suspected lung abscess or empyema. The objective of this study was to determine if a pharmacist-led workflow could increase adherence to the 2019 CAP guideline recommendations by limiting anaerobic coverage to those rare occasions. Methods The hospital antimicrobial stewardship committee approved a pharmacist workflow and guidance document which outlines criteria to evaluate appropriateness of anaerobic coverage for hospitalized patients with CAP and no other indications for antibiotics. If anaerobic coverage is not indicated, the pharmacist submits a standardized message to the treating provider via the electronic medical record, recommending discontinuation of metronidazole. This workflow was implemented on October 3, 2019. Metronidazole days of therapy (DOT) per 1000 patient days in quarters 1 through 4 of 2019 and quarter 1 of 2020 were collected as well as percent acceptance of documented pharmacist interventions from October 3, 2019 until March 31, 2020. Results Between October 3, 2019 and March 31, 2020, a total of 221 interventions were made by pharmacists to discontinue metronidazole in hospitalized CAP patients where anaerobic coverage was not indicated. Out of those 221 interventions, 164 (74%) were accepted by providers and only 57 (26%) were rejected. The DOT per 1000 patient days of metronidazole was assessed for the three quarters prior to our intervention and the two quarters after the intervention. Compared to the three quarters prior, metronidazole DOT per 1000 patient days decreased by 26.6% for the two quarters following implementation of the pharmacist-led intervention (Figure 1). Figure 1: Metronidazole DOT per 1000 patient days from January 1, 2019 through March 31, 2020. Vertical line indicates when pharmacist workflow was implemented. Conclusion A pharmacist antimicrobial stewardship intervention at our institution increased adherence to CAP guidelines and decreased unnecessary antibiotic exposure in hospitalized CAP patients when anaerobic coverage was not indicated. Disclosures All Authors: No reported disclosures

scholarly journals An evaluation of toxigenic Clostridioides difficile positivity as a patient outcome metric of antimicrobial stewardship in Saudi Arabia

2021 ◽  
Author(s):  
Christopher A. Okeahialam ◽  
Ali A. Rabaan ◽  
Albert Bolhuis
Keyword(s):  
Patient Outcome ◽  
Saudi Arabia ◽  
Antimicrobial Stewardship ◽  
Laboratory Data ◽  
Hospitalized Patients ◽  
Antimicrobial Stewardship Program ◽  
Repeated Testing ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
The Impact

AbstractBackgroundAntimicrobial stewardship has been associated with a reduction in the incidence of health care associated Clostridium difficile infection (HA-CDI). However, CDI remains under-recognized in many low and middle-income countries where clinical and surveillance resources required to identify HA-CDI are often lacking. The rate of toxigenic C. difficile stool positivity in the stool of hospitalized patients may offer an alternative metric for these settings, but its utlity remains largely untested.Aim/ObjectiveTo examine the impact of an antimicrobial stewardship on the rate of toxigenic C. difficile positivity among hospitalized patients presenting with diarrhoeaMethodsA 12-year retrospective review of laboratory data was conducted to compare the rates of toxigenic C. difficile in diarrhoea stool of patients in a hospital in Saudi Arabia, before and after implementation of an antimicrobial stewardship programResultThere was a significant decline in the rate of toxigenic C difficile positivity from 9.8 to 7.4% following the implementation of the antimicrobial stewardship program, and a reversal of a rising trend.DiscussionThe rate of toxigenic C. difficile positivity may be a useful patient outcome metric for evaluating the long term impact of antimicrobial stewardship on CDI, especially in settings with limited surveillance resources. The accuracy of this metric is however dependent on the avoidance of arbitrary repeated testing of a patient for cure, and testing only unformed or diarrhoea stool specimens. Further studies are required within and beyond Saudi Arabia to examine the utility of this metric.

scholarly journals Implementing a socio-technical system for computer-aided tuberculosis diagnosis in Peru: A field trial among health professionals in resource-constraint settings

2020 ◽  
Vol 26 (4) ◽  
pp. 2762-2775
Author(s):  
Cesar Ugarte-Gil ◽  
Maria Icochea ◽  
Juan Carlos Llontop Otero ◽  
Katerine Villaizan ◽  
Nicola Young ◽  
...  
Keyword(s):  
Median Duration ◽  
Field Trial ◽  
Interquartile Range ◽  
Technical System ◽  
Health Centers ◽  
Successful Implementation ◽  
X Rays ◽  
X Ray ◽  
Computer Aided ◽  
Tuberculosis Diagnosis

A major challenge of tuberculosis diagnosis is the lack of universal accessibility to bacteriological confirmation. Computer-aided diagnostic interventions have been developed to address this gap and their successful implementation depends on many health systems factors. A socio-technical system to implement a computer-aided diagnostic tuberculosis diagnosis was preliminary tested in five primary health centers located in Lima, Peru. We recruited nurses (n = 7) and tuberculosis physicians (n = 5) from these health centers to participate in a field trial of an mHealth tool (eRx X-ray diagnostic app). From September 2018 to February 2019, the nurses uploaded images of chest X-rays using smartphones and the physicians reviewed those images on web-based platforms using tablets. Both completed weekly written feedback about their experience. Each nurse participated for a median duration of 12 weeks (interquartile range = 7.5–15.5), but image upload was only possible at a median of 58 percent (interquartile range = 35.1%–84.4%) of those weeks. Each physician participated for a median duration of 17 weeks (interquartile range = 12–17), but X-ray image review was only possible at a median of 52 percent (interquartile range = 49.7%–57.4%) of those weeks. Heavy workload was most frequently provided as the reason for missing data. Several infrastructural and technological challenges impaired the effective implementation of the mHealth tool, irrespective of its diagnostic accuracy.

scholarly journals Clinical characteristics of 41 patients with pneumonia due to 2019 novel coronavirus disease (COVID-19) in Jilin, China

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Qing Zhang ◽  
Qian Xu ◽  
Yi-yang Chen ◽  
Li-xin Lou ◽  
Li-he Che ◽  
...  
Keyword(s):  
Cardiac Troponin ◽  
Clinical Characteristics ◽  
Troponin I ◽  
Clinical Laboratory ◽  
Ground Glass Opacity ◽  
Hospitalized Patients ◽  
Cardiac Troponin I ◽  
Interquartile Range ◽  
Strong Positive Correlation ◽  
Novel Coronavirus

Abstract Background The clinical characteristics of patients with confirmed 2019 novel coronavirus disease (COVID-19) in Jilin Province, China were investigated. Methods Clinical, laboratory, radiology, and treatment data of 41 hospitalized patients with confirmed COVID-19 were retrospectively collected. The population was stratified by disease severity as mild, moderate, or severe, based on guidelines of the National Health and Medical Commission of China. Results The 41 hospitalized patients with COVID-19 were studied, and the median age was 45 years (interquartile range [IQR], 31–53; range, 10–87 years) and 18 patients (43.9%) were female. All of the patients had recently visited Wuhan or other places (ie, Beijing, Thailand) or had Wuhan-related exposure. Common symptoms included fever (32[78%]) and cough (29[70.7%]). All patients were without hepatitis B/C virus hepatitis. CRP (C-reactive protein, 11.3 mg/L [interquartile range {IQR}, 2.45–35.2]) was elevated in 22 patients (53.7%), and cardiac troponin I (1.5 ng/mL [IQR, 0.8–5.0]) was elevated in 41 patients (100%). Chest computed tomographic scans showed bilateral ground glass opacity (GGO) or GGO with consolidation in the lungs of 27(65.9%) patients. 31(75.6%) patients had an abnormal electrocardiograph (ECG). Comparing the three groups, the levels of CRP and cardiac troponin I, GGO distribution in bilateral lungs, and electrocardiogram changes were statistically significant (p < 0.05). Cardiac troponin I had a strong positive correlation with CRP (r = 0.704, p = 0.042) and LDH (r = 0.738, p = 0.037). Conclusion Significant differences among the groups suggest that several clinical parameters may serve as biomarkers of COVID-19 severity at hospital admission. Elevated cTnI could be considered as a predictor of severe COVID-19, reflecting the prognosis of patients with severe COVID-19. The results warrant further inspection and confirmation.

scholarly journals A Propensity Score Matched Study of the Positive Impact of Infectious Diseases Consultation on Antimicrobial Appropriateness in Hospitalized Patients with Antimicrobial Stewardship Oversight

2020 ◽  
Vol 64 (8) ◽  
Author(s):  
Jacqueline T. Bork ◽  
Kimberly C. Claeys ◽  
Emily L. Heil ◽  
Mary Banoub ◽  
Surbhi Leekha ◽  
...  
Keyword(s):  
Propensity Score ◽  
Infectious Diseases ◽  
Propensity Score Matching ◽  
Antimicrobial Stewardship ◽  
Positive Impact ◽  
Hospitalized Patients ◽  
Audit And Feedback ◽  
Medical Specialties ◽  
Infectious Diseases Consultation ◽  
The Impact

ABSTRACT Hospital-based antibiotic stewardship (AS) programs provide oversight and guidance for appropriate antimicrobial use in acute care settings. Infectious disease expertise is beneficial in the care of hospitalized patients with infections. The impact of infectious diseases consultation (IDC) on antimicrobial appropriateness in a large tertiary hospital with an established AS program was investigated. This was a cross-sectional study from October 2017 to March 2019 at a large academic hospital with an AS-directed prospective audit and feedback process and multiple IDC services. Antimicrobial appropriateness was adjudicated by an AS team member after antimicrobial start. Antimicrobial appropriateness was compared among antimicrobial orders with and without IDC using propensity score matching and multivariable logistic regression. Analyses were stratified by primary services caring for the patients. There were 10,508 antimicrobial orders from 6,165 unique patient encounters. Overall appropriateness was 92%, with higher appropriateness among patients with IDC versus without IDC (94% versus 84%; P < 0.0001). After propensity score matching and adjustment for certain antibiotics, organisms, syndromes, and locations, IDC was associated with a greater antimicrobial appropriateness odds ratio (OR) of 2.4 (95% confidence interval [CI], 1.9 to 3.0). Stratification by primary service showed an OR of 2.9 (95% CI, 2.1 to 3.8) for surgical specialties and an OR of 1.6 (95% CI, 1.1 to 2.2) for medical specialties. Even with a high overall antimicrobial appropriateness, patients with IDC had greater odds of antimicrobial appropriateness than those without IDC, and this impact was greater in surgical specialties. Infectious diseases consultation can be synergistic with antimicrobial stewardship programs.

scholarly journals Factors Associated With Intubation and Prolonged Intubation in Hospitalized Patients With COVID-19

2020 ◽  
Vol 163 (1) ◽  
pp. 170-178 ◽  
Author(s):  
Kevin Hur ◽  
Caroline P. E. Price ◽  
Elizabeth L. Gray ◽  
Reeti K. Gulati ◽  
Matthew Maksimoski ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Body Mass ◽  
Clinical Signs ◽  
Hospitalized Patients ◽  
Interquartile Range ◽  
Multivariable Logistic Regression Analysis ◽  
Prolonged Intubation ◽  
Factors Associated ◽  
Chicago Metropolitan Area ◽  
History Of

Objective To identify risk factors associated with intubation and time to extubation in hospitalized patients with coronavirus disease 2019 (COVID-19). Study Design Retrospective observational study. Setting Ten hospitals in the Chicago metropolitan area. Subjects and Methods Patients with laboratory-confirmed COVID-19 admitted between March 1 and April 8, 2020, were included. We evaluated sociodemographic and clinical characteristics associated with intubation and prolonged intubation for acute respiratory failure secondary to COVID-19 infection. Results Of the 486 hospitalized patients included in the study, the median age was 59 years (interquartile range, 47-69); 271 (55.8%) were male; and the median body mass index was 30.6 (interquartile range, 26.5-35.6). During the hospitalization, 138 (28.4%) patients were intubated; 78 (56.5%) were eventually extubated; 21 (15.2%) died; and 39 (28.3%) remained intubated at a mean ± SD follow-up of 19.6 ± 6.7 days. Intubated patients had a significantly higher median age (65 vs 57 years, P < .001) and rate of diabetes (56 [40.6%] vs 104 [29.9%], P = .031) as compared with nonintubated patients. Multivariable logistic regression analysis identified age, sex, respiratory rate, oxygen saturation, history of diabetes, and shortness of breath as factors predictive of intubation. Age and body mass index were the only factors independently associated with time to extubation. Conclusion In addition to clinical signs of respiratory distress, patients with COVID-19 who are older, male, or diabetic are at higher risk of requiring intubation. Among intubated patients, older and more obese patients are at higher risk for prolonged intubation. Otolaryngologists consulted for airway management should consider these factors in their decision making.

scholarly journals Is Transition between Peritoneal Dialysis and Hemodialysis Really a Gradual Process?

2013 ◽  
Vol 33 (4) ◽  
pp. 391-397 ◽  
Author(s):  
Lucie Boissinot ◽  
Isabelle Landru ◽  
Eric Cardineau ◽  
Elie Zagdoun ◽  
Jean-Philippe Ryckelycnk ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Median Duration ◽  
Charlson Comorbidity Index ◽  
Transition Period ◽  
Self Care ◽  
Interquartile Range ◽  
Median Score ◽  
Gradual Process ◽  
Duration Of Hospitalization ◽  
Comorbidity Index

BackgroundTransfer to hemodialysis (HD) is a frequent cause of peritoneal dialysis (PD) cessation. In the present study, we set out to describe the transition period between PD and HD.MethodsAll patients in 4 centers of Basse-Normandie who had been treated with PD for more than 90 days and who were permanently transferred to HD between 1 January 2005 and 31 December 2009 were retrospectively reviewed. The rate of unplanned HD start was evaluated.ResultsIn the 60 patients (39 men, 21 women) included in the study, median score on the Charlson comorbidity index at PD initiation was 5 [interquartile range (IQR): 3 – 7], median age at HD initiation was 62 years (IQR: 54 – 76 years), and median duration on PD was 22 months (IQR: 12 – 36 months). Among the 60 patients, 37 had an unplanned HD initiation. Peritonitis was the most frequent cause of unplanned HD start ( n = 20), and dialysis inadequacy ( n = 11), the main cause of planned HD start. During the transition period, all patients were hospitalized. Median duration of hospitalization was 4.5 days (IQR: 0 – 25.5 days). Within 2 months after HD initiation, 9 patients died. Two months after starting HD, 6 of the remaining 51 patients were being treated in a self-care HD unit and only 23 patients had a mature fistula.ConclusionsUnplanned HD start is a common problem in patients transferred from PD. Further studies are needed to improve the rate of planned HD start in PD patients transferred to HD.

Audit and Feedback Processes Among Antimicrobial Stewardship Programs: A Survey of the Society for Healthcare Epidemiology of America Research Network

2016 ◽  
Vol 37 (6) ◽  
pp. 704-706 ◽  
Author(s):  
D. J. Livorsi ◽  
B. Heintz ◽  
J. T. Jacob ◽  
S. L. Krein ◽  
D. J. Morgan ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Interquartile Range ◽  
Infect Control Hosp ◽  
Audit And Feedback ◽  
Research Network ◽  
Hospital Beds ◽  
Healthcare Epidemiology ◽  
Optimal Implementation

Optimal implementation of audit-and-feedback is an important part of advancing antimicrobial stewardship programs. Our survey demonstrated variability in how 61 programs approach audit-and-feedback. The median (interquartile range) number of recommendations per week was 9 (5–19) per 100 hospital-beds. A major perceived barrier to more comprehensive stewardship was lack of resources.Infect Control Hosp Epidemiol 2016;37:704–706

scholarly journals Symptomatic Features of 932 Hospitalized Patients with COVID-19 in Wuhan

2021 ◽  
Author(s):  
Liang-Liang Sun ◽  
Jian Wang ◽  
Yu-Sheng Wang ◽  
Ping-Fang Hu ◽  
Zheng-Qing Zhao ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Median Duration ◽  
Multivariate Logistic Regression Analysis ◽  
Hospitalized Patients ◽  
Multiple Systems ◽  
Illness Onset ◽  
Taste Disorders

Abstract BackgroundMuch remains unknown about COVID-19 onset and rehabilitation's symptomatic features, especially the long-term health consequences of patients with COVID-19 who have been discharged from the hospital.MethodsIn this cohort study, we collected the first pandemic data of hospitalized patients in Wuhan from February 20 to March 31, 2020. All patients completed a 3-month follow-up after discharge. We carefully analyzed the detailed symptomatic characteristics of severe COVID-19 at illness onset and three months after discharge, compared it with non-severe patients, and used multiple logistic regression to determine potential symptomatic risk factors for severe COVID-19.ResultsA total of 932 hospitalized patients with COVID-19 were enrolled, including 52 severe cases and 880 non-severe cases. Fever (60%), cough (50.8%), and fatigue (36.4%) were the most common symptoms, followed by anorexia (21.8%) and dyspnea (19.2%). The median duration of fever was seven days, which was characterized by persistent low fever. The median duration of cough was 17 days, characterized by dry cough without sputum. Most dyspnea occurred on the fourth day after symptom onset, with a median duration of 16 days. The incidences of taste loss and olfactory disturbance were only 6.2% and 3.1%, respectively. Multivariate logistic regression analysis showed that age over 65 years old (OR 6.52, 95% CI 3.27-13.02, P<0.0001), male sex (3.71, 1.90-7.26, P = 0.0001), fever lasting for more than five days (1.90, 1.00-3.62, P=0.0498), anorexia at onset (2.61, 1.26-5.40, P=0.0096), and modified Medical Research Council level above grade 2 when dyspnea occurred (14.19,7.01-28.71, P<0.0001) were symptomatic risk factors for severe COVID-19. Three months after discharge from the hospital, 6.2% of patients still cough, 7.2% of patients still dyspnea, and 1.8% still fatigue, and 1.5% of patients had olfactory or taste disorders.ConclusionsCOVID-19 caused clusters of symptoms, with multiple systems involved. Specific symptomatic features at the onset of illness have predictive value for severe COVID-19. Persistent legacy symptoms are more frequent in severe COVID-19 patients.

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