scholarly journals Use of a Beta-Lactam Graded Challenge Process at an Academic Medical Center

2020 ◽  
Vol 41 (S1) ◽  
pp. s502-s502
Author(s):  
Andrew Watkins ◽  
Lee Amaya ◽  
Macey Wolfe ◽  
John Schoen ◽  
Erica Stohs ◽  
...  
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Guidance Document ◽  
Beta Lactam ◽  
Full Dose ◽  
Stewardship Program ◽  
Academic Medical ◽  
Ige Mediated ◽  
Graded Challenge ◽  
Order Set

Background: A penicillin allergy guidance document containing an algorithm for challenging penicillin allergic patients with β-lactams was developed by the antimicrobial stewardship program (ASP). As part of this algorithm, a “graded challenge” order set was created containing antimicrobial orders and safety medications along with monitoring instructions. The process is designed to challenge patients at low risk of reaction with infusions of 1% of the target dose, then 10%, and finally the full dose, each 30 minutes apart. We evaluated outcomes from the order set. Methods: Orders of the graded challenge over 17 months (March 2018 through July 2019) were reviewed retrospectively. Data were collected on ordering and outcomes of the challenges and allergy documentation. Use was evaluated based on ASP-recommended indications: history of IgE-mediated or unknown reaction plus (1) no previous β-lactam tolerance and the reaction occurred >10 years ago, or (2) previous β-lactam tolerance, now requiring a different β-lactam for treatment. Only administered challenges were included and descriptive statistics were utilized. Results: Of 67 orders, 57 graded challenges were administered to 56 patients. The most common allergies were penicillins (87.7%) and cephalosporins (38.6%), with the most common reactions being unknown (41.7%) or hives (22%). The most common antibiotics challenged were ceftriaxone (43.9%), cefepime (21.1%), and cefazolin (5.3%). Antibiotics given prior to challenge included vancomycin (48.2%), fluoroquinolones (35.7%), carbapenems (21.4%), aztreonam (19.6%), and clindamycin (12.5%). The median duration of challenged antibiotic was 6 days. The infectious diseases service was consulted on 59.6% of challenges and 75.4% of challenges were administered in non-ICU settings. There was 1 reaction (1.8%) involving a rash with the second infusion, which was treated with oral diphenhydramine and had no lasting effects. Based on indications, 80.7% of challenges were aligned with ASP guidance criteria. The most common use outside of these criteria was in patients without IgE-mediated reactions (10.5%). Most of these had minor rashes and could have received a full dose of a cephalosporin. Allergy information was updated in the electronic health record after 91.2% of challenges. Conclusions: We demonstrated the utility of a graded challenge process at our academic medical center. It was well tolerated, ordered frequently by noninfectious diseases clinicians, administered primarily in non-ICU settings, and regularly resulted in updated allergy information in the medical record. With many patients initially receiving broad-spectrum antibiotics with high costs or increased rates of adverse effects, graded challenges can potentially prevent the use of suboptimal therapies with minimal time and resource investment.Funding: NoneDisclosures: Scott Bergman reports a research grant from Merck.

Implementation of a Dexmedetomidine Stewardship Program at a Tertiary Academic Medical Center

2013 ◽  
Vol 47 (11) ◽  
pp. 1400-1405 ◽  
Author(s):  
Rachel M. Blum ◽  
Craig A. Stevens ◽  
Danielle M. Carter ◽  
Aaron P. Hussey ◽  
Kathleen A. Marquis ◽  
...  
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Stewardship Program ◽  
Academic Medical

Intravenous Immune Globulin Stewardship Program at a Tertiary Academic Medical Center

2016 ◽  
Vol 51 (2) ◽  
pp. 135-139 ◽  
Author(s):  
Megan A. Rocchio ◽  
James W. Schurr ◽  
Aaron P. Hussey ◽  
Paul M. Szumita
Keyword(s):  
Immune Globulin ◽  
Medical Center ◽  
Academic Medical Center ◽  
Intravenous Immune Globulin ◽  
Solid Organ ◽  
Organ Rejection ◽  
Guideline Compliance ◽  
Stewardship Program ◽  
Academic Medical ◽  
Number Of Patients

Background: In October 2010, a pharmacist-driven stewardship program was implemented at the Brigham and Women’s Hospital to ensure continued adherence to the prescribing guideline, focusing on indications for intravenous immune globulin (IVIG) use and dosing per ideal body weight. Objective: The primary objective was to describe an IVIG stewardship program at a tertiary academic medical center. Methods: This was a prospective, observational study from January 2013 through December 2014. All patients ordered to receive IVIG during the defined study period were included. The intervention assessed describes a pharmacist-driven IVIG stewardship program for medication approval. The primary end point was guideline compliance based on indication, dose, dosing weight, and frequency. Secondary end points included the number of patients receiving IVIG, indications, orders discontinued as a result of guideline nonadherence, and total amount dispensed. Results: A total of 418 patients were identified during the study time frame. The top indications were: hypogammaglobulinemia in bone marrow transplantation and hematological malignancy (50.7%), acute solid organ rejection (11.8%), and immune thrombocytopenia with bleeding (10.1%). In all, 12 patients (2.9%) received IVIG for an indication nonadherent with the IVIG prescribing guideline; 9 patients (2.2%) and 2 patients (0.5%), respectively, received a different dose or frequency per the prescribed indication; and 12 orders (2.9%) for indications nonadherent to the guideline were discontinued. A total of 26 033 g of IVIG were dispensed during the study period. Conclusions: An IVIG stewardship program, including an institution-specific prescribing guideline and a pharmacist-driven stewardship program, may ensure guideline compliance for appropriateness of indication and dose at an academic medical center.

scholarly journals Improvement of gram-negative susceptibility to fluoroquinolones after implementation of a pre-authorization policy for fluoroquinolone use: A decade-long experience

2018 ◽  
Vol 39 (12) ◽  
pp. 1419-1424 ◽  
Author(s):  
Rachael A. Lee ◽  
Morgan C. Scully ◽  
Bernard C. Camins ◽  
Russell L. Griffin ◽  
Danielle F. Kunz ◽  
...  
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Rate Of Change ◽  
Gram Negative ◽  
E Coli ◽  
Stewardship Program ◽  
Restriction Policy ◽  
Academic Medical ◽  
Days Of Therapy ◽  
Gram Negative Organisms

AbstractObjectiveDue to concerns over increasing fluoroquinolone (FQ) resistance among gram-negative organisms, our stewardship program implemented a preauthorization use policy. The goal of this study was to assess the relationship between hospital FQ use and antibiotic resistance.DesignRetrospective cohort.SettingLarge academic medical center.MethodsWe performed a retrospective analysis of FQ susceptibility of hospital isolates for 5 common gram-negative bacteria: Acinetobacter spp., Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Primary endpoint was the change of FQ susceptibility. A Poisson regression model was used to calculate the rate of change between the preintervention period (1998–2005) and the postimplementation period (2006–2016).ResultsLarge rates of decline of FQ susceptibility began in 1998, particularly among P. aeruginosa, Acinetobacter spp., and E. cloacae. Our FQ restriction policy improved FQ use from 173 days of therapy (DOT) per 1,000 patient days to <60 DOT per 1,000 patient days. Fluoroquinolone susceptibility increased for Acinetobacter spp. (rate ratio [RR], 1.038; 95% confidence interval [CI], 1.005–1.072), E. cloacae (RR, 1.028; 95% CI, 1.013–1.044), and P. aeruginosa (RR, 1.013; 95% CI, 1.006–1.020). No significant change in susceptibility was detected for K. pneumoniae (RR, 1.002; 95% CI, 0.996–1.008), and the susceptibility for E. coli continued to decline, although the decline was not as steep (RR, 0.981; 95% CI, 0.975–0.987).ConclusionsA stewardship-driven FQ restriction program stopped overall declining FQ susceptibility rates for all species except E. coli. For 3 species (ie, Acinetobacter spp, E. cloacae, and P. aeruginosa), susceptibility rates improved after implementation, and this improvement has been sustained over a 10-year period.

scholarly journals Impact of an Antimicrobial Stewardship Program at a Large Academic Medical Center, a Decade of Experience

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S264-S265
Author(s):  
Susan Kline ◽  
Kimberly Boeser ◽  
Samantha Saunders ◽  
Kari Gand ◽  
Jeana Houseman ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Antimicrobial Stewardship Program ◽  
Stewardship Program ◽  
Academic Medical

scholarly journals 177. Implementation of Pharmacist-Driven Penicillin Allergy Evaluation and Testing with a Focus on Bypassing Penicillin Skin Testing at an Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S95-S96
Author(s):  
YoungYoon Ham ◽  
Shyam Joshi ◽  
Ellie Sukerman ◽  
Kendall J Tucker ◽  
Diana Yu ◽  
...  
Keyword(s):  
Medical Center ◽  
Skin Testing ◽  
Academic Medical Center ◽  
Penicillin Allergy ◽  
Patient Interview ◽  
Academic Medical ◽  
Number Of Patients ◽  
The Us ◽  
Graded Challenge ◽  
Negative Health Outcomes

Abstract Background Penicillin allergies are reported by approximately 10% of the US population; however, studies reveal that &gt;90% of those patients can tolerate penicillins. Penicillin allergies are associated with negative health outcomes, both clinical and financial, due to reduced efficacy and increased adverse effects of alternative antibiotics. Patient interview, penicillin skin testing (PST) and/or an oral graded challenge can be used to evaluate penicillin allergies. Different facilities use various algorithms for testing. The objective of this project was to determine whether a pharmacist-driven penicillin allergy evaluation and testing protocol which largely bypasses PST could safely de-label patients. Methods Adult patients (≥18 years) admitted with a penicillin allergy were evaluated for eligibility between September 2019 and June 2020. Pregnant patients, critically-ill patients, and patients receiving test-invalidating medication were excluded. Patients were evaluated and tested using institutional protocols, which allowed for the majority of patients to be challenged without PST. Allergies were removed with standardized documentation, and patients were given a pamphlet and counseled to discourage relabeling. Data collected included but were not limited to, the number of patients challenged and de-labeled, number of patients who were relabeled, and number of patients whose change in allergy status resulted in change of therapy. Results Forty-eight patients were interviewed and evaluated. One patient was evaluated by PST and oral graded challenge while 27 patients underwent an oral graded challenge only. Twenty patients were de-labeled as a result of patient interview. One patient failed oral challenge with minor itching that did not require any treatment, while 27 patients passed. Forty-seven allergies were removed or modified. Two patients who were de-labeled were relabeled with no record of a new reaction. Of de-labeled patients, 50% received a penicillin following removal of the allergy. Conclusion Penicillin allergies can be evaluated and removed using a pharmacy-driven algorithm that prioritizes direct challenges when appropriate. Risks of a reaction are low, and removal leads to change in treatment in a significant portion of patients. Disclosures All Authors: No reported disclosures

scholarly journals Effect of default order set settings on telemetry ordering

2019 ◽  
Vol 26 (12) ◽  
pp. 1488-1492 ◽  
Author(s):  
David Rubins ◽  
Robert Boxer ◽  
Adam Landman ◽  
Adam Wright
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Intervention Period ◽  
Post Intervention ◽  
Medicine Service ◽  
Academic Medical ◽  
Order Sets ◽  
Control Order ◽  
Multiple Domains ◽  
Order Set

Abstract Objective To investigate the effects of adjusting the default order set settings on telemetry usage. Materials and Methods We performed a retrospective, controlled, before-after study of patients admitted to a house staff medicine service at an academic medical center examining the effect of changing whether the admission telemetry order was pre-selected or not. Telemetry orders on admission and subsequent orders for telemetry were monitored pre- and post-change. Two other order sets that had no change in their default settings were used as controls. Results Between January 1, 2017 and May 1, 2018, there were 1, 163 patients admitted using the residency-customized version of the admission order set which initially had telemetry pre-selected. In this group of patients, there was a significant decrease in telemetry ordering in the post-intervention period: from 79.1% of patients in the 8.5 months prior ordered to have telemetry to 21.3% of patients ordered in the 7.5 months after (χ2 = 382; P &lt; .001). There was no significant change in telemetry usage among patients admitted using the two control order sets. Discussion Default settings have been shown to affect clinician ordering behavior in multiple domains. Consistent with prior findings, our study shows that changing the order set settings can significantly affect ordering practices. Our study was limited in that we were unable to determine if the change in ordering behavior had significant impact on patient care or safety. Conclusion Decisions about default selections in electronic health record order sets can have significant consequences on ordering behavior.

scholarly journals 220Ongoing Impact of an Antimicrobial Stewardship Program at A Large Academic Medical Center, 7 years of experience

2014 ◽  
Vol 1 (suppl_1) ◽  
pp. S96-S97
Author(s):  
Susan Kline ◽  
Kimberly Boeser ◽  
Teresa Rakoczy ◽  
Amanda Guspiel ◽  
Anita Guelcher ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Antimicrobial Stewardship Program ◽  
Years Of Experience ◽  
Stewardship Program ◽  
Academic Medical
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