1131. You’re Never Too Old for a Time-Out: Implementing Antibiotic Time-Outs on Pediatric Inpatient Teams

Abstract Background Antibiotic overuse leads to antimicrobial resistance, adverse events, and excess costs. Antibiotic time-outs (ABTOs) offer a structured approach to reevaluate antimicrobial regimens, but implementing and maintaining ABTOs can be challenging. In this project, we built on previous ABTO implementation in adult inpatient units to incorporate ABTOs in pediatrics using quality improvement (QI) methods. Methods We identified champions, including attending physicians, residents, nurses, team coordinators, and pharmacists. Following pilot testing, ABTOs began in November 2019 and January 2020 for two general pediatric teams, and in June 2020 in the pediatric ICU (PICU). Patients were eligible for an ABTO if they had been on antibiotics for 36-72 hours. ABTOs were documented in the electronic medical record (EMR) with a structured note template. These notes along with patient antimicrobial regimens were extracted and analyzed using an automated EMR query. Metrics included: (1) Proportion of ABTO-eligible patients with an ABTO; (2) Proportion of ABTOs conducted within goal time frame; (3) Documented plan changes in ABTO (e.g. change IV antibiotics to PO); and (4) Proportion of documented changes completed within 24 hours Results To date, there have been 342 pediatric ABTOs over 145 team weeks on the general pediatrics teams and 50 weeks in the PICU, representing 96.9% of eligible patients. 77.8% of ABTOs were completed within the recommended time frame. A majority of ABTOs (67%) resulted in no change to antibiotic regimen, and 18% of patients had already had de-escalation. In 10.5% of patients, the ABTO led to a de-escalation (antibiotics discontinued in 2%, converted from IV to PO in 8.5%). 86.8% of planned changes occurred within 24 hours of ABTO. Figure 1. Compliance with antibiotic time-outs over time, by week. The green line represents the goal of 80%, and the orange line represents median performance. Figure 2. Planned changes to antimicrobial regimen documented in antibiotic time-out. Table 1. Antibiotic time-out performance on participating pediatric services. Conclusion This project demonstrates that ABTOs can be implemented across a variety of teams and showed successful spread of an adult-based QI project to pediatrics. ABTOs led to clear de-escalation in 10.5% of cases, with other changes made in 5% of cases. Future directions include continued spread to inpatient teams, development of EMR-based ABTO alerts, comparison of overall antibiotic use and adverse events before and after ABTO implementation, and characterization of antimicrobial optimization prior to ABTO. Disclosures All Authors: No reported disclosures

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Safety of meningococcal group B vaccination in hospitalised premature infants

Archives of Disease in Childhood - Fetal and Neonatal Edition ◽

10.1136/archdischild-2017-314152 ◽

2018 ◽

Vol 104 (2) ◽

pp. F171-F175 ◽

Cited By ~ 6

Author(s):

Alison Kent ◽

Kazim Beebeejaun ◽

Serena Braccio ◽

Seilesh Kadambari ◽

Paul Clarke ◽

...

Keyword(s):

Adverse Events ◽

Premature Infants ◽

Antibiotic Use ◽

Neurological Status ◽

Serious Adverse Events ◽

Historical Cohort ◽

Protein Levels ◽

Reactive Protein ◽

Before And After ◽

Group B

ObjectivesTo assess the risk of significant adverse events in premature infants receiving the novel 4-component group B meningococcal vaccine (4CMenB) with their routine immunisations at 2 months of age.Participants, design and settingIn December 2015, Public Health England requested neonatal units across England to voluntarily participate in a national audit; 19 units agreed to participate. Anonymised questionnaires were completed for infants receiving 4CMenB alongside their routine immunisations. For comparison, a historical cohort of premature infants receiving their primary immunisations without 4CMenB or paracetamol prophylaxis was used.Main outcome measuresParacetamol use; temperature, cardiovascular, respiratory and neurological status before and after vaccination; and management and investigations postvaccination, including serum C reactive protein levels, infection screens and antibiotic use.ResultsComplete questionnaires were returned for 133 premature infants (<35 weeks’ gestation) who received their first dose of 4CMenB at 8 weeks of age, including 108 who received prophylactic paracetamol according to national recommendations. Overall, 7% (8/108) of infants receiving 4CMenB with paracetamol had fever (>38°C) after vaccination compared with 20% (5/25) of those receiving 4CMenB without paracetamol (P=0.06) and none of those in the historical cohort. There were no significant differences between cohorts in the proportion of infants with apnoea, bradycardia, desaturation and receiving respiratory support after vaccination.Conclusions4CMenB does not increase the risk of serious adverse events in hospitalised premature infants. This audit supports the current national recommendations to offer 4CMenB with other routine vaccinations and prophylactic paracetamol to premature infants at their chronological age.

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Effect of antibiotic time-outs on modification of antibiotic prescriptions in nursing homes

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.75 ◽

2020 ◽

Vol 41 (6) ◽

pp. 635-640

Author(s):

Chi-Yin Liao ◽

David A. Nace ◽

Christopher J. Crnich ◽

Mozhdeh Bahrainian ◽

James H. Ford

Keyword(s):

Nursing Homes ◽

Broad Spectrum ◽

Intervention Study ◽

Early Discontinuation ◽

Antibiotic Overuse ◽

Potential Value ◽

Time Out ◽

Before And After ◽

And Control ◽

The Impact

AbstractBackground:Antibiotic overuse and misuse is a common problem in nursing homes. Antibiotic time-out (ATO) interventions have led to improvements in antibiotic uses in hospitals, but their impact in nursing homes remain understudied.Objective:To evaluate the impact of a stewardship intervention, promoting use of ATOs on the frequency and types of antibiotic change events (ACEs) in nursing homes.Design:Controlled before-and-after intervention study.Setting:Nursing homes in Wisconsin and Pennsylvania.Method:Data on antibiotic prescriptions in 11 nursing homes were collected for 25 months. We categorized ACEs as (1) early discontinuation, (2) class modification, or (3) administration modification. Class modification ACEs were further classified based on whether the change narrowed, expanded, or had no effect on bacterial spectrum coverage. Analyses were performed using a difference-in-difference (DiD) approach.Result:Of 2,647 antibiotic events initiated in study nursing homes, 376 (14.2%) were associated with an ACE. The overall proportion of ACEs did not significantly differ between intervention and control nursing homes. Early discontinuation ACEs increased in intervention nursing homes (DiD, 2.5%; P = .01), primarily affecting residents initiated on broad-spectrum antibiotics (DiD, 2.9%; P < .01). Class modification ACEs decreased in intervention nursing homes but remained unchanged in control nursing homes.Conclusion:The impact of an ATO intervention in study nursing homes was mixed with increases in early discontinuation ACEs offset by reductions in class modification ACEs. More research on the potential value of ATO interventions in nursing homes is warranted.

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Prevent Antibiotic overUSE (PAUSE): Impact of a Provider Driven Antibiotic-Time out on Antibiotic Use and Prescribing

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx162.050 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S20-S20 ◽

Cited By ~ 1

Author(s):

Kerri Thom ◽

Pranita D Tamma ◽

Anthony D Harris ◽

Daniel Morgan ◽

Kathryn Dzintars ◽

...

Keyword(s):

Antibiotic Use ◽

Base Period ◽

Intervention Period ◽

Front Line ◽

Antibiotic Overuse ◽

Time Out ◽

Empiric Antibiotic ◽

Quasi Experimental ◽

The Impact ◽

Study Inclusion

Abstract Background Empiric antibiotic (abx) therapy is often not readdressed after clinical progress becomes apparent and the results of diagnostic studies become available. We sought to evaluate whether an antibiotic time out (ATO) by front-line clinicians after 3–5 days of abx therapy could lead to a reduction in unnecessary abx use. Methods A quasi-experimental study to evaluate the impact of an ATO on decreasing abx use was performed over a 6-month base period and 9-month intervention period in 11 units across 6 hospitals in the greater Maryland region was conducted. Patients who received abx for at least 3 calendar days were eligible for study inclusion. Outcomes included days of abx therapy (DOT) per admission to cohort as well as percent of patients with a change in abx regimen on day 3–5 and appropriateness of abx regimens on days 3–5. Appropriateness of abx therapy was adjudicated by infectious diseases (ID) clinicians using prespecified criteria. Regression analysis was used to compare outcomes between the base and intervention periods. Results A total of 3,448 abx courses were reviewed, including 1,541 during the base and 1,907 during the intervention period. Overall DOT per cohort admission was similar between the two periods (12.7 vs. 12.2 hospital DOT per admission in the base and intervention periods, respectively, and was not statistically significant after controlling for unit and season (P = 0.18). After adjusting for season, unit, ID consultation, and comorbidities, there was a 36% increase in the odds of changing or discontinuing abx on days 3–5 in the intervention period compared with the base period (48% vs. 54%, P < 0.05). Similarly, there was an 89% increase in the odds of receiving an appropriate abx regimen on days 3–5 in the intervention period compared with the base period (53% vs. 68%, P < 0.01). There was no difference in the rate of Clostridium difficile lab-events in the two study periods. Conclusion In this multicenter study, we found that performance of an ATO by front-line providers was effective at improving the appropriateness of abx therapy 3–5 days after initiation, but did not change the amount of abx use, suggesting that additional interventions, perhaps later during hospitalization or at discharge, are needed to impact duration of abx therapy. Disclosures All authors: No reported disclosures.

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Algorithmic prediction of failure modes in healthcare

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzaa151 ◽

2020 ◽

Author(s):

Ayala Kobo-Greenhut ◽

Ortal Sharlin ◽

Yael Adler ◽

Nitza Peer ◽

Vered H Eisenberg ◽

...

Keyword(s):

Adverse Events ◽

Failure Modes ◽

Medical Center ◽

Hazard Analysis ◽

Working Hours ◽

Hazard Identification ◽

Patient Identification ◽

Complete Identification ◽

Before And After ◽

Fmea Method

Abstract Background Preventing medical errors is crucial, especially during crises like the COVID-19 pandemic. Failure Modes and Effects Analysis (FMEA) is the most widely used prospective hazard analysis in healthcare. FMEA relies on brainstorming by multi-disciplinary teams to identify hazards. This approach has two major weaknesses: significant time and human resource investments, and lack of complete and error-free results. Objectives To introduce the algorithmic prediction of failure modes in healthcare (APFMH) and to examine whether APFMH is leaner in resource allocation in comparison to the traditional FMEA and whether it ensures the complete identification of hazards. Methods The patient identification during imaging process at the emergency department of Sheba Medical Center was analyzed by FMEA and APFMH, independently and separately. We compared between the hazards predicted by APFMH method and the hazards predicted by FMEA method; the total participants’ working hours invested in each process and the adverse events, categorized as ‘patient identification’, before and after the recommendations resulted from the above processes were implemented. Results APFMH is more effective in identifying hazards (P < 0.0001) and is leaner in resources than the traditional FMEA: the former used 21 h whereas the latter required 63 h. Following the implementation of the recommendations, the adverse events decreased by 44% annually (P = 0.0026). Most adverse events were preventable, had all recommendations been fully implemented. Conclusion In light of our initial and limited-size study, APFMH is more effective in identifying hazards (P < 0.0001) and is leaner in resources than the traditional FMEA. APFMH is suggested as an alternative to FMEA since it is leaner in time and human resources, ensures more complete hazard identification and is especially valuable during crisis time, when new protocols are often adopted, such as in the current days of the COVID-19 pandemic.

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A Review of Evidence-Based Recommendations for Pericoronitis Management and a Systematic Review of Antibiotic Prescribing for Pericoronitis among Dentists: Inappropriate Pericoronitis Treatment Is a Critical Factor of Antibiotic Overuse in Dentistry

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18136796 ◽

2021 ◽

Vol 18 (13) ◽

pp. 6796

Author(s):

Jan Schmidt ◽

Martina Kunderova ◽

Nela Pilbauerova ◽

Martin Kapitan

Keyword(s):

Systematic Review ◽

Local Therapy ◽

Critical Factor ◽

Antibiotic Use ◽

Narrative Review ◽

Antibiotic Prescribing ◽

Evidence Based ◽

Antibiotic Overuse ◽

Clinically Significant

This work provides a narrative review covering evidence-based recommendations for pericoronitis management (Part A) and a systematic review of antibiotic prescribing for pericoronitis from January 2000 to May 2021 (Part B). Part A presents the most recent, clinically significant, and evidence-based guidance for pericoronitis diagnosis and proper treatment recommending the local therapy over antibiotic prescribing, which should be reserved for severe conditions. The systematic review includes publications analyzing sets of patients treated for pericoronitis and questionnaires that identified dentists' therapeutic approaches to pericoronitis. Questionnaires among dentists revealed that almost 75% of them prescribed antibiotics for pericoronitis, and pericoronitis was among the top 4 in the frequency of antibiotic use within the surveyed diagnoses and situations. Studies involving patients showed that antibiotics were prescribed to more than half of the patients with pericoronitis, and pericoronitis was among the top 2 in the frequency of antibiotic use within the monitored diagnoses and situations. The most prescribed antibiotics for pericoronitis were amoxicillin and metronidazole. The systematic review results show abundant and unnecessary use of antibiotics for pericoronitis and are in strong contrast to evidence-based recommendations summarized in the narrative review. Adherence of dental professionals to the recommendations presented in this work can help rapidly reduce the duration of pericoronitis, prevent its complications, and reduce the use of antibiotics and thus reduce its impact on patients' quality of life, healthcare costs, and antimicrobial resistance development.

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The impact of a multimodel approach to designing a new orthopedic department

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1345 ◽

2020 ◽

pp. 1-6

Author(s):

Elad Keren ◽

Abraham Borer ◽

Lior Nesher ◽

Tali Shafat ◽

Rivka Yosipovich ◽

...

Keyword(s):

Hand Hygiene ◽

Antibiotic Stewardship ◽

Infection Prevention ◽

Tertiary Care ◽

Surgical Site Infections ◽

Antibiotic Use ◽

Prevention Measures ◽

Orthopedic Department ◽

Before And After ◽

The Impact

Abstract Objective: To determine whether a multifaceted approach effectively influenced antibiotic use in an orthopedics department. Design: Retrospective cohort study comparing the readmission rate and antibiotic use before and after an intervention. Setting: A 1,000-bed, tertiary-care, university hospital. Patients: Adult patients admitted to the orthopedics department between January 2015 and December 2018. Methods: During the preintervention period (2015–2016), 1 general orthopedic department was in operation. In the postintervention period (2017–2018), 2 separate departments were created: one designated for elective “clean” surgeries and another that included a “complicated wound” unit. A multifaceted strategy including infection prevention measures and introducing antibiotic stewardship practices was implemented. Admission rates, hand hygiene practice compliance, surgical site infections, and antibiotic treatment before versus after the intervention were analyzed. Results: The number of admissions and hospitalization days in the 2 periods did not change. Seven-day readmissions per annual quarter decreased significantly from the preintervention period (median, 7 days; interquartile range [IQR], 6–9) to the postintervention period (median, 4 days; IQR, 2–7; P = .038). Hand hygiene compliance increased and surgical site infections decreased in the postintervention period. Although total antibiotic use was not reduced, there was a significant change in the breakdown of the different antibiotic classes used before and after the intervention: increased use of narrow-spectrum β-lactams (P < .001) and decreased use of β-lactamase inhibitors (P < .001), third-generation cephalosporins (P = .044), and clindamycin (P < .001). Conclusions: Restructuring the orthopedics department facilitated better infection prevention measures accompanied by antibiotic stewardship implementation, resulting in a decreased use of broad-spectrum antibiotics and a significant reduction in readmission rates.

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STMO-07 Adverse events related to the glioblastoma surgery and their perioperative management in our hospital

Neuro-Oncology Advances ◽

10.1093/noajnl/vdaa143.042 ◽

2020 ◽

Vol 2 (Supplement_3) ◽

pp. ii10-ii10

Author(s):

Hideki Kashiwagi ◽

Shinji Kawabata ◽

Seigo Kimura ◽

Ryokichi Yagi ◽

Naokado Ikeda ◽

...

Keyword(s):

Adverse Events ◽

Venous Thrombosis ◽

Perioperative Management ◽

Perioperative Complications ◽

Epileptic Seizures ◽

Residual Tumor ◽

Complete Removal ◽

Tumor Localization ◽

Vein Thrombosis ◽

Before And After

Abstract Background: The standard treatment for glioblastoma is surgical resection following chemoradiation therapy. The rate of removal or the amount of residual tumor has some impact on the prognosis of patients with glioblastoma, but the highly invasive nature of this tumor makes complete removal limited to the contrast-enhanced lesions difficult due to its localization. Furthermore, when postoperative seizures and venous thrombosis are included in surgery-related complications, these perioperative adverse events can cause delays in the initiation of chemoradiotherapy and delay the return to work and home, such as prolonged hospitalization and rehabilitation time. Methods: We retrospectively reviewed the perioperative status of the recent 50 consecutive cases with histologically confirmed as glioblastoma at our hospital, the patient background, tumor localization, and perioperative treatment, and so on. Results: The major perioperative complications were ischemic or hemorrhagic complications, epileptic seizures, venous thrombosis, and pneumonia; CTCAE grade 2 or higher, grade 3 or higher, and grade 4 occurred in about 40%, 20%, and 10%, respectively, with some patients having multiple complications. Discussion: Although there was a tendency for ischemic changes around the cavity of the resection as the resection rate increased, most cases were asymptomatic and it seemed to be acceptable if residual brain function could be preserved. Residual tumors tended to show hemorrhagic changes and epileptic seizures because this is thought to be that the tumor was deliberately left in place to preserve function, based on the localization of the tumor. Postoperative FDP levels were useful in predicting the development of deep vein thrombosis and pulmonary artery thromboembolism. Conclusion: Because glioblastoma has short survival time and patient PS before and after surgery varies greatly depending on tumor localization, it is important to consider risk-benefit strategies for each case and to establish a scheme for a seamless transition from perioperative management to the introduction of postoperative therapy and maintenance therapy.

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Effect of educational intervention on the appropriate use of oral antimicrobials in oral and maxillofacial surgery: a retrospective secondary data analysis

BMC Oral Health ◽

10.1186/s12903-020-01367-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Junya Kusumoto ◽

Atsushi Uda ◽

Takeshi Kimura ◽

Shungo Furudoi ◽

Ryosuke Yoshii ◽

...

Keyword(s):

Educational Intervention ◽

Oral Surgery ◽

Maxillofacial Surgery ◽

Antibiotic Use ◽

Oral And Maxillofacial Surgery ◽

Third Generation ◽

Oral Antibiotics ◽

Appropriate Use ◽

Before And After ◽

Third Generation Cephalosporins

Abstract Background In Japan, oral third-generation cephalosporins with broad-spectrum activity are commonly prescribed in the practices of dentistry and oral surgery. However, there are few reports on the appropriate use of antibiotics in the field of oral surgery. This study aimed to evaluate the appropriateness of antibiotic use before and after an educational intervention in the Department of Oral and Maxillofacial Surgery, Kobe University Hospital. Methods The use of oral antibiotics was investigated among inpatients and outpatients before and after an educational intervention conducted by the antimicrobial stewardship team. Additionally, the frequency of surgical site infection after the surgical removal of an impacted third mandibular molar under general anesthesia and the prevalence of adverse effects of the prescribed antibiotics were comparatively evaluated between 2013 and 2018. Results After the educational intervention, a remarkable reduction was noted in the prescription of oral third-generation cephalosporins, but increased use of penicillins was noted among outpatients. There was reduced use of macrolides and quinolones in outpatients. Although a similar trend was seen for inpatients, the use of quinolones increased in this population. Despite the change in the pattern of antibiotic prescription, inpatients who underwent mandibular third molar extraction between 2013 and 2018 did not show a significant increase in the prevalence of surgical site infections (6.2% vs. 1.8%, p = .336) and adverse effects of drugs (2.1% vs. 0%, p = .466). Conclusions This study suggests that the judicious use of oral antibiotics is possible through conscious and habitual practice of appropriate antibiotic use. However, further investigation is required to develop measures for appropriate use of oral antibiotics.

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Investigating the Impact of Brief Outings on the Welfare of Dogs Living in US Shelters

Animals ◽

10.3390/ani11020548 ◽

2021 ◽

Vol 11 (2) ◽

pp. 548

Author(s):

Lisa M. Gunter ◽

Rachel J. Gilchrist ◽

Emily M. Blade ◽

Rebecca T. Barber ◽

Erica N. Feuerbacher ◽

...

Keyword(s):

Stress Reduction ◽

Physiological Measures ◽

Urinary Cortisol ◽

Short Term ◽

Animal Shelters ◽

Time Out ◽

Before And After ◽

Activity Measures ◽

The Impact ◽

Low Activity

Social isolation likely contributes to reduced welfare for shelter-living dogs. Several studies have established that time out of the kennel with a person can improve dogs’ behavior and reduce physiological measures of stress. This study assessed the effects of two-and-a-half-hour outings on the urinary cortisol levels and activity of dogs as they awaited adoption at four animal shelters. Dogs’ urine was collected before and after outings for cortisol:creatinine analysis, and accelerometer devices were used to measure dogs’ physical activity. In total, 164 dogs participated in this study, with 793 cortisol values and 3750 activity measures used in the statistical analyses. We found that dogs’ cortisol:creatinine ratios were significantly higher during the afternoon of the intervention but returned to pre-field trip levels the following day. Dogs’ minutes of low activity were significantly reduced, and high activity significantly increased during the outing. Although dogs’ cortisol and activity returned to baseline after the intervention, our findings suggest that short-term outings do not confer the same stress reduction benefits as previously shown with temporary fostering. Nevertheless, it is possible that these types of outing programs are beneficial to adoptions by increasing the visibility of dogs and should be further investigated to elucidate these effects.

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