scholarly journals 1139. Reducing Collection of Tracheal Aspirate Bacterial Cultures: A Diagnostic Test Stewardship Intervention

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S660-S661
Author(s):  
Kathleen Chiotos ◽  
Giyoung Lee ◽  
Guy Sydney ◽  
Heather Wolfe ◽  
Jennifer Blumenthal ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Bacterial Colonization ◽  
Tracheal Aspirate ◽  
Consensus Guideline ◽  
Broad Spectrum Antibiotic ◽  
Improvement Project ◽  
Bacterial Cultures ◽  
Pdsa Cycle ◽  
Number Of Patients ◽  
Days Of Therapy

Abstract Background Tracheal aspirate (TA) bacterial cultures are often collected in mechanically ventilated children to evaluate for ventilator-associated infections (VAI), including tracheitis and pneumonia. However, frequent bacterial colonization of tracheal tubes results in poor specificity of positive TA cultures for distinguishing bacterial infection from colonization, which contributes to antibiotic overuse for VAI. We performed a quality improvement project to reduce collection of TA cultures through implementation of a consensus guideline to standardize culture ordering, and measured its impact on antibiotic use in a tertiary PICU. Methods A multidisciplinary team including PICU, pulmonary, and ID clinicians developed the consensus guideline in November 2019-February 2020. The first Plan-Do-Study-Act (PDSA) cycle occurred in August 2020 and included provider education, providing a link to the guideline in the TA culture order, and signs and screensavers highlighting key guideline recommendations. The second PDSA cycle occurred in October-December 2020 and included weekly emails to on service PICU clinicians. Statistical process control charts were used to measure the number of TA cultures collected/100 ventilator days and broad-spectrum antibiotic DOT/100 ventilator days. The number of patients treated for VAI/100 ventilator days and guideline compliance were also measured. Results The baseline rate of TA culture collection was 4.58/100 ventilator days. A centerline shift to 3.33 cultures/100 ventilator days occurred in March 2020. Following PDSA 1 and 2 in October 2020, a second downward centerline shift to 2.22 cultures/100 ventilator days occurred (Figure 1). Broad-spectrum antibiotic days of therapy/100 ventilator days decreased in November 2019 coincident with the start of the project, but no further reductions occurred after PDSA 1 and 2 (Figure 2). The number of patients treated for VAI decreased from a baseline of 1.24/100 ventilator days to 0.66/100 ventilator days. Finally, the proportion of TA cultures ordered that were non-compliant with the guideline recommendations was unchanged throughout the study period (Table 1). Conclusion A consensus guideline reduced collection of TA cultures, with a modest reduction in the rate of antibiotic treatment for VAI. Disclosures All Authors: No reported disclosures

Quantifying Empiric Antibiotic Use in US Children’s Hospitals

2021 ◽  
Author(s):  
Kathleen Chiotos ◽  
Lauren D’Arinzo ◽  
Eimear Kitt ◽  
Rachael Ross ◽  
Jeffrey S. Gerber
Keyword(s):  
Broad Spectrum ◽  
Antibiotic Use ◽  
Level Variation ◽  
Hospital Level ◽  
Broad Spectrum Antibiotic ◽  
Children's Hospitals ◽  
Broad Spectrum Antibiotics ◽  
Children’S Hospitals ◽  
Days Of Therapy ◽  
Rule Out

OBJECTIVES Empirical broad-spectrum antibiotics are routinely administered for short durations to children with suspected bacteremia while awaiting blood culture results. Our aim for this study was to estimate the proportion of broad-spectrum antibiotic use accounted for by these “rule-outs.” METHODS The Pediatric Health Information System was used to identify children aged 3 months to 20 years hospitalized between July 2016 and June 2017 who received broad-spectrum antibiotics for suspected bacteremia. Using an electronic definition for a rule-out, we estimated the proportion of all broad-spectrum antibiotic days of therapy accounted for by this indication. Clinical and demographic characteristics, as well as antibiotic choice, are reported descriptively. RESULTS A total of 67 032 episodes of suspected bacteremia across 42 hospitals were identified. From these, 34 909 (52%) patients were classified as having received an antibiotic treatment course, and 32 123 patients (48%) underwent an antibiotic rule-out without a subsequent treatment course. Antibiotics prescribed for rule-outs accounted for 12% of all broad-spectrum antibiotic days of therapy. Third-generation cephalosporins and vancomycin were the most commonly prescribed antibiotics, and substantial hospital-level variation in vancomycin use was identified (range: 16%–58% of suspected bacteremia episodes). CONCLUSIONS Broad-spectrum intravenous antibiotic use for rule-out infections appears common across children’s hospitals, with substantial hospital-level variation in the use of vancomycin in particular. Antibiotic stewardship programs focused on intervening on antibiotics prescribed for longer durations may consider this novel opportunity to further standardize antibiotic regimens and reduce antibiotic exposure.

Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

2021 ◽  
pp. 001857872110557
Author(s):  
Jessica L. Colmerauer ◽  
Kristin E. Linder ◽  
Casey J. Dempsey ◽  
Joseph L. Kuti ◽  
David P. Nicolau ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Antibiotic Use ◽  
Community Acquired Pneumonia ◽  
Intervention Period ◽  
Provider Education ◽  
Broad Spectrum Antibiotic ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Days Of Therapy ◽  
Order Set

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

scholarly journals 2422. Effectiveness of a Probiotic for Primary Prevention of Clostridium difficile Infection and Antibiotic-Associated Diarrhea among Hospitalized Patients Receiving Broad-Spectrum Antibiotics

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S836-S837
Author(s):  
Khanh-Linh Le ◽  
Heather Young ◽  
Timothy C Jenkins ◽  
Robert Tapia ◽  
Katherine C Shihadeh
Keyword(s):  
Primary Prevention ◽  
Clostridium Difficile ◽  
Clostridium Difficile Infection ◽  
Broad Spectrum ◽  
Hospitalized Patients ◽  
Broad Spectrum Antibiotic ◽  
Probiotic Group ◽  
Broad Spectrum Antibiotics ◽  
Days Of Therapy ◽  
Antibiotic Associated Diarrhea

Abstract Background Prior to 2016, Denver Health Medical Center had a higher-than-expected rate of hospital onset Clostridium difficile infection (HO-CDI). A multifaceted CDI prevention plan was implemented, including the use of a probiotic as primary prevention for HO-CDI and antibiotic-associated diarrhea (AAD) in inpatients receiving broad-spectrum antibiotics. We aimed to study the effectiveness of probiotic use in this clinical context. Methods During the intervention, inpatient orders for a broad-spectrum antibiotic triggered a best practice advisory recommending once daily co-administration of 100 billion units of a probiotic containing Lactobacillus casei, L. rhamnosus, and L. acidophilus (BioK+ ®). To evaluate effectiveness and safety of this intervention, we performed a retrospective cohort study including adult inpatients who received > 24 hours of a broad-spectrum antibiotic between April 2016 and March 2018. The primary endpoint was the incidence of HO-CDI (> 3 days after admission) compared between patients who received antibiotics alone vs. antibiotics plus the probiotic. Secondary endpoints were the incidence of AAD, defined as a negative CDI test after antibiotic initiation, and the incidence of Lactobacillus species identified in clinical cultures. Results 3,291 patients were included; 1,835 received antibiotics alone and 1,456 received antibiotics plus the probiotic. Baseline characteristics between groups were similar, except patients in the antibiotic alone group had a greater incidence of cirrhosis and proton-pump inhibitor use (16.1% vs 10.1%, P < 0.001; 39.1% vs 31.5%, P < 0.001). Length of stay and antibiotic days of therapy were longer in the antibiotic plus probiotic group [6 days (IQR, 3–11) vs 6 days (IQR, 4–12), P = 0.014; 4 days (IQR, 3–7) vs 5 days (IQR, 3–7), P < 0.001]. The incidence of HO-CDI (37, 2% vs 35, 2.4%; P = 0.450) and AAD (231, 12.6% vs 199, 13.7%; P = 0.362) were similar between groups. Lactobacillus was identified in at least one clinical culture from 0.2% (3/1835) and 0.3% (4/1456) of patients in the antibiotic alone group and antibiotic plus probiotic group, respectively (P = 0.497). Conclusion In hospitalized patients receiving broad-spectrum antibiotics, co-administration of a probiotic did not appear to reduce the incidence of HO-CDI or AAD. Disclosures All authors: No reported disclosures.

NASAL POLYPOSIS IN PATIENTS WITH CYSTIC FIBROSIS

PEDIATRICS ◽  
1962 ◽  
Vol 30 (3) ◽  
pp. 389-401
Author(s):  
Harry Shwachman ◽  
Lucas L. Kulczycki ◽  
Harry L. Mueller ◽  
Carlyle G. Flake
Keyword(s):  
Cystic Fibrosis ◽  
Nasal Obstruction ◽  
Broad Spectrum ◽  
Nasal Polyposis ◽  
Clinical Course ◽  
Clinical Severity ◽  
Broad Spectrum Antibiotic ◽  
Paranasal Sinusitis ◽  
The Past ◽  
Number Of Patients

Among 742 patients with cystic fibrosis studied during the past 4 years, 50 (or 6.7%) were found to have nasal polyposis. Polyps were noted in patients of all ages, the youngest being 2½ years of age. Roentgenograms of the sinuses showed evidence of paranasal sinusitis in each case studied. An allergic investigation was conducted in each of the 50 patients with nasal polyposis. Twenty-four patients presented no evidence of allergy. The clinical severity of the basic disease (cystic fibrosis) was the same in both the allergic and nonallergic group. A brief description of the clinical course of the patient with nasal polyps is presented. The polyps are often multiple, may cause complete nasal obstruction, and tend to regrow. Their course is beneficially influenced by the administration of broad-spectrum antibiotics or systemic steroids. However, polyps did appear in many patients while on constant broad spectrum antibiotic therapy. Conservative management is suggested. Simple polypectomy is carried out when nasal obstruction is complete. In a small number of patients, repeated polypectomies have been necessary over a number of years. The severity of the pulmonary lesion is not reflected by the degree of alteration of the mucosal linings of the paranasal sinuses. Patients with nasal polyposis, regardless of the presence or absence of allergy, should be examined for evidence of cystic fibrosis, including family history, pulmonary evaluation, and appropriate laboratory tests.

scholarly journals Scedosporium apiospermum fungaemia: the ramification of broad-spectrum antimicrobial treatments

2014 ◽  
Vol 13 (3) ◽  
pp. 326-328
Author(s):  
Chuan Hun Ding ◽  
Najihan Abdul Samat Muttaqillah ◽  
Md. Mostafizur Rahman ◽  
Nor Zanariah Zainol Abidin ◽  
Suvra Biswas ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Medical Science ◽  
Tracheal Aspirate ◽  
Immunocompetent Patient ◽  
Scedosporium Apiospermum ◽  
Broad Spectrum Antibiotic ◽  
X Ray ◽  
Chest X Ray ◽  
Antimicrobial Treatments ◽  
Initial Blood

Scedosporium apiospermum is a cosmopolitan mycotic agent with unique characteristics. This is a case of a 65-year-old immunocompetent patient who presented with shortness of breath and fever. Consolidation was observed in both lung fields on chest X-ray. A diagnosis of aspiration pneumonia was made. Extended-spectrum ?-lactamase (ESBL)-producing Klebsiella pneumoniae was identified from his tracheal aspirate and imipenem was administered. Initial blood cultures were negative but after 10 days on imipenem, Candida glabrata was isolated. Amphotericin B was added to the treatment regimen, but after a week on this antifungal, Scedosporium apiospermum was cultured from the blood. The patient succumbed to illness before a change in the antifungal regimen. The case highlights the unwelcome consequence of using a broad spectrum antibiotic and later a broad spectrum antifungal agent. DOI: http://dx.doi.org/10.3329/bjms.v13i3.19154 Bangladesh Journal of Medical Science Vol.13(3) 2014 p.326-328Note: updated with minor changes on 20th June 2014. Last author added.

Audit and Feedback to Reduce Broad-Spectrum Antibiotic Use among Intensive Care Unit Patients A Controlled Interrupted Time Series Analysis

2012 ◽  
Vol 33 (4) ◽  
pp. 354-361 ◽  
Author(s):  
Marion Elligsen ◽  
Sandra A. N. Walker ◽  
Ruxandra Pinto ◽  
Andrew Simor ◽  
Samira Mubareka ◽  
...  
Keyword(s):  
Time Series ◽  
Critical Care ◽  
Intensive Care ◽  
Broad Spectrum ◽  
Interrupted Time Series ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Broad Spectrum Antibiotic ◽  
Days Of Therapy ◽  
Prospective Audit And Feedback

Objective.We aimed to rigorously evaluate the impact of prospective audit and feedback on broad-spectrum antimicrobial use among critical care patients.Design.Prospective, controlled interrupted time series.SettingSingle tertiary care center with 3 intensive care units.Patients and Interventions.A formal review of all critical care patients on their third or tenth day of broad-spectrum antibiotic therapy was conducted, and suggestions for antimicrobial optimization were communicated to the critical care team.Outcomes.The primary outcome was broad-spectrum antibiotic use (days of therapy per 1000 patient-days; secondary outcomes included overall antibiotic use, gram-negative bacterial susceptibility, nosocomial Clostridium difficile infections, length of stay, and mortality.Results.The mean monthly broad-spectrum antibiotic use decreased from 644 days of therapy per 1,000 patient-days in the preintervention period to 503 days of therapy per 1,000 patient-days in the postintervention period (P < .0001); time series modeling confirmed an immediate decrease (± standard error) of 119 ± 37.9 days of therapy per 1,000 patient-days (P = .0054). In contrast, no changes were identified in the use of broad-spectrum antibiotics in the control group (nonintervention medical and surgical wards) or in the use of control medications in critical care (stress ulcer prophylaxis). The incidence of nosocomial C. difficile infections decreased from 11 to 6 cases in the study intensive care units, whereas the incidence increased from 87 to 116 cases in the control wards (P = .04). Overall gram-negative susceptibility to meropenem increased in the critical care units. Intensive care unit length of stay and mortality did not change.Conclusions.Institution of a formal prospective audit and feedback program appears to be a safe and effective means to improve broad-spectrum antimicrobial use in critical care.

Evaluating a Pharmacy-Driven 72-Hour Antibiotic Monitoring Program Implemented in a Community Hospital

2019 ◽  
pp. 001857871986766
Author(s):  
Vishal Patel ◽  
Shaina Doyen
Keyword(s):  
Infectious Diseases ◽  
Antimicrobial Stewardship ◽  
Broad Spectrum ◽  
Community Hospital ◽  
Monitoring Program ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Broad Spectrum Antibiotic ◽  
Days Of Therapy ◽  
The Impact

Background: Antimicrobial stewardship programs commonly utilize infectious diseases pharmacists to guide appropriate utilization of broad-spectrum antimicrobials. Strategies should be developed to increase staff pharmacist’s participation in decreasing broad-spectrum antibiotic use. Objective: The purpose of this study was to determine the effectiveness of a pharmacy-driven 72-hour antimicrobial stewardship initiative. Methods: A pharmacy-driven 72-hour antibiotic review policy was implemented at a community hospital. Targeted antibiotics included ertapenem, meropenem, and daptomycin. The hospital’s infectious diseases pharmacist provided policy education to staff pharmacists. All pharmacists provided prospective audit and feedback to physicians. Preimplementation and postimplementation data were collected through a retrospective chart review to analyze the impact of the initiative. Results: There were a total of 570 targeted antibiotic orders for review, of which 155 antibiotic orders met criteria for inclusion; 97 in the preimplementation group and 58 in the postimplementation group. Targeted antibiotic orders decreased postimplementation during the study period. Days of therapy per 1000 patient days decreased between the 2 groups, although this was statistically significant neither for the pooled targeted antibiotics nor for each individual antibiotic. There was a statistically significant increase in the number of appropriately prescribed targeted antibiotics from preimplementation compared to postimplementation (from 35% to 64%, P < .01). Pharmacist interventions documented for patients receiving the targeted antibiotics increased significantly during the intervention period ( P < .01). In addition, there was a total of $28 795.96 in cost avoidance based on the difference in antibiotic use between the 2 groups. Conclusion: Implementation of a pharmacy-driven 72-hour broad-spectrum antibiotic review in a large community-based hospital resulted in a reduction in utilization and hospital spending and a significant increase in appropriate use of targeted antibiotics, while also increasing pharmacist engagement with antimicrobial stewardship.

scholarly journals 109. Develop and Implement a Novel Pediatric Antimicrobial Stewardship Program in a Non-Freestanding Children’s Hospital Located in an Adult-Centered Community Hospital in San Joaquin Valley, California

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S168-S169
Author(s):  
Tsung-Chi Lien ◽  
Laurie Covarrubias ◽  
Alice Ip ◽  
Harlan Husted ◽  
Emi Suzuki ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Broad Spectrum ◽  
Medical Center ◽  
Antimicrobial Use ◽  
Antimicrobial Stewardship Program ◽  
Broad Spectrum Antibiotic ◽  
Children's Hospital ◽  
Stewardship Program ◽  
Days Of Therapy ◽  
Children’S Hospital

Abstract Background A pediatric-specific antimicrobial stewardship program (Ped ASP) has been shown to optimize antimicrobial use, improve patient outcomes, and reduce healthcare expenditures in this population. Opportunities and challenges exist when developing a Ped ASP for a children’s hospital within an adult-centered medical center primarily due to mixed infrastructure. The objective of this study is to provide process and outcome data of a new Ped ASP in a non-freestanding children’s hospital within an adult-centered tertiary hospital. Methods A pediatric infectious disease physician and four pediatric pharmacists designed a Ped ASP utilizing direct and indirect patient care activities to optimize pediatric antimicrobial use in 21 bed-pediatric services within a 685-bed, adult-centered medical center. Implemented in 2020, Ped ASP activities include thrice weekly chart reviews followed by handshake rounds and quarterly reviews of documented interventions. The Ped ASP team also developed policies, education, and other resources to further guide appropriate antimicrobial use, in collaboration with the adult team. Results Ped ASP was initiated on general pediatric (PED) and pediatric intensive care (PICU) units. In 2020, a total of 286 charts were reviewed with 199 antibiotic interventions provided, including optimization of antimicrobial selection (23%), IV-to-PO conversion (15%), and antimicrobial dosage adjustment (13%). Annual average antibiotic length and days of therapy per 1000 patient-days were 241 and 290 respectively in PED, and 388 and 432 in PICU. The overall trend from 2020 to 2021 decreased in PED but increased in PICU (Fig. 1). The ratio of narrow to broad spectrum antibiotic use increased for both PED and PICU (Fig. 2). Simultaneously, a pediatric-specific antibiogram, extended-infusion protocol of beta-lactams, and neonatal sepsis treatment algorithm were developed and implemented. Antibiotic Days of Therapy per 1000 Patient Days Ratio of Narrow: Broad Spectrum Antibiotic Usage Conclusion A Ped ASP was successfully developed in a non-freestanding children’s hospital. Continual metrics served as an important tool to identify areas for improvement. Future goals include expansion of Ped ASP to other service lines, enhanced ASP education and development of additional pediatric antimicrobial treatment pathways. Disclosures All Authors: No reported disclosures

scholarly journals 1149. Reducing Piperacillin/Tazobactam Use in Children with Acute Perforated Appendicitis

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S410-S410
Author(s):  
Talal B Seddik ◽  
Laura Bio ◽  
Hannah Bassett ◽  
Despina Contopoulos-Ioannidis ◽  
Lubna Qureshi ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Broad Spectrum ◽  
Perforated Appendicitis ◽  
Antibiotic Use ◽  
Broad Spectrum Antibiotic ◽  
Post Intervention ◽  
Stewardship Program ◽  
Days Of Therapy ◽  
Significant Difference ◽  
The Impact

Abstract Background Children with perforated appendicitis have more frequent complications compared with nonperforated appendicitis. Existing data suggest broad-spectrum antibiotics are not superior to narrow-spectrum antibiotics for this condition. In an effort to safely decrease broad-spectrum antibiotic use at our hospital, we evaluated the impact of an antimicrobial stewardship program (ASP) intervention on the use of piperacillin/tazobactam (PT) and clinical outcomes in children with perforated appendicitis. Methods Single-center, retrospective cohort study of children ≤ 18 years with perforated appendicitis who underwent primary appendectomy. Children with primary nonoperative management or interval appendectomy were excluded. Prior to the intervention, children at our hospital routinely received PT for perforated appendicitis. An electronic health record (EHR)-integrated guideline that recommended ceftriaxone and metronidazole for perforated appendicitis was released on July 1, 2017 (Figure 1). We compared PT utilization, measured in days of therapy (DOT) per 1,000 patient-days, and clinical outcomes before and after the intervention. Results A total of 74 children with perforated appendicitis were identified: 23 during the pre-intervention period (June 1, 2016 to June 30, 2017) and 51 post-intervention (July 1, 2017 to September 30, 2018). Thirty-three patients (45%) were female and the median age was 8 years (IQR: 5–11.75 years). Post-intervention rate of guideline compliance was 84%. PT use decreased from 556 DOT per 1000 patient-days to 131 DOT per 1000 patient-days; incidence rate ratio of 0.24 (95% CI: 0.16–0.35), post-intervention vs. pre-intervention. There was no statistically significant difference in duration of intravenous antibiotics, total antibiotic duration, postoperative length of stay (LOS), total LOS, ED visits/readmission, or surgical site infection (SSI) between pre- and post-intervention periods (Table 1). Conclusion An EHR-integrated ASP intervention targeting children with perforated appendicitis resulted in decreased broad-spectrum antibiotic use with no statistically significant difference in clinical outcomes. Larger, multicenter trials are needed to confirm our findings. Disclosures All authors: No reported disclosures.

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