scholarly journals 47. Transitioning to Batch Dosing of High-Cost Antimicrobials in the Inpatient Setting

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S144-S144
Author(s):  
Matthew Lokant ◽  
Shu Xian Lee ◽  
Connor Nevin ◽  
John D Lindsay ◽  
Colby Acri ◽  
...  
Keyword(s):  
Cost Savings ◽  
Early Morning ◽  
Inpatient Setting ◽  
Antimicrobial Use ◽  
Medication Waste ◽  
Antimicrobial Utilization ◽  
Early Afternoon ◽  
Medication Dosage ◽  
Specific Formulation ◽  
Appropriate Antimicrobial Use

Abstract Background Antimicrobial stewardship (AMS) committees ensure appropriate antimicrobial utilization. One stewardship intervention is to evaluate the delivery model of high-cost antimicrobials to better utilize resources and mitigate expenses. We analyzed the total medication waste and costs of high-cost antimicrobials, specifically daptomycin, ertapenem, amphotericin, and micafungin, at our institution and propose innovative cost-savings changes at a systems level. Methods This retrospective study consisted of 263 patients. All patients were at least 18 years old who was admitted to our academic institution from January 2020 to April 2021 and received daptomycin, ertapenem, amphotericin, or micafungin. Demographics, daily medication dosage, total doses received, the date and time of the start of the medication, last administered dose, and discontinued order were recorded. Results The daptomycin cohort consisted of 143 patients with 46.2% females and average age of 56.3 years. In this group, 145.3 vials were wasted which equated to a loss of &22,630. The ertapenem group had 53 patients with 62.3% females and a mean age of 62.3 years. There were 24 vials wasted with a calculated loss of &1080. The amphotericin cohort had 32 patients with an average age of 52.2 years and 43.8% females. There were 189 vials wasted with a loss of &46,116. The micafungin group had 35 patients with 42.9% females and average age of 60.4 years. This group had 12 vials wasted with a loss of &2052. Conclusion Each antimicrobial has a specific formulation protocol. Daptomycin and ertapenem formulation occurs in the early morning. Amphotericin formulation occurs 2 hours prior to medication use. Micafungin formulation occurs at the time the order label prints. These medications were more often administered in the late morning to early afternoon timeframe. The order to discontinue the medications also occurred at the same interval. One reason could be due to decisions made on morning rounds from primary teams and specialty input. These orders would then be placed after rounds. A cost-saving method would be to batch and change the formulation time for all antimicrobials to later in the afternoon, which would not only prevent waste, but also allow the AMS team to effectively audit appropriate antimicrobial use. Disclosures All Authors: No reported disclosures

Preventing the Emergence of Multidrug-Resistant Microorganisms Through Antimicrobial Use Controls: The Complexity of the Problem

1996 ◽  
Vol 17 (8) ◽  
pp. 490-495 ◽  
Author(s):  
William R. Jarvis
Keyword(s):  
Multidisciplinary Approach ◽  
Cost Savings ◽  
Pathogen Resistance ◽  
Multidrug Resistant ◽  
Outpatient Setting ◽  
Inpatient Setting ◽  
Antimicrobial Use ◽  
Administrative Staff ◽  
Substantial Cost ◽  
Clinician Education

AbstractWidespread use of antimicrobials in the inpatient and outpatient setting has been associated with the emergence of multidrug-resistant microorganisms. A variety of methods exist to improve the appropriateness of antimicrobial use in the inpatient setting, including guidelines, antimicrobial use evaluations, microbiology laboratory guidance, formulary development and antimicrobial restriction, use of antimicrobial order or automatic stop order forms, and antimicrobial audits. To decrease the selective pressure that leads to development of pathogen resistance and to reduce antimicrobial expenditures, infectious disease, infection control, pharmacy, and administrative staff need to improve clinician use of antimicrobials through development and implementation of antimicrobial use committees. Through the implementation of a comprehensive, multidisciplinary approach to antimicrobial use and development of clinician education programs, inappropriate antimicrobial use can be reduced, patient care can be improved, and substantial cost savings can be realized.

scholarly journals Choose Wisely: Metered Dose Inhalers Versus Nebulized Inhaled Solutions in The Inpatient Setting

2021 ◽  
Vol 67 (4) ◽  
pp. 13-16
Author(s):  
Meera Alshamali ◽  
Robin Lee ◽  
Alice Change ◽  
Johnny Wong
Keyword(s):  
Drug Cost ◽  
Medical Center ◽  
Cost Savings ◽  
Secondary Outcome ◽  
Inpatient Setting ◽  
Metered Dose Inhalers ◽  
Implementation Phase ◽  
Medication Waste ◽  
Hospitalization Costs ◽  
Metered Dose

Background Healthcare expenditures continue to rise, and hospitalization costs remain the driving factor for nationally increasing health expenditures.(1,3) Affordability initiatives targeted at minimizing inpatient drug spending and medication waste are vital. Metered dose-inhalers (MDIs) impose high potential for medication waste as their bulk nature provides a day supply that far exceeds average hospitalization length of stay.(1,7) Kaiser Permanente Baldwin Park Medical Center inpatient pharmacy adopted a cost saving initiative aimed at converting the commonly prescribed ipratropium MDI to its equivalent nebulized solution. Methods This was a retrospective medication use evaluation (MUE), assessing the overall drug cost impact of converting patients from ipratropium MDI to ipratropium nebulized solution. The study period consisted of two phases: the pre-implementation phase from 11/1/2017 to 09/30/2018, and the post-implementation phase from 11/01/2018 to 09/30/2019.The study population consisted of patients admitted to the Critical Care Unit (CCU) and Step-Down Unit (SDU), who were prescribed an ipratropium MDI or ipratropium nebulized solution. Patients who were under the age of 18 years old were excluded. The primary outcome was to analyze the drug cost savings of prescribing nebulized solutions over MDIs in the inpatient setting. The secondary outcome was to assess overall compliance with the conversion protocol. Results Ipratropium MDI administrations declined by 91% (from 3,751 to 336) during the post-implementation phase. An estimated drug cost savings of $68,700 occurred by converting the ipratropium MDIs to ipratropium nebulized solution. Conclusion This conversion protocol was successful at reducing MDI waste and attaining substantial drug cost savings at our medical center over a period of 1 year since implementation.

Intra- and inter-day variability in plasma tCO2 concentration in sedentary horses

2014 ◽  
Vol 10 (1) ◽  
pp. 39-47
Author(s):  
B.E. Bergstrom ◽  
J.H. Foreman ◽  
C.R. Foreman ◽  
A.M. Barger
Keyword(s):  
Blood Test ◽  
Indoor Environment ◽  
Early Morning ◽  
Time Of Day ◽  
Individual Variability ◽  
Strong Ion Difference ◽  
Serum Chemistry ◽  
Blood Samples ◽  
Early Afternoon ◽  
Glass Tubes

Sodium bicarbonate and other alkalinising solutions (‘milkshakes’) have been given to horses surreptitiously before exercise to provide exogenous buffering effects. After an initial positive blood test, some accused horse trainers claim that their horses ‘naturally test high’, so some jurisdictions allow a secured quarantine in which the horse is tested multiple times. The objective of this experiment was to determine the intra- and inter-day variability of plasma total CO2 (tCO2) and other plasma strong ions in a group of sedentary horses housed similarly to a quarantine period. The hypothesis was that plasma tCO2 would not remain constant over a multi-day monitoring interval, but would vary measurably during that interval. Eight sedentary (unconditioned) horses were studied for 2 weeks. Horses were acclimated to a climate-controlled indoor environment and an alfalfa-only diet for a minimum of 10 days prior to sampling. Horses were sampled 3 times daily for 5 consecutive days at 7:00, 11:00 and 15:00 h. Blood samples were collected directly into 10 ml heparinised evacuated glass tubes by jugular venipuncture using a double-ended 0.91 mm needle. Samples were chilled until concentrations of plasma tCO2, Na+, K+, and Cl-, were determined within 1-3 h of sampling using an automated serum chemistry analyzer which was calibrated daily using commercial reagents obtained from the manufacturer as well as externally-obtained NIST-traceable calibrating solutions. Mean results documented mild variations in mean plasma tCO2 (range 28.9-31.6 mmol/l), but individual horses’ plasma tCO2 ranged over 4-7 units. Results showed that there was considerable intra- and inter-individual variability in plasma tCO2. Mean pooled tCO2 and measured strong ion difference (SIDm) differed by time-of-day, with both late morning and early afternoon values lower than early morning values (P<0.001). There was a strong positive linear relationship between plasma SIDm and tCO2 (r=0.75, P<0.001).

Diurnal rhythms and effects of fasting and refeeding on rat adipose tissue lipoprotein lipase

1996 ◽  
Vol 271 (6) ◽  
pp. E1092-E1097 ◽  
Author(s):  
M. Bergo ◽  
G. Olivecrona ◽  
T. Olivecrona
Keyword(s):  
Adipose Tissue ◽  
Lipoprotein Lipase ◽  
Specific Activity ◽  
Early Morning ◽  
Diurnal Rhythms ◽  
Mrna Levels ◽  
Short Term ◽  
Early Afternoon ◽  
Rat Adipose Tissue ◽  
Adipose Tissue Lipoprotein Lipase

The activity of lipoprotein lipase (LPL) in adipose tissue is modulated by changes in the nutritional status. We have measured LPL activity, mass, and mRNA levels in rat adipose tissue during normal feeding cycles, during short- and long-term fasting, and during refeeding after fasting. LPL activity displayed a diurnal rhythm. The activity was highest during the night and early morning, decreased to a minimum during the early afternoon, and then increased again. These changes corresponded to the feeding pattern. The increases and/or decreases resulted from changes in LPL synthetic rate compounded by posttranslational mechanisms. During short-term fasting, LPL specific activity decreased to < 30% of control. The specific activity was restored within 4 h by refeeding. On longer fasting, LPL mRNA decreased. This became significant from 36 h. On refeeding, it took 12 h to restore the mRNA levels, whereas tissue LPL activity and mass could not be fully restored by 36 h of refeeding. These data show that LPL activity during short-term fasting is regulated posttranscriptionally, which allows for quick upregulation after refeeding. On longer fasting, other mechanisms affecting LPL transcription and synthesis come into play, and upregulation after refeeding is slowed down.

scholarly journals Climatology of rapid geomagnetic variations at high latitudes over two solar cycles

2011 ◽  
Vol 29 (10) ◽  
pp. 1783-1792 ◽  
Author(s):  
A. Viljanen ◽  
E. Tanskanen
Keyword(s):  
Maximum Amplitude ◽  
Early Morning ◽  
Clear Correlation ◽  
High Latitudes ◽  
Solar Cycles ◽  
Horizontal Magnetic Field ◽  
Geomagnetic Variations ◽  
Early Afternoon ◽  
Magnetometer Data ◽  
Equivalent Currents

Abstract. We investigate the characteristics of rapid geomagnetic variations at high latitudes based on the occurrence of large time derivatives of the horizontal magnetic field (dH/dt exceeding 1 nT s−1). Analysis of IMAGE magnetometer data from North Europe in 1983–2010, covering more than two solar cycles, confirms and specifies several previous findings. We show that dH/dt activity is high around the midnight and early morning hours, and nearly vanishes at noon and early afternoon. This happens during all seasons, although the midnight maximum is nearly invisible during summer. As indicated by modelled ionospheric equivalent currents, large dH/dt values occur predominantly during westward ionospheric electrojets. Before and around midnight, dH/dt tends to be north-south oriented, whereas in the morning hours, its direction is more west-east directed. dH/dt tends to be more strictly north-south oriented during winter than other seasons. The seasonal occurrence of large dH/dt values is similar to the variation of the maximum amplitude of westward equivalent currents. The yearly fraction of east-west directed large dH/dt vectors at the Kilpisjärvi station (MLAT 65.88) varies from 31 to 47 % without any clear correlation with the general geomagnetic activity nor with the yearly averages of solar wind parameters.

scholarly journals First Major Practical Step toward Appropriate Antimicrobial Use by the Government of Japan

2019 ◽  
Vol 72 (1) ◽  
pp. 56-57 ◽  
Author(s):  
Hiroki Saito ◽  
Hiroyuki Noda ◽  
Shunji Takakura ◽  
Kazuaki Jindai ◽  
Rieko Takahashi McLellan ◽  
...  
Keyword(s):  
Antimicrobial Use ◽  
The Government ◽  
Appropriate Antimicrobial Use

scholarly journals The Role of Weather during the Greek–Persian “Naval Battle of Salamis” in 480 B.C.

Atmosphere ◽  
2020 ◽  
Vol 11 (8) ◽  
pp. 838 ◽  
Author(s):  
Christos Zerefos ◽  
Stavros Solomos ◽  
Dimitris Melas ◽  
John Kapsomenakis ◽  
Christos Repapis
Keyword(s):  
Sea Breeze ◽  
Weather Conditions ◽  
Early Morning ◽  
Area Of Interest ◽  
Open Sea ◽  
Early Afternoon ◽  
Wind Climatology ◽  
South Sea ◽  
Diurnal Wind

The Battle of Salamis in 480 B.C. is one of the most important naval battles of all times. This work examines in detail the climatically prevailing weather conditions during the Persian invasion in Greece. We perform a climatological analysis of the wind regime in the narrow straits of Salamis, where this historic battle took place, based on available station measurements, reanalysis and modeling simulations (ERA5, WRF) spanning through the period of 1960–2019. Our results are compared to ancient sources before and during the course of the conflict and can be summarized as follows: (i) Our climatological station measurements and model runs describing the prevailing winds in the area of interest are consistent with the eyewitness descriptions reported by ancient historians and (ii) The ancient Greeks and particularly Themistocles must have been aware of the local wind climatology since their strategic plan was carefully designed and implemented to take advantage of the diurnal wind variation. The combination of northwest wind during the night and early morning, converging with a south sea breeze after 10:00 A.M., formed a “pincer” that aided the Greeks at the beginning of the clash in the morning, while it brought turmoil to the Persian fleet and prevented them to escape to the open sea in the early afternoon hours.

scholarly journals Old In Vitro Antimicrobial Breakpoints Are Misleading Stewardship Efforts, Delaying Adoption of Innovative Therapies, and Harming Patients

2020 ◽  
Vol 7 (7) ◽  
Author(s):  
Paul G Ambrose ◽  
Sujata M Bhavnani ◽  
David R Andes ◽  
John S Bradley ◽  
Robert K Flamm ◽  
...  
Keyword(s):  
Antimicrobial Agents ◽  
Economic Viability ◽  
Government Agencies ◽  
Antimicrobial Use ◽  
Biotechnology Company ◽  
Antimicrobial Susceptibility Test ◽  
Perceived Utility ◽  
Innovative Therapies ◽  
Appropriate Antimicrobial Use

Abstract The current antimicrobial market and old (pre-2000) in vitro antimicrobial susceptibility test interpretative criteria (STIC) are not working properly. Malfunctioning susceptibility breakpoints and antimicrobial markets have serious implications for both patients (ie, from a safety and efficacy perspective) and antibiotic-focused pharmaceutical and biotechnology company economic viability. Poorly functioning STIC fail both patients and clinicians since they do not discriminate between likely effective and ineffective antimicrobial regimens. Poor economic viability fails patients and clinicians as it decreases the industry’s ability to develop antimicrobial agents that clinicians and patients urgently require now and in the future. Herein, we review how STIC for older antimicrobial agents were determined and how their correction can impact the perceived utility of old relative to new antimicrobial agents. Moreover, we describe the data and analysis needs to systematically reevaluate older STIC values. We call for professional infectious diseases societies, government agencies, and other consensus bodies interested in the appropriate use of antimicrobial agents to join an effort to systematically evaluate and, where warranted, correct STIC for all relevant antimicrobial agents. This effort will amplify the effects of other measures designed to increase appropriate antimicrobial use (ie, good antimicrobial stewardship), development, and regulation.

Short-term temporal dynamics of yeast abundance on the tall fescue phylloplane

2008 ◽  
Vol 54 (4) ◽  
pp. 299-304 ◽  
Author(s):  
Shannon S. Nix ◽  
Leon L. Burpee ◽  
Kimberly L. Jackson ◽  
James W. Buck
Keyword(s):  
Tall Fescue ◽  
Festuca Arundinacea ◽  
Temporal Dynamics ◽  
Early Morning ◽  
Water Control ◽  
Short Term ◽  
Yeast Community ◽  
Early Afternoon ◽  
Colonization Model ◽  
Phylloplane Yeasts

Six replicate trials were conducted to determine the short-term temporal dynamics and the effects of foliar applications of nutrients on the phylloplane yeast community of tall fescue ( Festuca arundinacea Schreb.). In each trial, 2% sucrose + 0.5% yeast extract solution or sterile deionized water (control) was applied to the experiment plots. Twelve hours post-treatment (at 0600 hours), leaf samples were collected and yeast colony-forming units (cfu) were enumerated by dilution plating. This process was repeated at 1200, 1800, and 2400 hours in each trial. Significant differences were observed between the number of yeast cfu and the time at which the samples were collected. On average, the number of yeast cfu recovered was significantly less at 1800 hours and significantly greatest at 2400 hours when compared with all other sampling times. Averaged over all time intervals, we observed a trend of increased yeast abundance in turf treated with the nutrient solution compared with control treatments. In a separate investigation, atmospheric yeast abundance above the canopy of tall fescue was assessed in the morning (0900) and in the afternoon (1500) using a Thermo Andersen single stage viable particle sampler. In 5 of the 6 trials of this experiment, atmospheric yeast abundance was significantly greater in the morning than in the afternoon. Results suggest the following colonization model: phylloplane yeasts on tall fescue reproduce during the late evening and early morning, stabilize during the late morning and early afternoon through exchange of immigrants and emigrants, and decline during the late afternoon and (or) early evening.

scholarly journals Impact of Changes in Urine Culture Ordering Practice on Antimicrobial Utilization in Intensive Care Units at an Academic Medical Center

2016 ◽  
Vol 37 (4) ◽  
pp. 448-454 ◽  
Author(s):  
Mohamed Sarg ◽  
Greer E. Waldrop ◽  
Mona A. Beier ◽  
Emily L. Heil ◽  
Kerri A. Thom ◽  
...  
Keyword(s):  
Intensive Care ◽  
Urine Culture ◽  
Medical Center ◽  
Academic Medical Center ◽  
Intervention Group ◽  
Antimicrobial Use ◽  
Post Intervention ◽  
Icu Patients ◽  
Antimicrobial Utilization ◽  
Academic Medical

OBJECTIVETo assess antimicrobial utilization before and after a change in urine culture ordering practice in adult intensive care units (ICUs) whereby urine cultures were only performed when pyuria was detected.DESIGNQuasi-experimental studySETTINGA 700-bed academic medical centerPATIENTSPatients admitted to any adult ICUMETHODSAggregate data for all adult ICUs were obtained for population-level antimicrobial use (days of therapy [DOT]), urine cultures performed, and bacteriuria, all measured per 1,000 patient days before the intervention (January–December 2012) and after the intervention (January–December 2013). These data were compared using interrupted time series negative binomial regression. Randomly selected patient charts from the population of adult ICU patients with orders for urine culture in the presence of indwelling or recently removed urinary catheters were reviewed for demographic, clinical, and antimicrobial use characteristics, and pre- and post-intervention data were compared.RESULTSStatistically significant reductions were observed in aggregate monthly rates of urine cultures performed and bacteriuria detected but not in DOT. At the patient level, compared with the pre-intervention group (n=250), in the post-intervention group (n=250), fewer patients started a new antimicrobial therapy based on urine culture results (23% vs 41%, P=.002), but no difference in the mean total DOT was observed.CONCLUSIONA change in urine-culture ordering practice was associated with a decrease in the percentage of patients starting a new antimicrobial therapy based on the index urine-culture order but not in total duration of antimicrobial use in adult ICUs. Other drivers of antimicrobial use in ICU patients need to be evaluated by antimicrobial stewardship teams.Infect. Control Hosp. Epidemiol. 2016;37(4):448–454

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