scholarly journals 49. Impact of a Rapid Genotypic Platform for Gram-negative Bloodstream Infections, Paired with an Antimicrobial Stewardship Intervention, on Time to Optimal Antimicrobial Therapy

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S145-S145
Author(s):  
Madison Donnelly ◽  
Jennifer Walls ◽  
Katlyn Wood ◽  
Aiman Bandali
Keyword(s):  
Length Of Stay ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Intervention Group ◽  
Bloodstream Infections ◽  
Post Intervention ◽  
Gram Negative ◽  
E Coli ◽  
Optimal Therapy ◽  
The Impact

Abstract Background Gram-negative bacteremia is associated with significant morbidity and mortality. Development of an algorithm for antimicrobial selection, using institution-specific antibiogram data and rapid diagnostics (RDT), achieves timely and appropriate antimicrobial therapy. The objective of this study is to assess the impact of a pharmacy-driven antimicrobial stewardship initiative in conjunction with ePlex® BCID on time to optimal antimicrobial therapy for patients with gram-negative bloodstream infections. Methods This retrospective, observational, single-center study included adult patients with a documented gram-negative bloodstream infection in whom the ePlex® BCID was employed. A pharmacist-driven antimicrobial stewardship intervention was initiated on December 1, 2020; pre-intervention (December 2019 – March 2020) was compared to the post-intervention (December 2020 – February 2020) period. The following organisms were included: Citrobacter spp., Escherichia coli, Klebsiella aerogenes/pneumoniae/oxytoca, Proteus spp, Enterobacter spp., Pseudomonas aeruginosa, and Acinetobacter baumannii. Polymicrobial bloodstream infections or those who had an ePlex® panel performed prior to admission were excluded. The following clinical outcomes were assessed: time to optimal antimicrobial therapy, length of stay (LOS), and inpatient-30-day mortality. Results One hundred and sixty-three met criteria for inclusion; 98 patients in the pre-intervention group and 65 patients in the post-intervention group. The mean Pitt Bacteremia Score was 1 in both groups (p=0.741). The most common organism identified by ePlex® BCID was E. coli (65.3% vs 70.8%; p=0.676). Eight E. Coli isolates were CTX-M positive; no other gene targets were detected. The most common suspected source of bacteremia was genitourinary (72.5% vs 72.3%; p=1.0). Time to optimal therapy was reduced by 29 hours [37 (31 – 55) vs. 8 (4 – 28); p=0.048). Length of stay and mortality was similar between groups. Conclusion Implementation of a rapid blood culture identification panel along with an antimicrobial stewardship intervention significantly reduced time to optimal therapy. Further studies are warranted to confirm these results. Disclosures All Authors: No reported disclosures

scholarly journals Implementation of a Rapid Phenotypic Susceptibility Platform for Gram-Negative Bloodstream Infections With Paired Antimicrobial Stewardship Intervention: Is the Juice Worth the Squeeze?

2021 ◽  
Author(s):  
Evan D Robinson ◽  
Allison M Stilwell ◽  
April E Attai ◽  
Lindsay E Donohue ◽  
Megan D Shah ◽  
...  
Keyword(s):  
Median Time ◽  
Antimicrobial Stewardship ◽  
A Priori ◽  
Bloodstream Infections ◽  
Standard Of Care ◽  
Post Intervention ◽  
Gram Negative ◽  
Stewardship Program ◽  
Days Of Therapy ◽  
The Impact

Abstract Background Implementation of the Accelerate PhenoTM Gram-negative platform (RDT) paired with antimicrobial stewardship program (ASP) intervention projects to improve time to institutional-preferred antimicrobial therapy (IPT) for Gram-negative bacilli (GNB) bloodstream infections (BSIs). However, few data describe the impact of discrepant RDT results from standard of care (SOC) methods on antimicrobial prescribing. Methods A single-center, pre-/post-intervention study of consecutive, nonduplicate blood cultures for adult inpatients with GNB BSI following combined RDT + ASP intervention was performed. The primary outcome was time to IPT. An a priori definition of IPT was utilized to limit bias and to allow for an assessment of the impact of discrepant RDT results with the SOC reference standard. Results Five hundred fourteen patients (PRE 264; POST 250) were included. Median time to antimicrobial susceptibility testing (AST) results decreased 29.4 hours (P < .001) post-intervention, and median time to IPT was reduced by 21.2 hours (P < .001). Utilization (days of therapy [DOTs]/1000 days present) of broad-spectrum agents decreased (PRE 655.2 vs POST 585.8; P = .043) and narrow-spectrum beta-lactams increased (69.1 vs 141.7; P < .001). Discrepant results occurred in 69/250 (28%) post-intervention episodes, resulting in incorrect ASP recommendations in 10/69 (14%). No differences in clinical outcomes were observed. Conclusions While implementation of a phenotypic RDT + ASP can improve time to IPT, close coordination with Clinical Microbiology and continued ASP follow up are needed to optimize therapy. Although uncommon, the potential for erroneous ASP recommendations to de-escalate to inactive therapy following RDT results warrants further investigation.

Automated Alerts Coupled with Antimicrobial Stewardship Intervention Lead to Decreases in Length of Stay in Patients with Gram-Negative Bacteremia

2014 ◽  
Vol 35 (2) ◽  
pp. 132-138 ◽  
Author(s):  
Jason M. Pogue ◽  
Ryan P. Mynatt ◽  
Dror Marchaim ◽  
Jing J. Zhao ◽  
Viktorija O. Barr ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Blood Culture ◽  
Antimicrobial Stewardship ◽  
Positive Blood Culture ◽  
Medical Center ◽  
Intervention Group ◽  
Gram Negative ◽  
Gram Negative Bacteremia ◽  
Appropriate Therapy ◽  
The Impact

Objective.To assess the impact of active alerting of positive blood culture data coupled with stewardship intervention on time to appropriate therapy, length of stay, and mortality in patients with gram-negative bacteremia.Design.Quasi-experimental retrospective cohort study in patients with gram-negative bacteremia at the Detroit Medical Center from 2009 to 2011.Setting.Three hospitals (1 community, 2 academic) with active antimicrobial stewardship programs within the Detroit Medical Center.Patients.All patients with monomicrobial gram-negative bacteremia during the study period.Intervention.Active alerting of positive blood culture data coupled with stewardship intervention (2010-2011) compared with patients who received no formalized stewardship intervention (2009).Results.Active alerting and intervention led to a decreased time to appropriate therapy (8 [interquartile range (IQR), 2-24] vs 14 [IQR, 2-35] hours; P = .014) in patients with gram-negative bacteremia. After controlling for differences between groups, being in the intervention arm was associated with an independent reduction in length of stay (odds ratio [OR], 0.73 [95% confidence interval (CI), 0.62-0.86]), correlating to a median attributable decrease in length of stay of 2.2 days. Additionally, multivariate modeling of patients who were not on appropriate antimicrobial therapy at the time of initial culture positivity showed that patients in the intervention group had a significant reduction in both length of stay (OR, 0.76 [95% CI, 0.66-0.86]) and infection-related mortality (OR, 0.24 [95% CI, 0.08-0.76]).Conclusions.Active alerting coupled with stewardship intervention in patients with gram-negative bacteremia positively impacted time to appropriate therapy, length of stay, and mortality and should be a target of antimicrobial stewardship programs.

scholarly journals 1998. Impact of Rapid Blood Culture Identification with Real-Time Antimicrobial Stewardship (ASP) in Patients with Staphylococcus aureus (S. aureus) and Enterococcus spp. Bacteremia at a Large Academic Medical Center

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S670-S670
Author(s):  
Hannah Ryan Russo ◽  
Kady Phe ◽  
Mayar Al Mohajer ◽  
Jessica Hirase
Keyword(s):  
Blood Culture ◽  
Real Time ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Intervention Group ◽  
Active Therapy ◽  
Post Intervention ◽  
Optimal Therapy ◽  
Enterococcus Spp ◽  
Culture Identification

Abstract Background The initiation of appropriate antimicrobial therapy is dependent on timely identification of the pathogen. FilmArray Blood Culture Identification Panel (BCID) is a rapid, multiplex polymerase chain reaction (PCR) panel that identifies 24 pathogens and 3 antibiotic resistance genes associated with bloodstream infections within 1 hour of growth. The purpose of this study was to compare the clinical impact of rapid BCID testing vs. standard blood culture processing, both coupled with real-time ASP, in patients with S. aureus and Enterococcus spp. bacteremia. Methods This was a single-center, retrospective chart review conducted as a pre-post intervention quasi-experimental study. The pre-intervention group included adult patients with S.aureus and Enterococcus spp. bacteremia identified by standard blood culture processing (PRE) and the post-intervention group included those identified by rapid BCID testing (POST). The primary endpoint was time in hours from positive Gram stain to initiation of optimal antimicrobial therapy [defined as vancomycin (VAN), linezolid (LZD), daptomycin (DAP), or ceftaroline for methicillin-resistant S. aureus (MRSA); nafcillin or cefazolin for methicillin-susceptible S. aureus (MSSA); DAP or LZD for VAN-resistant Enterococcus (VRE); VAN or ampicillin (if susceptible) for VAN-susceptible Enterococcus (VSE)]. Secondary endpoints included time to active therapy (defined as an antimicrobial to which the organism was susceptible), time to identification of pathogen, length of hospital stay (LOS) after positive culture, and 30-day mortality. Results 132 patients were included. Mean time to optimal therapy decreased from 21.4 hours PRE to 10.7 hours POST (P = 0.048). Time to optimal therapy was shorter POST for MSSA [59.2 hours PRE vs. 25.8 hours POST (P < 0.001)] and VRE bacteremia [24.6 hours PRE vs. 5.6 hours POST (P = 0.005)]. Time to identification of pathogen decreased from 75.6 hours PRE to 2.7 hours POST (P < 0.001). Groups did not differ in time to active therapy, LOS, nor 30-day mortality. Conclusion Antimicrobial Stewardship coupled with rapid BCID testing significantly decreased time to pathogen identification as well as time to optimal therapy in patients with S. aureus and Enterococcus spp. bacteremia, most notably for MSSA and VRE. Disclosures All authors: No reported disclosures.

scholarly journals 192. Augmenting Utility of Rapid Diagnostic Testing in Treatment of Gram-Negative Bacteremia with Stewardship Intervention

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S115-S116
Author(s):  
Jessica Gerges ◽  
Karan Raja ◽  
Mitesh Patel ◽  
Ruben Patel ◽  
Brandon Chen ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Diagnostic Testing ◽  
Intervention Group ◽  
Bloodstream Infections ◽  
Resistance Marker ◽  
Post Intervention ◽  
Predictive Values ◽  
Gram Negative ◽  
E Coli ◽  
Days Of Therapy

Abstract Background Rapid diagnostic tests (RDT) can identify pathogens in bloodstream infections (BSI) in less than 24 hours. Our institution utilizes an RDT for blood cultures (BCx) that can detect various organisms and resistance determinants. A retrospective evaluation conducted in our institution calculated the negative predictive values (NPV) of various Gram-negative pathogens and susceptibility to target antimicrobials in the absence of detected resistance markers. Resultant NPV >90% for E. coli and K. pneumoniae to ceftriaxone support use of RDT with stewardship intervention for more rapid de-escalation of antimicrobial therapy in patients with resistance marker-negative BSI. Methods In our facility, all positive BCx are processed through RDT. In the post-intervention group, pharmacists monitored RDT results and provided recommendations. Our IRB-approved, prospective study assessed time to antimicrobial de-escalation in treatment of resistance marker-negative E. coli and K. pneumoniae BSI before (January 1 to December 31, 2018) and after Stewardship intervention (January 1 to March 31, 2019). Secondary outcomes included days of therapy (DOT) of target narrow-spectrum β-lactams, carbapenems, and non-carbapenem anti-pseudomonal (NCAP) β-lactams, length of stay (LOS), and treatment failure. Data were analyzed using the Fisher exact or Chi-square and t-test for categorical and continuous data, respectively. Results Of the 12,893 evaluated RDT results in the pre-intervention group and 2,238 post intervention, 41 and 12 patients met inclusion criteria, respectively. Baseline characteristics were similar in both groups. Time to de-escalation to a target agent was decreased by 24 hours after stewardship intervention (50 v 74.6 hours) (P = 0.14). There were no statistically significant differences in DOTs for target agents (5.19 v 5.25 DOT; P = 0.48), carbapenems (1.29 v 1.08 DOT; P = 0.41), or NCAP β-lactams (1.73 v 2.33; P = 0.25). Treatment failure (2 in each group; P = 0.17) and LOS (10.9 v 11.9 days; P = 0.4) were similar between groups. Protocol compliance and intervention acceptance rate was approximately 60%. Conclusion Appreciation of NPVs and utilization of stewardship intervention allowed for early de-escalation of empiric therapy in patients with resistance marker-negative E. coli and K. pneumoniae bacteremia. Disclosures All authors: No reported disclosures.

scholarly journals Cumulative Effect of an Antimicrobial Stewardship and Rapid Diagnostic Testing Bundle on Early Streamlining of Antimicrobial Therapy in Gram-Negative Bloodstream Infections

2017 ◽  
Vol 61 (9) ◽  
Author(s):  
P. B. Bookstaver ◽  
E. B. Nimmich ◽  
T. J. Smith ◽  
J. A. Justo ◽  
J. Kohn ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Phase 1 ◽  
Bloodstream Infections ◽  
Antimicrobial Stewardship Program ◽  
Phase 2 ◽  
Beta Lactams ◽  
Gram Negative ◽  
Stewardship Program ◽  
Tof Ms

ABSTRACT The use of rapid diagnostic tests (RDTs) enhances antimicrobial stewardship program (ASP) interventions in optimization of antimicrobial therapy. This quasi-experimental cohort study evaluated the combined impact of an ASP/RDT bundle on the appropriateness of empirical antimicrobial therapy (EAT) and time to de-escalation of broad-spectrum antimicrobial agents (BSAA) in Gram-negative bloodstream infections (GNBSI). The ASP/RDT bundle consisted of system-wide GNBSI treatment guidelines, prospective stewardship monitoring, and sequential introduction of two RDTs, matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and the FilmArray blood culture identification (BCID) panel. The preintervention period was January 2010 through December 2013, and the postintervention period followed from January 2014 through June 2015. The postintervention period was conducted in two phases; phase 1 followed the introduction of MALDI-TOF MS, and phase 2 followed the introduction of the FilmArray BCID panel. The interventions resulted in significantly improved appropriateness of EAT (95% versus 91%; P = 0.02). Significant reductions in median time to de-escalation from combination antimicrobial therapy (2.8 versus 1.5 days), antipseudomonal beta-lactams (4.0 versus 2.5 days), and carbapenems (4.0 versus 2.5 days) were observed in the postintervention compared to the preintervention period (P < 0.001 for all). The reduction in median time to de-escalation from combination therapy (1.0 versus 2.0 days; P = 0.03) and antipseudomonal beta-lactams (2.2 versus 2.7 days; P = 0.04) was further augmented during phase 2 compared to phase 1 of the postintervention period. Implementation of an antimicrobial stewardship program and RDT intervention bundle in a multihospital health care system is associated with improved appropriateness of EAT for GNBSI and decreased utilization of BSAA through early de-escalation.

scholarly journals Evaluation of the impact of the Accelerate Pheno™ system on time to result for differing antimicrobial stewardship intervention models in patients with gram-negative bloodstream infections

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Gerald Elliott ◽  
Michael Malczynski ◽  
Viktorjia O. Barr ◽  
Doaa Aljefri ◽  
David Martin ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Bloodstream Infections ◽  
Standard Of Care ◽  
Resistance Mechanisms ◽  
Gram Negative ◽  
Intervention Models ◽  
Gram Negative Bacteremia ◽  
Potential Impact ◽  
Potential Clinical Impact ◽  
The Impact

Abstract Background Initiating early effective antimicrobial therapy is the most important intervention demonstrated to decrease mortality in patients with gram-negative bacteremia with sepsis. Rapid MIC-based susceptibility results make it possible to optimize antimicrobial use through both escalation and de-escalation. Method We prospectively evaluated the performance of the Accelerate Pheno™ system (AXDX) for identification and susceptibility testing of gram-negative species and compared the time to result between AXDX and routine standard of care (SOC) using 82 patient samples and 18 challenge organisms with various confirmed resistance mechanisms. The potential impact of AXDX on time to antimicrobial optimization was investigated with various simulated antimicrobial stewardship (ASTEW) intervention models. Results The overall positive and negative percent agreement of AXDX for identification were 100 and 99.9%, respectively. Compared to VITEK® 2, the overall essential agreement was 96.1% and categorical agreement was 95.4%. No very major or major errors were detected. AXDX reduced the time to identification by an average of 11.8 h and time to susceptibility by an average of 36.7 h. In 27 patients evaluated for potential clinical impact of AXDX on antimicrobial optimization, 18 (67%) patients could potentially have had therapy optimized sooner with an average of 18.1 h reduction in time to optimal therapy. Conclusion Utilization of AXDX coupled with simulated ASTEW intervention notification substantially shortened the time to potential antimicrobial optimization in this cohort of patients with gram-negative bacteremia. This improvement in time occurred when ASTEW support was limited to an 8-h coverage model.

scholarly journals 102. Effects of an Antimicrobial Stewardship-guided MRSA Nasal Screening Review on Vancomycin Utilization for Respiratory Infections: A Quasi-Experimental Study

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S65-S65
Author(s):  
Ross Pineda ◽  
Meganne Kanatani ◽  
Jaime Deville
Keyword(s):  
Antimicrobial Stewardship ◽  
Respiratory Infections ◽  
Intervention Group ◽  
Small Sample ◽  
Post Intervention ◽  
Predictive Values ◽  
Days Of Therapy ◽  
Significant Difference ◽  
Quasi Experimental ◽  
The Impact

Abstract Background Methicillin-resistant Staphylococcus aureus (MRSA) remains a significant pathogen in patients with respiratory infections. Guidelines recommend empiric MRSA coverage in patients at increased risk, resulting in substantial vancomycin use. Recent literature highlights the use of MRSA nasal assays as a rapid screening tool for MRSA pneumonia, demonstrating high negative predictive values and allowing for shorter empiric coverage. We aimed to evaluate the impact of MRSA nasal screening review by the antimicrobial stewardship program (ASP) on vancomycin utilization for respiratory infections. Methods This was a retrospective, quasi-experimental, pre-post intervention study. The intervention saw the addition of an MRSA screening review tool into the ASP electronic record, highlighting patients on vancomycin (actively or recently administered) with a negative MRSA screening. Vancomycin days of therapy (DOT) was collected for all orders indicated for a respiratory infection in the two weeks following a negative screening. Additional outcomes include vancomycin total dose and DOT per 1,000 patient days. Outcomes were compared via independent samples t-tests. Results 1,110 MRSA screenings resulted across 2 months, of which the majority were excluded for either not having vancomycin ordered, or for having vancomycin ordered for a non-respiratory indication, leaving 37 and 35 evaluable screenings in the pre- and post-intervention groups, respectively. Regarding vancomycin DOT, we did not identify a significant difference between pre- and post-intervention groups with respective means of 2.45 (SD=1.52) and 2.14 (SD=1.12) (p=0.35). We identified a total 8.78 vancomycin DOT per 1,000 patient days in the pre-intervention group versus 6.69 in the post-intervention group. Conclusion ASP-guided review of MRSA screenings was associated with a nonsignificant decrease in mean vancomycin DOT and lower total DOT per 1,000 patient days for respiratory infections following a negative screen. Given the recent implementation of our intervention, our analysis covered a small sample size, highlighting the need for continued data collection. MRSA screenings are not always fully or immediately utilized in our institution, demonstrating room to de-escalate MRSA-targeted antibiotics. Disclosures All Authors: No reported disclosures

scholarly journals 1043. Evaluation of Early Clinical Failure Criteria for Gram-Negative Bloodstream Infections

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S311-S312
Author(s):  
Hana Rac ◽  
Alyssa Gould ◽  
P Brandon Bookstaver ◽  
Julie Ann Justo ◽  
Joseph Kohn ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Antimicrobial Therapy ◽  
Bloodstream Infections ◽  
Failure Criteria ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Clinical Failure ◽  
Gram Negative ◽  
Additional Criterion ◽  
Prolonged Hospitalization

Abstract Background Early identification of patients at high risk of morbidity and mortality following Gram-negative bloodstream infections (GN-BSI) based on initial clinical course may prompt adjustments to optimize diagnostic and treatment plans. This retrospective cohort study aims to develop early clinical failure criteria (ECFC) to predict unfavorable outcomes in patients with GN-BSI. Methods Adults with community-onset GN-BSI who survived hospitalization for at least 96 hours at Palmetto Health hospitals in Columbia, SC, USA from January 1, 2010 to June 30, 2015 were identified. Multivariate logistic regression was used to examine association between clinical variables within 72–96 hours of BSI and unfavorable outcomes (28-day mortality or hospital length of stay &gt;14 days). Results Among 766 patients with GN-BSI, 225 (29%) had unfavorable outcomes. After adjustments for Charlson Comorbidity Index and appropriateness of empirical antimicrobial therapy in multivariate model, predictors of unfavorable outcomes included systolic blood pressure &lt;100 mmHg or vasopressor use (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1–2.5), heart rate &gt;100/minute (aOR 1.7, 95% CI 1.1–2.5), respiratory rate ≥22/minute or mechanical ventilation (aOR 2.1, 95% CI 1.4–3.3), altered mental status (aOR 4.5, 95% CI 2.8–7.1), and peripheral WBC count &gt;12 × 103/mm3 (aOR 2.7, 95% CI 1.8–4.1) at 72–96 hours from index BSI. Area under receiver operating characteristic curve of ECFC model in predicting unfavorable outcomes was 0.77 (0.84 and 0.71 in predicting 28-day mortality and prolonged hospitalization separately, respectively). Predicted 28-day mortality increased from 1% in patients with no ECFC to 3%, 7%, 16%, 32%, and 54% in presence of each additional criterion (P &lt; 0.001). Predicted hospital length of stay was 7.5 days in patients without any ECFC and increased by 4.0 days (95% CI 3.1–4.9, P &lt; 0.001) in presence of each additional criterion. Conclusion Risk of 28-day mortality or prolonged hospitalization can be estimated within 72–96 hours of GN-BSI using ECFC. These criteria may have utility in future clinical research in assessing response to antimicrobial therapy based on a standard evidence-based definition of early clinical failure. Disclosures P. B. Bookstaver, CutisPharma: Scientific Advisor, &lt;$1,000. Melinta Therapeutics: Speaker’s Bureau, &lt;$1,000.

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