scholarly journals 83. Impact of a Urine Culture Best Practice Advisory on Collection of Urine Cultures and Subsequent Antibiotic Therapy

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S157-S158
Author(s):  
Logan White ◽  
Andrea Dooley-Wood ◽  
Hien Nguyen ◽  
Aiman Bandali
Keyword(s):  
Antibiotic Therapy ◽  
Adverse Drug Reactions ◽  
Best Practice ◽  
Urine Culture ◽  
Asymptomatic Bacteriuria ◽  
Resistant Bacteria ◽  
Drug Reactions ◽  
Practice Advisory ◽  
Tract Infections ◽  
The Impact

Abstract Background In the acute care setting, urinary tract infections (UTIs) may be over diagnosed in up to 40% of cases. In most scenarios, asymptomatic bacteriuria (ASB) is not an indication for antibiotic therapy; inappropriate therapy is associated with a higher incidence of antibiotic-resistant bacteria and adverse drug reactions. Limiting inappropriate collection of urine cultures may decrease unnecessary treatment of ASB. The objective of this study is to assess the impact of a urine culture best practice advisory (BPA) on collection of unnecessary urine cultures. Methods This retrospective, observational, single-center study included adult inpatients with an order for urinalysis/urine culture. Those who were pregnant, had a concomitant infection other than UTI and/or were taking antimicrobials for a non-UTI indication, and were undergoing urological procedures were excluded. Duplicate urine culture collections and/or admissions were excluded. Incorporation of a BPA into computerized provider order entry, allowing providers to assess need and document indication for urine culture collection, was implemented on July 2019. The following clinical outcomes were assessed: number of unnecessary urine cultures collected, number of antibiotic treatments, and antibiotic-associated adverse reactions. Results Two hundred met criteria for inclusion; 96 in the pre-BPA group (Aug – Oct 2018) and 104 in the post-BPA group (Aug – Oct 2019). Seventy-four (37%) were male and the mean age was 64 and 70 years (p=0.249), respectively. The Charlson Comorbidity Index (CCI) was similar between groups (4 vs. 5, p=0.162) and majority were admitted to a general medical ward (94.5%). Seventy patients (72.9%) in the pre-BPA group and 47 (51.6%) in the post-BPA group had inappropriately ordered urinalysis/urine cultures (OR 0.40; 95% CI 0.22-0.73; p=0.003). Of these patients, 15 (21.4%) and 9 (19.1%) from the pre- and post-BPA groups, respectively, were treated (p=0.077). Among those treated, only two adverse drug reactions were reported. Conclusion Implementation of a BPA significantly reduced the number of inappropriate urinalysis/urine culture orders. There was a trend towards decreased antibiotic use for ASB. Future studies are warranted to assess sustainability of these results. Disclosures All Authors: No reported disclosures

scholarly journals 87. Effectiveness of a Best Practice Advisory in Reducing Inappropriate Urine Cultures

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S159-S159
Author(s):  
Margaret Cooper ◽  
Katherine C Shihadeh ◽  
Cory Hussain ◽  
Timothy C Jenkins
Keyword(s):  
Pregnant Women ◽  
Best Practice ◽  
Urine Culture ◽  
Asymptomatic Bacteriuria ◽  
Urinary Symptoms ◽  
Intervention Period ◽  
Post Intervention ◽  
Absolute Increase ◽  
Practice Advisory ◽  
The Impact

Abstract Background Inappropriate urine cultures can contribute to overutilization of antibiotic treatment for asymptomatic bacteriuria. The objective of this study was to evaluate the appropriateness of urine cultures and the impact of a clinical decision support (CDS) intervention. Methods The CDS intervention involved embedding three questions in the urine culture order: whether the patient has fever, leukocytosis or urinary symptoms. When the answer to all three questions is no, a best practice advisory (BPA) alerts the provider that the patient may not meet criteria for a urine culture and suggests cancellation of the order. Cultures obtained in patients experiencing fever, leukocytosis, or urinary symptoms, and those who were pregnant, undergoing invasive urologic procedure, or < 3 years old were classified as appropriate. We performed a quasi-experimental study assessing appropriateness of urine cultures before and after implementation of the BPA. The pre-intervention period was 5/9/19 to 7/31/20 and the intervention period was 2/3/21 to 4/27/21. Random samples of 100 cases from pre- and post-intervention were reviewed to assess appropriateness. Results There were 12,679 and 8,270 urine cultures performed pre-intervention and post-intervention, respectively. In 100 cases reviewed pre-intervention, 74% of the cultures were appropriate. Of these, 54% were ordered due to fever or leukocytosis, 50% due to urinary symptoms, and 12% in pregnant women. Post-intervention, the BPA fired on 458 orders and 106 (23%) were subsequently discontinued. Of the 100 cases reviewed post-intervention, 5 orders were discontinued after the BPA fired. Of the remaining 95 cultures, 78% were appropriate. Of these, 41% were ordered for fever or leukocytosis, 69% for urinary symptoms, and 11% in pregnant women. The change in the proportion of appropriate cultures pre- and post-intervention was not statistically significant (74% vs 78%, respectively, p=0.906). Conclusion In nearly one quarter of urine cultures performed, there was not an appropriate indication. Our intervention led to cancellation of 23% urine culture orders and resulted in an absolute increase in 4% of the cultures being ordered appropriately. However, the change in appropriateness was not statistically significant. Disclosures All Authors: No reported disclosures

scholarly journals Sustained decrease in urine culture utilization after implementing a reflex urine culture intervention: A multicenter quasi-experimental study

2020 ◽  
Vol 41 (3) ◽  
pp. 369-371 ◽  
Author(s):  
Jessica R. Howard-Anderson ◽  
Shanza Ashraf ◽  
Elizabeth C. Overton ◽  
Lisa Reif ◽  
David J. Murphy ◽  
...  
Keyword(s):  
Experimental Study ◽  
Urinary Tract ◽  
Urine Culture ◽  
Asymptomatic Bacteriuria ◽  
Diagnostic Efficiency ◽  
Urinary Catheters ◽  
Laboratory Findings ◽  
Quasi Experimental ◽  
Tract Infections ◽  
The Impact

Accurately diagnosing urinary tract infections (UTIs) in hospitalized patients remains challenging, requiring correlation of frequently nonspecific symptoms and laboratory findings. Urine cultures (UCs) are often ordered indiscriminately, especially in patients with urinary catheters, despite the Infectious Diseases Society of America guidelines recommending against routine screening for asymptomatic bacteriuria (ASB).1,2 Positive UCs can be difficult for providers to ignore, leading to unnecessary antibiotic treatment of ASB.2,3 Using diagnostic stewardship to limit UCs to situations with a positive urinalysis (UA) can reduce inappropriate UCs since the absence of pyuria suggests the absence of infection.4–6 We assessed the impact of the implementation of a UA with reflex to UC algorithm (“reflex intervention”) on UC ordering practices, diagnostic efficiency, and UTIs using a quasi-experimental design.

scholarly journals 136. Impact of an OPAT Pharmacist on Guideline Adherence and Clinical Outcomes

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S83-S84
Author(s):  
Alice Lin ◽  
Trisha S Nakasone ◽  
Nancy N Nguyen ◽  
Catherine Yang
Keyword(s):  
Antibiotic Therapy ◽  
Adverse Drug Reactions ◽  
Guideline Adherence ◽  
Clinical Cure ◽  
Pharmacist Intervention ◽  
Laboratory Monitoring ◽  
Drug Reactions ◽  
Cure Rates ◽  
The Impact

Abstract Background Outpatient parenteral antibiotic therapy (OPAT) provides select patients a cost-effective alternative to completing intravenous (IV) antibiotic therapy outside the hospital. The Infectious Diseases Society of America (IDSA) OPAT practice guidelines and handbook recommend weekly laboratory monitoring and timely follow-up for OPAT patients. An analysis at VA Palo Alto Healthcare System (VAPAHCS) conducted prior to pharmacist involvement demonstrated that IDSA recommendations were not routinely followed, leading to a clinical cure rate of 62.7%. This led to the implementation of an OPAT pharmacist in 2019. This analysis aims to determine the impact of a pharmacist-managed OPAT program at VAPAHCS. Methods This comparative, retrospective analysis included patients who received OPAT at VAPAHCS between October 1, 2019 and September 30, 2020 and those who received OPAT in a prior analysis. Primary outcomes included rates of adherence to IDSA recommendations on follow-up visits and weekly lab monitoring during OPAT. Secondary outcomes included rates of clinical cure, 90-day readmission, and adverse events or complications. Data was analyzed using Fisher’s exact test and independent t-test. Results This analysis included 74 patients and 76 total OPAT episodes. Bacteremia was the most common diagnosis (n=35, 38.0%), and the most common organism was methicillin-susceptible Staphylococcus aureus (MSSA) (n=23, 29.9%). With respect to guideline adherence pre- and post- pharmacist-managed OPAT, 31.3% versus 93.4% of patients had follow-up within 7 to 14 days of discharge (p< 0.001). Rates of weekly lab monitoring of CBC, BMP, and LFTs pre-pharmacist were 63.2%, 63.3%, and 49.5%, respectively, compared to post-pharmacist rates of 93.0%, 92.1%, and 83.6%, respectively. Clinical cure rates were 62.7% pre-pharmacist and 89.6% post-pharmacist (p< 0.001). More adverse drug reactions were identified in the post-pharmacist period, of which 30% required pharmacist intervention. Figure 1. Weekly Laboratory Monitoring of Antimicrobials (%) Figure 2. Adherence to IDSA Guideline Follow-up Recommendation Figure 3. Rates of Clinical Cure Conclusion Pharmacist involvement in OPAT significantly increased IDSA guideline adherence to lab monitoring and follow-up visits, and clinical cure rates. Identification of adverse drug reactions prompting pharmacist intervention further highlights the importance of follow-up in OPAT patients. Disclosures All Authors: No reported disclosures

scholarly journals 1413. Effect of Automated Identification of Antimicrobial Stewardship Opportunities for Urinary Tract Infections

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S791-S792
Author(s):  
Connor Deri ◽  
Rebekah Wrenn ◽  
Rebekah W Moehring ◽  
Justin Spivey ◽  
Michael E Yarrington
Keyword(s):  
Median Time ◽  
Antimicrobial Stewardship ◽  
Best Practice ◽  
Asymptomatic Bacteriuria ◽  
Clinical Decision ◽  
Automated Identification ◽  
Exact Test ◽  
Increased Risk ◽  
Tract Infections ◽  
The Impact

Abstract Background The treatment of asymptomatic bacteriuria (ASB) does not improve clinical outcomes in most patients and may be associated with an increased risk of adverse events such as Clostridioides difficile infection. A best practice alert (BPA) was created to identify patients with possible ASB for antimicrobial stewardship (AS) review. We aimed to determine whether automated identification of ASB improved the timing of stewardship intervention. Methods An electronic health record BPA message to inpatient AS pharmacists was activated on 01/19/2021. The BPA identified inpatients with a new antibiotic order with an associated genitourinary indication and a preceding urinalysis with 0 to 5 WBC/hpf. BPAs were reviewed by an AS pharmacist during weekdays and normal business hours. We retrospectively evaluated the impact of the BPA on time from order to stewardship intervention between a cohort of pre-BPA (01/2020 to 12/2020) and post-BPA (01/20/2021 to 04/10/2021) patients. Included patients met the BPA criteria and had an AS intervention within 7 days of the antibiotic order. We specified interventions that were UTI-related. The median time from antibiotic order entry to any AS intervention was compared pre- to post-BPA using the Mann Whitney U test. Rates of UTI-related interventions were compared with Fisher’s Exact test. Results 327 antibiotic orders met BPA criteria and were analyzed: 245 and 82 in the pre- and post-BPA group, respectively. Groups had similar baseline characteristics (Table 1). A total of 33 (27 UTI-related) pre-BPA group and 24 (17 UTI-related) post-BPA group interventions were documented by the AS team. The median time to any intervention was 28 hours (IQR 18-64.5) in the pre-BPA group compared to 13.5 hours (IQR 3.5-28.75) in the post-BPA group (p = 0.03, Figure). The pre-BPA group had a lower rate of UTI-related interventions compared to the post-BPA group (11.0% vs 20.7%, p = .04). Conclusion Automated identification of antibiotics targeting UTI with urinalysis showing absence of pyuria reduced the time to stewardship intervention and increased rate of UTI-specific interventions. The use of clinical decision support may aid in efficiency of AS review and syndrome-targeted AS impact. Disclosures Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties)

Impact of a Best Practice Advisory for Pediatric Patients With Staphylococcus aureus Bacteremia

2020 ◽  
Author(s):  
Elizabeth C Lloyd ◽  
Emily T Martin ◽  
Nicholas Dillman ◽  
Jerod Nagel ◽  
Robert Chang ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Antibiotic Therapy ◽  
Best Practice ◽  
Cox Regression ◽  
Meca Gene ◽  
Optimal Therapy ◽  
Its Analysis ◽  
Staphylococcus Aureus Bacteremia ◽  
Practice Advisory ◽  
The Impact

Abstract Background Infectious diseases (ID) consultation and optimal antibiotic therapy improve outcomes in Staphylococcus aureus bacteremia (SAB). Data on strategies to improve adherence to these practices in children are limited. Methods This was a quasi-experimental study evaluating the impact of an electronic medical record (EMR)–based best practice advisory (BPA) for SAB, recommending ID consult and optimal antibiotic therapy based on rapid mecA gene detection. Inpatients < 21 years old with SAB before (January 2015–July 2017) and after (August 2017–December 2018) BPA implementation were included. Primary outcome was receipt of ID consult. Secondary outcomes included receipt of optimal therapy, time to ID consult and optimal therapy, recurrent SAB, and 30-day all-cause mortality. ID consultation rates pre- and postimplementation were compared using interrupted time series (ITS) analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) for time to optimal therapy were calculated using Cox regression. Results We included 99 SAB episodes (70 preintervention, 29 postintervention). Preintervention, 48 (68.6%) patients received an ID consult compared to 27 (93.1%) postintervention, but this was not statistically significant on ITS analysis due to a preexisting trend of increasing consultation. Median hours to optimal therapy decreased from 26.1 to 5.5 (P = .03), most notably in patients with methicillin-sensitive S. aureus (MSSA) (42.2 to 10.8; P < .01). On Cox regression, BPA implementation was associated with faster time to optimal therapy (HR, 3.22 [95% CI, 1.04–10.01]). Conclusions Implementation of an EMR-based BPA for SAB resulted in faster time to optimal antibiotic therapy, particularly for patients with MSSA. ID consultation increased throughout the study period and was not significantly impacted by the BPA.

scholarly journals Patient-reported effectiveness and safety of Pamidronate in NSAIDs-refractory chronic recurrent multifocal osteomyelitis in children

2021 ◽  
Author(s):  
Bartłomiej Juszczak ◽  
Jerzy Sułko
Keyword(s):  
Adverse Drug Reactions ◽  
Social Life ◽  
Chronic Recurrent Multifocal Osteomyelitis ◽  
Daily Activities ◽  
Drug Reactions ◽  
Patient Reported ◽  
Multifocal Osteomyelitis ◽  
Drug Dependent ◽  
Treatment Onset ◽  
The Impact

AbstractTo evaluate patient-reported effectiveness, safety and social influence of Pamidronate in the therapy of NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis in children. Authors reviewed self-created questionnaires, which asked patients for symptoms alleviation, adverse drug reactions frequency and degree of severity and daily activities self-reliance. Only surveys with complete answers, which were returned to authors by an e-mail from juvenile patients treated for NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at the University Children’s Hospital of Cracow were analyzed. Between 2010 and 2019, 61 children were diagnosed with NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at our department. Out of 61 requests sent, 42 complete replies (33 females, 9 males) were gathered and analyzed. All patients included in this research were administered with at least one set of Pamidronate intravenously in the dose of 1 mg/kg/day for 3 consecutive days. Our analysis shows remarkable in terms of patient’s impressions decrease of pain intensity after 2.5 series of Pamidronate on average, and total pain resolution after 5.9 series on average. Overall number of adverse drug reaction events reported by responders was 105. One patient developed drug-dependent renal insufficiency in the course of therapy. Outcome assessment indicates that nearly 50% of the studied population was more eager to participate in social life just after the first infusion of the drug. 95% of the surveyed unanimously agreed to recommend Pamidronate therapy to cure NSAIDs-refractory CRMO. 39 out of 42 (93%) patients considered Pamidronate effective at the end of the treatment. Onset of Pamidronate’s action is gradual and differs in terms of symptoms alleviation between sexes. The therapy can induce considerable number of adverse drug reactions (2.5 per patient). Only 3 out of 42 (7%) patients were free from any ADRs. To demonstrate the impact of the use of Pamidronate on daily activities more precisely, further research with quantification of the quality of life is warranted.

scholarly journals Catheter-Associated Urinary Tract Infections (CAUTIs) Reduction: A Multidisciplinary Approach

2020 ◽  
Vol 41 (S1) ◽  
pp. s154-s154
Author(s):  
Hanish Jain ◽  
Elizabeth Hartigan ◽  
Joseph Tschopp ◽  
Paul Suits ◽  
Kristopher Paolino
Keyword(s):  
Best Practice ◽  
Registered Nurse ◽  
Urine Analysis ◽  
Urine Culture ◽  
Care Center ◽  
Foley Catheter ◽  
Tertiary Care ◽  
Culture Collection ◽  
Institutional Cost ◽  
Tract Infections

Background: CAUTIs remain one of the most common hospital-acquired infections (HAIs) accounting for prolonged hospital stay and increased healthcare costs. According to the NHSN, the standardized infection ratio (SIR) at our institution was 1.6 compared to national average of 0.84 in 2018. We highlight the interventions implemented in our institution to prevent CAUTIs. These interventions have shown a reduction in the rate of CAUTIs, the SIR, Foley catheter days, and institutional cost. Methods: In addition to standard CAUTI prevention practices, we hypothesized that we could decrease CAUTIs through the daily implementation of specific practices. We developed a comprehensive interdisciplinary team which included the staff or charge registered nurse (RN), the unit manager, an infection preventionist, an advanced practice registered nurse (APRN), a pharmacist with an antimicrobial focus, and a physician from the infectious disease department who would conduct daily rounds on different units in the institution for education and assessment of catheter indications. A detailed review and analysis of the urine culture orders for patients with a Foley catheter was performed. A nurse-driven Foley catheter removal protocol before urine culture collection was initiated. We implemented a Foley catheter bundle that has guidelines for Foley insertion, best practice competency, and urinary catheter best practice algorithm and advocated alternative use of male or female external catheter. We educated physicians about ordering a reflexive urine analysis test followed by urine culture instead of testing either individually after removal of a Foley catheter. Lastly, we performed a root-cause analysis on all reported CAUTIs. These policies were implemented in a 435-bed tertiary-care center in November 2018, and we present data from 1-year before and after the interventions. Results: At our institution, we had 71 CAUTIs, with an SIR of 1.6, a standardized utilization ratio (SUR) of 0.92, 27,621 Foley days, and institutional cost of $979,303 compared to 40 CAUTIs with an SIR of 1, an SUR of 0.88, 24,193 Foley days, and institutional cost $537,927 after implementing our interventions. Conclusions: CAUTIs can be reduced by implementing specific measures that include infection control team rounds, nurse-driven protocol, and the use of Foley catheter bundles. Measures should be undertaken to prioritize these practices as part of a protocol. We advocate further studies to evaluate these measures. Education programs for healthcare professionals concerning CAUTIs and its complications can be implemented to carry out the prevention methods efficiently.Funding: NoneDisclosures: None

scholarly journals Polymyxins Nebulization over Intravenous Injection: Pharmacokinetics and Pharmacodynamics-Based Therapeutic Evaluation

2019 ◽  
pp. 1-10
Author(s):  
Md. Jahidul Hasan
Keyword(s):  
Respiratory Tract ◽  
Adverse Drug Reactions ◽  
Intravenous Administration ◽  
Polymyxin B ◽  
Multidrug Resistant ◽  
Drug Reactions ◽  
Pharmacokinetics And Pharmacodynamics ◽  
Gram Negative ◽  
Tract Infections

Polymyxins are the last line potential antibiotics against multi-drug resistant gram-negative bacteria and consist of two sister antibiotics: Polymyxin B and colistin (polymyxin E). Intravenous use of polymyxins was started from a long ago in the treatment of serious gram-negative infections and once their uses were restricted due to potential adverse drug reactions, such as nephrotoxicity and neurotoxicity. Lack of in vivo clinical studies on polymyxins mostly, in human body makes the pharmacokinetics and pharmacodynamics of polymyxin B and colistin unclear in many aspects, such as the distribution of polymyxins in different compartments of lung. The nebulization of polymyxins is practicing very limitedly and lack of clinical evidence has not justified this administration technique yet properly to date. The main objective of this review study was to evaluate the pharmacokinetic and pharmacodynamic properties of intravenous and nebulized polymyxins and the related therapeutic potentialities. Aerosolized polymyxins directly administered to the respiratory tract was found with higher drug concentration in different subcompartments of lungs than the intravenous administration and sustainably meets the minimum inhibitory concentration locally with superior bactericidal properties in respiratory tract infections. In contrast, intravenous administration of polymyxins shows similar anti-infective superiority in other organs, such as blood, urinary tract etc. So, during this alarming situation of rapidly emerging multidrug-resistant organisms in human communities, therapeutic administration techniques of last resort polymyxins should be clinically evidence-based for achieving optimum therapeutic outcomes with minimum chance of adverse drug reactions.  

scholarly journals Body Weight as a Determining Factor in the Predominance of Adverse Drug Reactions Induced by Fixed-Dose Adalimumab Injections in Female Patients in a Korean Hospital Setting

2020 ◽  
Vol 9 (2) ◽  
pp. 461
Author(s):  
Kwi Suk Kim ◽  
Young Hee Choi ◽  
Aree Moon ◽  
Sang Geon Kim
Keyword(s):  
Body Weight ◽  
Adverse Drug Reactions ◽  
Laboratory Data ◽  
Fixed Dose ◽  
Drug Reactions ◽  
Female Patients ◽  
Adalimumab Therapy ◽  
Male Patients ◽  
The Impact ◽  
Determining Factor

Adalimumab is used at 40-mg dose to treat systemic inflammatory diseases. Given the impact of adverse drug reactions (ADRs), which particularly result in the discontinuation of adalimumab therapy in female patients, this study examined whether sex affects the frequency and type of ADRs induced by adalimumab. In this study, the prescription records and laboratory data of patients aged ≥19 years who had been admitted to the Seoul National University Hospital (SNUH) and prescribed adalimumab were analyzed using an electronic medical record database. The analysis revealed that female patients more frequently experienced adalimumab-induced ADRs compared with male patients (63.2% vs. 52.2%). The incidence of ADRs was significantly higher in female patients with ankylosing spondylitis or rheumatoid arthritis than in male patients with similar conditions (81.5% vs. 60.7% or 64.4% vs. 50.0%, respectively). The median body weight (BW) was lower in female patients than in male patients (54.0 vs. 66.0 kg). Moreover, the incidence of ADRs in patients with a BW of <54.0 kg (i.e., the median female BW) was higher than for those with a BW of ≥54.0 kg, in both males and females. Our results suggested that the predominance of ADRs induced by adalimumab in females was because of their relatively lower BW. This suggests the importance of BW as a determining factor in sex disparity of ADR occurrences.

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