Antimicrobial Stewardship Program for Broad-Spectrum Oral Antibiotic Use in a Pediatric Emergency Department: an Interrupted Time-Series Analysis

Background: Automatic discontinuation of antimicrobial orders after a prespecified duration of therapy has been adopted as a strategy for reducing excess days of therapy (DOT) as part of antimicrobial stewardship efforts. Automatic stop orders have been shown to decrease antimicrobial DOT. However, inadvertent treatment interruptions may occur as a result, potentially contributing to adverse patient outcomes. To evaluate the effects of this practice, we examined the impact of the removal of an electronic 7-day ASO program on hospitalized patients. Methods: We performed a quasi-experimental study on inpatients in 3 acute-care academic hospitals. In the preintervention period (automatic stop orders present; January 1, 2016, to February 28, 2017), we had an electronic dashboard to identify and intervene on unintentionally missed doses. In the postintervention period (April 1, 2017, to March 31, 2018), the automatic stop orders were removed. We compared the primary outcome, DOT per 1,000 patient days (PD) per month, for patients in the automatic stop orders present and absent periods. The Wilcoxon rank-sum test was used to compare median monthly DOT/1,000 PD. Interrupted time series analysis (Prais-Winsten model) was used to compared trends in antibiotic DOT/1,000 PD and the immediate impact of the automatic stop order removal. Manual chart review on a subset of 300 patients, equally divided between the 2 periods, was performed to assess for unintentionally missed doses. Results: In the automatic stop order period, a monthly median of 644.5 antibiotic DOT/1,000 PD were administered, compared to 686.2 DOT/1,000 PD in the period without automatic stop orders (P < .001) (Fig. 1). Using interrupted time series analysis, there was a nonsignificant increase by 46.7 DOT/1,000 PD (95% CI, 40.8 to 134.3) in the month immediately following removal of automatic stop orders (P = .28) (Fig. 2). Even though the slope representing monthly change in DOT/1,000 PD increased in the period without automatic stop orders compared to the period with automatic stop orders, it was not statistically significant (P = .41). Manual chart abstraction revealed that in the period with automatic stop orders, 9 of 150 patients had 17 unintentionally missed days of therapy, whereas none (of 150 patients) in the period without automatic stop orders did. Conclusions: Following removal of the automatic stop orders, there was an overall increase in antibiotic use, although the change in monthly trend of antibiotic use was not significantly different. Even with a dashboard to identify missed doses, there was still a risk of unintentionally missed doses in the period with automatic stop orders. Therefore, this risk should be weighed against the modest difference in antibiotic utilization garnered from automatic stop orders.Funding: NoneDisclosures: None

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1089. Implementation of a Febrile Neutropenia Management Algorithm on Antibiotic Use and Outcomes: An Interrupted Time Series Analysis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.953 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S386-S387

Author(s):

Trang D Trinh ◽

Luke Strnad ◽

Lloyd E Damon ◽

John H Dzundza ◽

Larissa R Graff ◽

...

Keyword(s):

Time Series ◽

Febrile Neutropenia ◽

Time Series Analysis ◽

Clinical Outcomes ◽

Interrupted Time Series ◽

Antibiotic Use ◽

Evidence Based ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

Management Algorithm

Abstract Background Febrile neutropenia (FN) is a common complication of cancer therapy and often necessitates prolonged antibiotic treatment. Antibiotic de-escalation can be challenging given tenuous clinical status. Furthermore, a microbiological or clinical etiology is identified in a minority of FN patients. In 2016 we implemented several evidence-based strategies to guide antibiotic use in high-risk FN patients including specifying vancomycin use indications, minimizing carbapenem escalation in stable patients with ongoing fevers, and defining antibiotic durations regardless of neutrophil count. The study objective was to characterize and evaluate our experience implementing these strategies on antibiotic use and clinical outcomes. Methods Interrupted time series analysis of all admissions to the Malignant Hematology service at the University of California, San Francisco between June 2014 and December 2018. The primary outcome was monthly days of therapy (DOT) per 1,000 patient-days of broad-spectrum IV antibiotics (aztreonam, cefepime, piperacillin–tazobactam, meropenem, and vancomycin). Secondary outcomes included DOT/1,000 patient-days for each IV antibiotic, incidence rates of bloodstream infections (BSI) and C. difficile infections (CDI), and in-hospital all-cause mortality. A segmented regression analysis was conducted to evaluate the impact of the FN management algorithm implementation on antibiotic use and clinical outcomes. Summary statistics and time series scatter plots were used to visualize the trends and outliers. Results 2319 unique patients with 6,788 encounters were included. The median (IQR) age was 59 (46–68) years and 60% were male. Regression results and time series plots are shown in Table 1 and Figures 1–3. Conclusion Implementation of an evidence-based FN management algorithm led to decreased vancomycin and meropenem use without a statistically significant impact on overall antibiotic use, CDI rates, or mortality.While BSI rates fluctuated in the 2 months post-implementation, rates returned to baseline thereafter. A multidisciplinary effort facilitated successful implementation of this stewardship project. This collaboration remains essential to addressing future antimicrobial management strategies in this population. Disclosures All authors: No reported disclosures.

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Impact of integrated care on trends in the rate of emergency department visits among older persons in Stockholm County: an interrupted time series analysis

BMJ Open ◽

10.1136/bmjopen-2019-036182 ◽

2020 ◽

Vol 10 (6) ◽

pp. e036182

Author(s):

Megan Doheny ◽

Janne Agerholm ◽

Nicola Orsini ◽

Pär Schön ◽

Bo Burström

Keyword(s):

Emergency Department ◽

Time Series ◽

Time Series Analysis ◽

Integrated Care ◽

Older Persons ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Stockholm County ◽

Series Analysis ◽

Ed Visits

ObjectiveTo investigate the association between the implementation of an integrated care (IC) system in Norrtälje municipality and changes in trends of the rate of emergency department (ED) visits.DesignInterrupted time series analysis from 2000 to 2015.SettingStockholm County.ParticipantsAll inhabitants 65+ years in Stockholm County on 31 December of each study year.InterventionIC was established by combining the funding, administration and delivery of health and social care for older persons in Norrtälje municipality, within Stockholm County.OutcomeRates of hospital-based ED visits.ResultsIC was associated with a decrease in the rate of ED visits (incidence rate ratio: 0.997, 95% CI 0.995 to 0.998) among inhabitants 65+ years in Norrtälje. However, the rate of ED visits remained higher in Norrtälje than the rest of Stockholm in the preintervention and postintervention periods. Stratified analyses showed that IC was associated with a decline in the trend of the rate of ED visits among those 65–79 years, the lowest income group and born outside of Sweden. However, there was no significant decrease in the trend among those 80+ years.ConclusionThe implementation of IC was associated with a modest change in the trend of ED visits in Norrtälje, though the rate of ED visits remained higher than in the rest of Stockholm. Changes in the composition of the population and contextual changes may have impacted our findings. Further research, using other outcome measures is needed to assess the impact of IC on healthcare utilisation.

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Impact of infection control interventions and antibiotic use on hospital MRSA: a multivariate interrupted time-series analysis

International Journal of Antimicrobial Agents ◽

10.1016/j.ijantimicag.2007.04.005 ◽

2007 ◽

Vol 30 (2) ◽

pp. 169-176 ◽

Cited By ~ 44

Author(s):

A. Mahamat ◽

F.M. MacKenzie ◽

K. Brooker ◽

D.L. Monnet ◽

J.P. Daures ◽

...

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Infection Control ◽

Interrupted Time Series ◽

Antibiotic Use ◽

Interrupted Time Series Analysis ◽

Series Analysis

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Long-Term Outcomes of an Antimicrobial Stewardship Program Implemented in a Hospital with Low Baseline Antibiotic Use

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2015.41 ◽

2015 ◽

Vol 36 (6) ◽

pp. 664-672 ◽

Cited By ~ 23

Author(s):

Timothy C. Jenkins ◽

Bryan C. Knepper ◽

Katherine Shihadeh ◽

Michelle K. Haas ◽

Allison L. Sabel ◽

...

Keyword(s):

Time Series ◽

Outcome Measures ◽

Antimicrobial Stewardship ◽

Antibiotic Use ◽

Safety Net ◽

Antimicrobial Stewardship Program ◽

Long Term Outcomes ◽

Patient Centered ◽

Stewardship Program

OBJECTIVETo evaluate the long-term outcomes of an antimicrobial stewardship program (ASP) implemented in a hospital with low baseline antibiotic use.DESIGNQuasi-experimental, interrupted time-series study.SETTINGPublic safety net hospital with 525 beds.INTERVENTIONImplementation of a formal ASP in July 2008.METHODSWe conducted a time-series analysis to evaluate the impact of the ASP over a 6.25-year period (July 1, 2008–September 30, 2014) while controlling for trends during a 3-year preintervention period (July 1, 2005–June 30, 2008). The primary outcome measures were total antibacterial and antipseudomonal use in days of therapy (DOT) per 1,000 patient-days (PD). Secondary outcomes included antimicrobial costs and resistance, hospital-onset Clostridium difficile infection, and other patient-centered measures.RESULTSDuring the preintervention period, total antibacterial and antipseudomonal use were declining (−9.2 and −5.5 DOT/1,000 PD per quarter, respectively). During the stewardship period, both continued to decline, although at lower rates (−3.7 and −2.2 DOT/1,000 PD, respectively), resulting in a slope change of 5.5 DOT/1,000 PD per quarter for total antibacterial use (P=.10) and 3.3 DOT/1,000 PD per quarter for antipseudomonal use (P=.01). Antibiotic expenditures declined markedly during the stewardship period (−$295.42/1,000 PD per quarter, P=.002). There were variable changes in antimicrobial resistance and few apparent changes in C. difficile infection and other patient-centered outcomes.CONCLUSIONIn a hospital with low baseline antibiotic use, implementation of an ASP was associated with sustained reductions in total antibacterial and antipseudomonal use and declining antibiotic expenditures. Common ASP outcome measures have limitations.Infect Control Hosp Epidemiol 2015;00(0): 1–9

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