1036. Clinical impact of an antibiotic time out initiative at an academic medical center

Abstract Background The Infectious Diseases Society of America’s guideline for implementing antibiotic (abx) stewardship recommends routine review of abx use. Several studies demonstrate antibiotic time out (ATO) programs result in de-escalation, but there is limited evidence of improved outcomes. The aim of this study was to evaluate the clinical impact of ATO. Methods This retrospective study included hospitalized patients at The Ohio State University Wexner Medical Center receiving abx and a documented ATO from 7/1/2017 to 6/30/2018. ATO patients were matched by infection type to abx-treated patients lacking an ATO note. Patients were excluded if they were identified as a protected population, were in the ICU at the time of ATO, had an ATO within 48 hours of discharge, cystic fibrosis, or febrile neutropenia. The primary objective was to evaluate abx optimization in patients with documented ATO vs. those without ATO. Abx optimization was defined as the selection of ideal abx based on guidelines, culture and susceptibility results, or expert opinion when undefined. Secondary outcomes included vancomycin-associated acute kidney injury (VAN-AKI), infection-related length of stay (LOS), all-cause 30-day readmission or mortality, abx days, and nosocomial C. difficile infection (CDI) rates. The Student t-test/Fisher’s exact test and Wilcoxon-rank sum were utilized as appropriate. Results One hundred ATO patients were compared with 100 non-ATO patients. Baseline characteristics and infection types were similar between groups. ATO resulted in improved optimization of abx selection (P = 0.05) and duration (P < 0.01), and reduced piperacillin/tazobactam (P/T) and vancomycin (VAN) utilization. No difference was observed in VAN-AKI (22 vs. 20%, P = 0.73), 30-day readmission (28 vs. 27%, P = 0.87), mortality (5 vs. 5%, P = 1), or CDI rates (6 vs. 5%, p = 0.76) in the ATO vs. non-ATO group. However, inpatient abx days (12 vs. 8, P = 0.004) and infection-related LOS (10 vs. 8, P = 0.0006) were shorter in the non-ATO group. Conclusion ATO improved optimization of abx selection and duration, and reduced P/T and VAN use. Despite this, clinical outcomes were not improved. Disclosures All authors: No reported disclosures.

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Evaluation of a Pharmacy-to-Dose Pneumococcal Vaccination Protocol at an Academic Medical Center

Annals of Pharmacotherapy ◽

10.1177/1060028018805439 ◽

2018 ◽

Vol 53 (4) ◽

pp. 364-370

Author(s):

Ashlee Baucom ◽

Christina Brizendine ◽

Ann Fugit ◽

Christopher Dennis

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Pneumococcal Vaccination ◽

Primary Objective ◽

Fisher Exact Test ◽

Inpatient Service ◽

Exact Test ◽

Vaccine Administration ◽

Vaccination Protocol ◽

Academic Medical

Background: In February 2016, a pharmacy-to-dose (PTD) pneumococcal vaccination protocol was implemented to aid in the appropriate selection of pneumococcal vaccines. Objective: The primary objective was to compare the rate of appropriate vaccine ordering with the PTD protocol. Secondary objectives were to assess vaccine administration rate and determine factors preventing patients from receiving the vaccine after appropriate selection. Methods: This was a single-center, retrospective cohort study of adult patients admitted to an inpatient service. Eligible patients were 19 years of age or older and had either a PTD pneumococcal vaccination order placed or an alert triggered indicating that the patient was a candidate for a vaccination. Patients were excluded if they had contraindications to receiving either pneumococcal vaccine. The Fisher exact test was used to evaluate the primary objective, and descriptive statistics were used to evaluate the secondary objectives. Results: A total of 327 patients were included in the analysis: 167 in the preprotocol cohort and 160 in the postprotocol cohort. The correct vaccine ordering rates were found to be 26.9% (45/167) and 83.1% (133/160) in the preprotocol and postprotocol cohorts, respectively ( P < 0.001). In the postprotocol cohort, 17.5% (28/160) of patients did not have a vaccine administered. Reasons for vaccine administration failure were identified as patient refusal, patient expired during admission, vaccine not dispensed by pharmacy, and vaccine dispensed by pharmacy but returned. Conclusions: The PTD pneumococcal vaccination protocol significantly improved correct vaccine ordering rates.

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Clinical Impact of an Antibiotic Time Out Initiative at an Academic Medical Center

Hospital Pharmacy ◽

10.1177/0018578719901274 ◽

2020 ◽

pp. 001857871990127

Author(s):

Amy Parks Taylor ◽

Kelci Coe ◽

Kurt Stevenson ◽

Lynn Wardlow ◽

Zeinab El Boghdadly ◽

...

Keyword(s):

Clinical Outcomes ◽

Infection Type ◽

Medical Center ◽

Academic Medical Center ◽

Adult Patients ◽

Antimicrobial Use ◽

Time Out ◽

Academic Medical ◽

The Impact ◽

Homogenous Population

Background: Various strategies aimed at limiting inappropriate antimicrobial use including antibiotic time out (ATO) have been proposed to combat the development of antimicrobial resistance, yet there are limited studies that have assessed the impact of ATO on clinical outcomes. Methods: This single-center retrospective study reviewed the effect of a passive ATO strategy by comparing 100 adult patients with an ATO matched by infection type to 100 antibiotic-treated adult patients lacking an ATO note. Results: No difference in clinical outcomes was observed, however, ATO did result in improved optimization of antibiotic selection and duration, and reduction of piperacillin/tazobactam and vancomycin use. Conclusion: Further studies are warranted to evaluate the impact of ATO on clinical outcomes of a larger homogenous population with specified infectious diagnoses and clinical characteristics.

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Effect of a Pediatric Prescription Medication Discharge Program on Reducing Hospital Readmission Rates

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-22.2.94 ◽

2017 ◽

Vol 22 (2) ◽

pp. 94-101 ◽

Cited By ~ 1

Author(s):

Laura A. Leathers ◽

Kristy L. Brittain ◽

Kelly Crowley

Keyword(s):

Hospital Readmission ◽

Medical Center ◽

Heart Defects ◽

Academic Medical Center ◽

Hospital Readmissions ◽

Kidney Injury ◽

Retrospective Chart Review ◽

Prescription Medication ◽

Primary Objective ◽

Counseling Program

OBJECTIVES To evaluate the pediatric prescription medication discharge delivery and counseling program, implemented at an 186-bed children's hospital integrated within a larger academic medical center, and its effectiveness on reducing hospital readmissions. METHODS This study was a retrospective chart review of existing data in the electronic medical record from patients <21 years of age who were discharged from our institution between September 1, 2014, and November 30, 2014. Patients who participated in the pediatric discharge program were compared to non-participants. The primary objective was to determine if the patient was readmitted within 30 days. Secondary objectives included time until readmission, diagnosis at discharge, and hospital unit at discharge. RESULTS In total, 1804 patients were assessed. After exclusions, 932 subjects were included in the analysis. In total, 393 (42.2%) patients participated in the pediatric medication discharge and counseling program, and 539 did not participate. Of the patients who participated in the program, 52 were readmitted within 30 days (13.2%), compared with 67 patients (12.4%) who did not participate in the discharge program, p = 0.717. Patients with the diagnoses of malignancy and kidney injury were more likely to be readmitted within this time frame, and those with the diagnoses of heart defects or cardiology disorders and malignancy were more likely to participate in the pediatric prescription medication discharge program. CONCLUSION Participation in the pediatric discharge medication delivery and counseling program did not reduce hospital readmission rate within 30 days.

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1310. Implementation of AUC:MIC Pharmacy to Dose in an Academic Medical Center: A Pilot Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1492 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S667-S668

Author(s):

Ann-Marie Idusuyi ◽

Maureen Campion ◽

Kathleen Belusko

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Area Under The Curve ◽

Kidney Injury ◽

Retrospective Chart Review ◽

Total Daily Dose ◽

Therapeutic Goals ◽

Academic Medical ◽

Progress Notes ◽

Implementation Period

Abstract Background The new ASHP/IDSA consensus guidelines recommend area under the curve (AUC) monitoring to optimize vancomycin therapy. Little is known about the ability to implement this recommendation in a real-world setting. At UMass Memorial Medical Center (UMMMC), an AUC pharmacy to dose protocol was created to manage infectious diseases (ID) consult patients on vancomycin. The service was piloted by the pharmacy residents and 2 clinical pharmacists. The purpose of this study was to determine if a pharmacy to dose AUC protocol can safely and effectively be implemented. Methods A first-order kinetics calculator was built into the electronic medical record and live education was provided to pharmacists. Pharmacists ordered levels, wrote progress notes, and communicated to teams regarding dose adjustments. Patients were included based upon ID consult and need for vancomycin. After a 3-month implementation period, a retrospective chart review was completed. Patients in the pre-implementation group were admitted 3 months prior to AUC pharmacy to dose, had an ID consult and were monitored by trough (TR) levels. The AUC group was monitored with a steady state peak and trough level to calculate AUC. The primary outcome evaluated time to goal AUC vs. time to goal TR. Secondary outcomes included number of dose adjustments made, total daily dose of vancomycin, and incidence of nephrotoxicity. Results A total of 64 patients met inclusion criteria, with 37 patients monitored by TR and 27 patients monitored by AUC. Baseline characteristics were similar except for weight in kilograms (TR 80.0 ±25.4 vs AUC 92.0 ±26.7; p=0.049). The average time to goal AUC was 4.13 (±2.08) days, and the average time to goal TR was 4.19 (±2.30) days (p=0.982). More dose adjustments occurred in the TR group compared to the AUC (1 vs 2; p=0.037). There was no difference between the two groups in dosing (TR 15.8 mg/kg vs AUC 16.4 mg/kg; p=0.788). Acute kidney injury occurred in 5 patients in the AUC group and 11 patients in the TR group (p=0.765). Conclusion Fewer dose adjustments and less nephrotoxicity was seen utilizing an AUC based protocol. Our small pilot has shown that AUC pharmacy to dose can be safely implemented. Larger studies are needed to evaluate reduction in time to therapeutic goals. Disclosures All Authors: No reported disclosures

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Comparison of rates of adherence to oral chemotherapy medications filled through an internal health-system specialty pharmacy vs external specialty pharmacies

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa135 ◽

2020 ◽

Vol 77 (14) ◽

pp. 1118-1127

Author(s):

Colleen C McCabe ◽

Meagan S Barbee ◽

Marley L Watson ◽

Alyssa Billmeyer ◽

Collin E Lee ◽

...

Keyword(s):

Health System ◽

Multiple Regression ◽

Patient Adherence ◽

Medical Center ◽

Academic Medical Center ◽

Medication Possession Ratio ◽

Primary Objective ◽

Wilcoxon Test ◽

Tumor Type ◽

Specialty Pharmacy

Abstract Purpose The primary objective of the study described here was to compare rates of patient adherence to anticancer medications filled at an internal health system specialty pharmacy (HSSP) vs external specialty pharmacies. The primary outcome was the medication possession ratio (MPR), and the secondary outcomes included proportion of days covered (PDC), and time to treatment (TTT). Methods A retrospective chart review was conducted to compare the MPR, PDC, and TTT for patients who received oral anticancer therapy using prescriptions claim data. A t test or Wilcoxon test was used to explore the effect of demographic and other factors on adherence and TTT. A multiple regression model with backward elimination was used to analyze significant factors to identify covariates significantly associated with the outcomes. Results Of the 300 patients screened for study inclusion, 204 patients whose records had complete MPR and PDC data and 164 whose records had TTT data were included in the analysis. There were significant between-group differences in mean MPR and mean PDC with patient use of the HSSP vs external pharmacies (1.00 vs 0.75 [P < 0.001] and 0.95 vs 0.7 [P < 0.001], respectively). Pharmacy type (P = 0.024) and tumor type (P = 0.048) were significantly associated with TTT. Conclusion The multiple regression analysis indicated that oncology patients who filled their anticancer medication precriptions at an internal HSSP at an academic medical center had significantly higher adherence, as measured by MPR and PDC, and quicker TTT than those who filled their prescriptions at an external specialty pharmacy.

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Influence of β-Lactam Infusion Strategy on Acute Kidney Injury

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00871-17 ◽

2017 ◽

Vol 61 (10) ◽

Cited By ~ 10

Author(s):

Sarah E. Cotner ◽

W. Cliff Rutter ◽

Donna R. Burgess ◽

Katie L. Wallace ◽

Craig A. Martin ◽

...

Keyword(s):

Acute Kidney Injury ◽

Medical Center ◽

Academic Medical Center ◽

Kidney Injury ◽

Intermittent Infusion ◽

Prolonged Infusion ◽

Infusion Group ◽

Academic Medical ◽

Baseline Creatinine ◽

End Stage

ABSTRACT Limited literature is available assessing nephrotoxicity with prolonged β-lactam infusions. This study compared the incidence of acute kidney injury (AKI) associated with a prolonged β-lactam infusion or an intermittent infusion. This was a retrospective, matched-cohort study at an academic medical center from July 2006 to September 2015. Adult patients who received piperacillin-tazobactam (TZP), cefepime (FEP), or meropenem (MEM) for at least 48 h were evaluated. Patients were excluded for preexisting renal dysfunction or pregnancy. The primary outcome was difference in incidence of AKI evaluated using the RIFLE (risk, injury, failure, loss, and end-stage) criteria. Patients in the intermittent group were matched 3:1 to patients in the prolonged-infusion group based on the following: β-lactam agent, age, gender, Charlson comorbidity index, baseline creatinine clearance, hypotension, receipt of vancomycin, and treatment in an intensive care unit. A total of 2,390 patients were included in the matched analysis, with 1,700 receiving intermittent infusions and 690 receiving prolonged infusion. The incidence of AKI was similar in the prolonged-infusion group to that in the intermittent-infusion group (21.6% versus 18.6%; P = 0.1). After multivariate regression, prolonged infusion was not associated with increased odds of AKI (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 0.83 to 1.39). Independent predictors of AKI included TZP therapy, concomitant nephrotoxins, hypotension, and heart failure. Although AKIs were numerically more common in patients receiving prolonged β-lactam infusions than those receiving intermittent infusions, prolonged infusion was not an independent risk factor for AKI.

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Vancomycin Area Under the Curve Dosing and Monitoring at an Academic Medical Center: Transition Strategies and Lessons Learned

Journal of Pharmacy Practice ◽

10.1177/0897190019834369 ◽

2019 ◽

Vol 33 (6) ◽

pp. 774-778 ◽

Cited By ~ 4

Author(s):

Eric R. Gregory ◽

Donna R. Burgess ◽

Sarah E. Cotner ◽

Jeremy D. VanHoose ◽

Alexander H. Flannery ◽

...

Keyword(s):

Technology Development ◽

Medical Center ◽

Academic Medical Center ◽

Area Under The Curve ◽

Kidney Injury ◽

Lessons Learned ◽

Academic Medical ◽

Transition Strategies ◽

Evaluation Stage ◽

Information Technology Development

Due to the inconsistent correlation of vancomycin trough concentrations with 24-hour area under the curve (AUC) and a desire to reduce rates of vancomycin-associated acute kidney injury, an institutional guideline was implemented by the Antimicrobial Stewardship Team in September 2017 to monitor vancomycin using AUC. Three stages were utilized to organize the process: preparation, implementation, and evaluation. The preparation stage was used to present literature to key stakeholders, and pharmacy meetings focused on the development of a dosing and monitoring guideline. Along with institution-wide education, the implementation stage included information technology development and support. The evaluation stage was comprised of quality improvement and clinical research. Future plans include dissemination of the results and analyses. Numerous lessons were learned due to barriers experienced during the process, but the transition was successful.

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1575. Vancomycin Loading Doses and Nephrotoxicity on Medicine Teaching Services

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1439 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S575-S575

Author(s):

Phillip Wagner ◽

Jon Arnold ◽

Kathleen R Sheridan

Keyword(s):

Drug Exposure ◽

Standard Dose ◽

Medical Center ◽

Academic Medical Center ◽

Kidney Injury ◽

Loading Dose ◽

Academic Medical ◽

Trough Concentrations ◽

Seriously Ill Patients ◽

The Relationship

Abstract Background IDSA guidelines recommend the usage of a loading dose when using vancomycin for seriously ill patients to rapidly achieve adequate trough concentrations. While the relationship between vancomycin and nephrotoxicity is the focus of many studies, and with the strength of that relationship still debated, few studies have examined the relationship between vancomycin loading doses and nephrotoxicity. Methods We performed a retrospective cohort study examining vancomycin dosing for internal medicine teaching services’ patients over the 2014–15 academic year at one academic medical center. We generated a list of all hospitalized patients aged 18–85 who received vancomycin and were admitted to a teaching service. Patient data were extracted from the inpatient EMR via manual chart review. Patients were excluded if their pretreatment calculated glomerular filtration rate (GFR) was less than 50 mL/minute, if they received less than three doses of vancomycin, or if their initial dose was subtherapeutic (<10 mg/kg). Nephrotoxicity was determined by 7-day acute kidney injury (AKI) rate. Patients in the loading dose (>20 mg/kg) cohort were compared with those in the standard dose cohort (10–20 mg/kg). Our primary modeling used multi-variable logistic regression with AKI as our outcome of interest. Results 438 of the initial 804 patients were enrolled. The loading dose (n = 365, 83%) and standard dosing (n = 73, 17%) cohorts were not significantly different regarding demographics, GFR, nephrotoxic drug exposure, total vancomycin received, trough levels, or comorbidities, and were only significantly different regarding body mass index (BMI). The 7-day AKI rate was not significantly different between the two arms (6.3% in the standard dosing arm and 8.2% in the loading dose arm P = 0.6). AKI rate significantly increased in both arms in the setting of concurrent piperacillin–tazobactam and vancomycin administration (OR 2.5, P = .04). There was no association between BMI and AKI. Conclusion Few studies have examined the relationship between nephrotoxicity and vancomycin loading doses. The results of this study provide evidence that the use of loading doses is not significantly associated with increased 7-day AKI rate. Disclosures All authors: No reported disclosures.

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