Evaluation of early de-escalation of empiric antimicrobial therapy in acute leukemia patients with febrile neutropenia at a large academic medical center

2021 ◽  
pp. 107815522110677
Author(s):  
Whitney J Ly ◽  
Erin E Brown ◽  
Zachary Pedretti ◽  
Jessica Auten ◽  
William S Wilson
Keyword(s):  
Febrile Neutropenia ◽  
Induction Chemotherapy ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Lymphoblastic Leukemia ◽  
Academic Medical Center ◽  
Beta Lactam ◽  
Documented Infection ◽  
Clostridioides Difficile ◽  
Empiric Antimicrobial Therapy

Introduction Recent trials have shown early de-escalation of empiric antimicrobial therapy (EAT) in febrile neutropenia has led to less adverse effects with no difference in patient mortality. In 2019, our institution adjusted internal guidelines to de-escalate EAT after 7 days of intravenous anti-pseudomonal therapy in patients with signs of clinical recovery from febrile neutropenia and no evidence of infection. Methods This was a retrospective, single-center, observational, cohort study. Eligible patients were adults with acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) who received induction chemotherapy and developed febrile neutropenia without documented infection. Patients were separated based on EAT duration: ≤ 9 days and > 9 days. Empiric antimicrobial therapy was defined as the initiation of an anti-pseudomonal beta-lactam. The primary outcome was the difference in number of EAT-free days. Secondary outcomes included fever recurrence, ICU admissions, fever duration, infections post de-escalation, and Clostridioides difficile infection (CDI). Results Forty-four encounters met inclusion. The EAT ≤ 9 days group had 7 more EAT-free days compared to the EAT > 9 days group (p < 0.001). No between-group differences were identified in terms of fever after EAT discontinuation (p = 0.335), ICU admission (p = 0.498), or CDI (p = 0.498). The EAT > 9 days group experienced longer initial fever (p < 0.001) and received addition of resistant Gram-positive coverage (p = 0.014). More patients receiving EAT > 9 days had a diagnosis of AML (p = 0.001). Conclusions Shorter EAT duration did not lead to worse outcomes in patients with AML or ALL who received induction chemotherapy and developed febrile neutropenia without a documented infection source.

scholarly journals Impact of Inactive Empiric Antimicrobial Therapy on Inpatient Mortality and Length of Stay

2006 ◽  
Vol 50 (10) ◽  
pp. 3355-3360 ◽  
Author(s):  
Kimberly K. Scarsi ◽  
Joe M. Feinglass ◽  
Marc H. Scheetz ◽  
Michael J. Postelnick ◽  
Maureen K. Bolon ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Bloodstream Infections ◽  
Empiric Therapy ◽  
Inpatient Mortality ◽  
In Vitro Susceptibility ◽  
Empiric Antimicrobial Therapy

ABSTRACT The consequences of inactive empiric antimicrobial therapy are not well-described and may cause prolonged hospitalization or infection-related mortality. In vitro susceptibility results for 884 patients hospitalized at an academic medical center with gram-negative bloodstream infections (GNBI) from 2001 to 2003 were matched to antimicrobial orders within 24 h of culture. Clinical characteristics, organism, inpatient mortality, and length of stay after culture for patients with GNBI were compared between patients receiving active versus inactive empiric antimicrobial therapy. A total of 14.1% of patients with GNBI received inactive empiric therapy, defined as no antimicrobial therapy within 24 h of the culture active against the identified organism based on in vitro microbiology reports. Patients who received inactive therapy were more likely to be younger, to be infected with Pseudomonas aeruginosa, to have a nosocomial infection, and to receive antimicrobial monotherapy but less likely to be bacteremic with Escherichia coli or to have sepsis (P < 0.05). There were no significant differences in mortality between patients receiving active versus inactive empiric therapy (16.1% versus 13.6%, respectively) or in length of stay after positive culture (11.5 days versus 12.6 days, respectively). Only 45 patients had greater than 2 days of exposure to inactive therapy; however, 8/30 patients (26.7%) who never received active antimicrobial therapy died while in the hospital. Inactive empiric therapy was more common in healthier patients. Inactive antimicrobial therapy in the first 24 h did not significantly impact average outcomes for GNBI among hospitalized patients but may have caused harm to specific individuals.

scholarly journals 460. Point-of-Care, In-Home SARS-CoV-2 IgG Antibody Testing to Assess Seroprevalence in At-Risk Health Care Workers

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S297-S297
Author(s):  
Eric G Meissner ◽  
Christine Litwin ◽  
Tricia Crocker ◽  
Elizabeth Mack ◽  
Lauren Card
Keyword(s):  
Health Care ◽  
At Risk ◽  
Health Care Workers ◽  
Medical Center ◽  
Point Of Care ◽  
Academic Medical Center ◽  
Significant Risk ◽  
Documented Infection ◽  
Inconclusive Result ◽  
Care Workers

Abstract Background Health care workers are at significant risk for infection with the novel coronavirus SARS-CoV-2. Methods We utilized a point-of-care, lateral flow SARS-CoV-2 IgG immunoassay (RayBiotech) to conduct a seroprevalence study in a cohort of at-risk health care workers (n=339) and normal-risk controls (n=100) employed at an academic medical center. To minimize exposure risk while conducting the study, consents were performed electronically, tests were mailed and then self-administered at home using finger stick blood, and subjects uploaded a picture of the test result while answering an electronic questionnaire. We also validated the assay using de-identified serum samples from patients with PCR-proven SARS-CoV-2 infection. Results Between April 14th and May 6th 2020, 439 subjects were enrolled. Subjects were 68% female, 93% white, and most were physicians (38%) and nurses (27%). In addition, 37% had at least 1 respiratory symptom in the prior month, 34% had cared for a patient with known SARS-CoV-2 infection, 57% and 23% were worried about exposure at work or in the community, respectively, and 5 reported prior documented SARS-CoV-2 infection. On initial testing, 3 subjects had a positive IgG test, 336 had a negative test, and 87 had an inconclusive result. Of those with an inconclusive result who conducted a repeat test (85%), 96% had a negative result. All 3 positive IgG tests were in subjects reporting prior documented infection. Laboratory validation showed that of those with PCR-proven infection more than 13 days prior, 23/30 were IgG positive (76% sensitivity), whereas 1/26 with a negative prior PCR test were seropositive (95% specificity). Repeat longitudinal serologic testing every 30 days for up to 4 times is currently in progress. Conclusion We conducted a contact-free study in the setting of a pandemic to assess SARS-CoV-2 seroprevalence in an at-risk group of health care workers. The only subjects found to be IgG positive were those with prior documented infection, even though a substantial proportion of subjects reported significant potential occupational or community exposure and symptoms that were potentially compatible with SARS-COV-2 infection. Disclosures All Authors: No reported disclosures

scholarly journals 183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S98-S98
Author(s):  
Hannah Kafisheh ◽  
Matthew Hinton ◽  
Amanda Binkley ◽  
Christo Cimino ◽  
Christopher Edwards
Keyword(s):  
Emergency Department ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Positive Culture ◽  
Culture Result ◽  
Academic Medical ◽  
Positive Culture Result ◽  
Therapy Modification

Abstract Background Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI). Methods This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed. Results A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p &lt; 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p &lt; 0.01). Conclusion The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA. Disclosures All Authors: No reported disclosures

Impact of Pharmacist Intervention on Selection and Timing of Appropriate Antimicrobial Therapy in Septic Shock

2017 ◽  
Vol 31 (1) ◽  
pp. 46-51 ◽  
Author(s):  
Melanie E. Laine ◽  
Jeremy D. Flynn ◽  
Alexander H. Flannery
Keyword(s):  
Septic Shock ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Empiric Therapy ◽  
Pharmacist Intervention ◽  
Entire Cohort ◽  
Sepsis Bundle ◽  
Selection Of ◽  
Antimicrobial Administration

Background: Current guidelines for septic shock management recommend administration of appropriate, broad-spectrum antimicrobials within 1 hour of recognition. Objective: To evaluate the interventions pharmacists make as part of a sepsis response team and to determine if these interventions increase the proportion of patients with appropriate empiric antimicrobial therapy. Methods: A retrospective cohort study was undertaken reviewing adult patients in a large, academic medical center with confirmed septic shock who had an order for a “sepsis bundle,” which includes notification of a pharmacist to assess adequacy of empiric therapy. Pharmacist interventions with regard to selection of empiric antimicrobials were documented. The proportion of patients with initial successful selection of antimicrobial therapy (SSAT) before and after pharmacist intervention was assessed as well as the time to first antimicrobial administration and time to appropriate antimicrobial administration. Results: A total of 76 patients were included. Pharmacist intervention increased the proportion of patients with SSAT from 66% to 80% ( P = .04). Median time to first antimicrobial administration was 43 minutes, and time to appropriate antimicrobial therapy was 1 hour, 34 minutes for the entire cohort, with pharmacist intervention decreasing the latter time significantly in patients without SSAT on initiation of the “sepsis bundle” ( P < .001). Conclusion: Pharmacist assessment of patients in septic shock offers the opportunity to improve SSAT. Systems designed to use a pharmacist responder for the care of patients with septic shock maximize the selection of antimicrobials, facilitate rapid administration, and improve surrogate outcomes for mortality in septic shock.

Test stewardship, frequency and fidelity: Impact on reported hospital-onset Clostridioides difficile

2019 ◽  
Vol 40 (6) ◽  
pp. 710-712 ◽  
Author(s):  
Michele S. Fleming ◽  
Olivia Hess ◽  
Heather L. Albert ◽  
Emily Styslinger ◽  
Michelle Doll ◽  
...  
Keyword(s):  
Decision Support ◽  
Medical Record ◽  
Critical Review ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clostridioides Difficile ◽  
Testing Frequency ◽  
Academic Medical ◽  
Support Matrix ◽  
The Impact

AbstractWe assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.

The Safety of Midline Catheters for Intravenous Therapy at a Large Academic Medical Center

2019 ◽  
Vol 54 (3) ◽  
pp. 232-238 ◽  
Author(s):  
Hangil Seo ◽  
Diana Altshuler ◽  
Yanina Dubrovskaya ◽  
Mark E. Nunnally ◽  
Catherine Nunn ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Intravenous Therapy ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
Medication Therapy ◽  
Academic Medical ◽  
Outpatient Group ◽  
Days Of Therapy

Background: Midline catheters (MCs) have arisen as alternatives to peripherally inserted central catheters (PICCs) for both general intravenous therapy and extended outpatient parenteral therapy. However, there is a lack of data concerning the safety of medication therapy through midline for extended durations. Objective: The purpose of this study is to evaluate the safety of MCs for extended intravenous use. Methods: This was a retrospective cohort study evaluating patients who received intravenous therapy through an MC at a tertiary care academic medical center. The primary end point was the incidence of composite catheter-related adverse events that included local events, catheter dislodgment, infiltration, catheter occlusion, catheter-related venous thromboembolism, extravasation, and line-associated infection. Results: A total of 82 MC placements and 50 PICC placements were included; 50 MCs were for outpatient parenteral antimicrobial therapy, and 32 were for inpatient intravenous use. There were 21 complications per 1000 catheter-days in the outpatient group and 7 complications per 1000 catheter-days in the PICC group ( P = 0.91). The median time to complication in both groups was 8 days. The antimicrobial classes commonly associated with complications were cephalosporins, carbapenems, and penicillins. Conclusion and Relevance: Our results suggest that intravenous therapy with MCs is generally safe for prolonged courses that do not exceed 14 days as compared with PICC lines, which can be placed for months. There is still limited evidence for the use of MCs between 14 and 28 days of therapy. This study can help guide our selection of intravenous catheters for the purpose of outpatient antimicrobial therapy.

scholarly journals Characteristics of patients infected with Clostridioides difficile at a Saudi Tertiary Academic Medical Center and assessment of antibiotic duration

Gut Pathogens ◽  
2021 ◽  
Vol 13 (1) ◽  
Author(s):  
Khadijah M. Alammari ◽  
Abrar K. Thabit
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Acid Suppression ◽  
Prior Exposure ◽  
Clostridioides Difficile ◽  
Academic Medical ◽  
Days Of Therapy ◽  
Acid Suppression Therapy ◽  
Medical Wards ◽  
Hospital Acquired

Abstract Background Clostridioides difficile infection (CDI) is a common hospital-associated diarrhea. Several antibiotics commonly associate with CDI; however, limited data are available on the duration of exposure prior to CDI. Moreover, studies on the characteristics of CDI patients in Saudi Arabia are limited. Therefore, this study aimed to characterize CDI patients identified over 10 years and assess antibiotic days of therapy (DOT) prior to CDI. Methods This was a retrospective descriptive analysis of CDI patients at a Saudi tertiary academic medical center between December 2007 and January 2018. Patients characteristics, prior exposure to known CDI risk factors, and DOT of antibiotics prior to CDI incidence were assessed. Results A total of 159 patients were included. Median age was 62 years. Most cases were hospital-acquired (71.1%), non-severe (44.7%), and admitted to medical wards (81.1%). Prior exposure to antibiotics and acid suppression therapy were reported with the majority (76.1 and 75.5%, respectively). The most frequently prescribed antibiotics were piperacillin/tazobactam, ceftriaxone, meropenem, and ciprofloxacin with median DOTs prior to CDI incidence of 14 days for the β-lactams and 26 days for ciprofloxacin. The distribution of DOT was significantly different for piperacillin/tazobactam in different units (P = 0.003) where its median DOT was the shortest in medical wards (11 days), and for ciprofloxacin among different severity groups (P = 0.013), where its median DOT was the shortest in severe CDI patients (11 days). Conclusion Most patients in this study had hospital-acquired non-severe CDI and were largely exposed to antibiotics and acid suppression therapy. Therefore, such therapies should be revised for necessity.

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