Reducing the use of empiric antibiotic therapy in COVID-19 on hospital admission

Abstract Background Empiric antibiotics for community acquired bacterial pneumonia (CABP) are often prescribed to patients with COVID-19, despite a low reported incidence of co-infections. Stewardship interventions targeted at facilitating appropriate antibiotic prescribing for CABP among COVID-19 patients are needed. We developed a guideline for antibiotic initiation and discontinuation for CABP in COVID-19 patients. The purpose of this study was to assess the impact of this intervention on the duration of empiric CABP antibiotic therapy among patients with COVID-19. Methods This was a single-center, retrospective, quasi-experimental study of adult patients admitted between 3/1/2020 to 4/25/2020 with COVID-19 pneumonia, who were initiated on empiric CABP antibiotics. Patients were excluded if they were initiated on antibiotics > 48 h following admission or if another source of infection was identified. The primary outcome was the duration of antibiotic therapy (DOT) prior to the guideline (March 1 to March27, 2020) and after guideline implementation (March 28 to April 25, 2020). We also evaluated the clinical outcomes (mortality, readmissions, length of stay) among those initiated on empiric CABP antibiotics. Results A total of 506 patients with COVID-19 were evaluated, 102 pre-intervention and 404 post-intervention. Prior to the intervention, 74.5% (n = 76) of patients with COVID-19 received empiric antibiotics compared to only 42% of patients post-intervention (n = 170), p < 0.001. The median DOT in the post-intervention group was 1.3 days shorter (p < 0.001) than the pre-intervention group, and antibiotics directed at atypical bacteria DOT was reduced by 2.8 days (p < 0.001). More patients in the post-intervention group were initiated on antibiotics based on criteria consistent with our guideline (68% versus 87%, p = 0.001). There were no differences between groups in terms of clinical outcomes. Conclusion Following the implementation of a guideline outlining recommendations for initiating and discontinuing antibiotics for CABP among COVID-19 inpatients, we observed a reduction in antibiotic prescribing and DOT. The guideline also resulted in a significant increase in the rate of guideline-congruent empiric antibiotic initiation.

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Reducing the use of empiric antibiotic therapy in patients on admission to the hospital with COVID-19

10.21203/rs.3.pex-1236/v1 ◽

2020 ◽

Author(s):

Natasha N. Pettit ◽

Cynthia T. Nguyen ◽

Alison Lew ◽

Palak Bhagat ◽

Allison Nelson ◽

...

Keyword(s):

Antibiotic Therapy ◽

Clinical Outcomes ◽

Intervention Group ◽

Empiric Antibiotic Therapy ◽

Antibiotic Prescribing ◽

Post Intervention ◽

Empiric Antibiotics ◽

Empiric Antibiotic ◽

The Impact ◽

Post Intervention Group

Abstract Background: Empiric antibiotics for community acquired bacterial pneumonia (CABP) are often prescribed to patients with COVID-19, despite a low reported incidence of co-infections. Stewardship interventions targeted at facilitating appropriate antibiotic prescribing for CABP among COVID-19 patients are needed. We developed a guideline for antibiotic initiation and discontinuation for CABP in COVID-19 patients. The purpose of this study was to assess the impact of this intervention on the duration of empiric CABP antibiotic therapy among patients with COVID-19. Methods: This was a single-center, retrospective, quasi-experimental study of adult patients admitted between 3/1/2020 to 4/25/2020 with COVID-19 pneumonia, who were initiated on empiric CABP antibiotics. Patients were excluded if they were initiated on antibiotics >48hours following admission or if another infection was identified. The primary outcome was the duration of antibiotic therapy (DOT) prior to the guideline (March 1 to March27, 2020) and after guideline implementation (March 28 to April 25, 2020). We also evaluated the clinical outcomes (mortality, readmissions, length of stay) among those initiated on empiric CABP antibiotics. Results: A total of 506 patients with COVID-19 were evaluated, 102 pre-intervention and 404 post-intervention. Prior to the intervention, 74.5% (n=76) of patients with COVID-19 received empiric antibiotics compared to only 42% of patients post-intervention (n=170), p<0.001. The median DOT in the post-intervention group was 1.3 days shorter (p<0.001) than the pre-intervention group, and atypical antibiotic DOT was reduced by 2.8 days (p<0.001). More patients in the post-intervention group were initiated on antibiotics based on criteria consistent with our guideline (68% versus 87%, p=0.001). There were no differences between groups in terms of clinical outcomes. Conclusion: Following the implementation of a guideline outlining recommendations for initiating and discontinuing antibiotics for CABP among COVID-19 inpatients, we observed a reduction in antibiotic prescribing and DOT. The guideline also resulted in a significant increase in the rate of guideline-congruent empiric antibiotic initiation.

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Reducing the use of empiric antibiotic therapy in patients on admission to the hospital with COVID-19

10.21203/rs.3.rs-94854/v1 ◽

2020 ◽

Author(s):

Natasha N. Pettit ◽

Cynthia T. Nguyen ◽

Alison Lew ◽

Palak B. Bhagat ◽

Allison Nelson ◽

...

Keyword(s):

Antibiotic Therapy ◽

Clinical Outcomes ◽

Intervention Group ◽

Empiric Antibiotic Therapy ◽

Antibiotic Prescribing ◽

Post Intervention ◽

Empiric Antibiotics ◽

Empiric Antibiotic ◽

The Impact ◽

Post Intervention Group

Abstract Background: Empiric antibiotics for community acquired bacterial pneumonia (CABP) are often prescribed to patients with COVID-19, despite a low reported incidence of co-infections. Stewardship interventions targeted at facilitating appropriate antibiotic prescribing for CABP among COVID-19 patients are needed. We developed a guideline for antibiotic initiation and discontinuation for CABP in COVID-19 patients. The purpose of this study was to assess the impact of this intervention on the duration of empiric CABP antibiotic therapy among patients with COVID-19.Methods: This was a single-center, retrospective, quasi-experimental study of adult patients admitted between 3/1/2020 to 4/25/2020 with COVID-19 pneumonia, who were initiated on empiric CABP antibiotics. Patients were excluded if they were initiated on antibiotics >48hours following admission or if another infection was identified. The primary outcome was the duration of antibiotic therapy (DOT) prior to the guideline (March 1 to March27, 2020) and after guideline implementation (March 28 to April 25, 2020). We also evaluated the clinical outcomes (mortality, readmissions, length of stay) among those initiated on empiric CABP antibiotics.Results: A total of 506 patients with COVID-19 were evaluated, 102 pre-intervention and 404 post-intervention. Prior to the intervention, 74.5% (n=76) of patients with COVID-19 received empiric antibiotics compared to only 42% of patients post-intervention (n=170), p<0.001. The median DOT in the post-intervention group was 1.3 days shorter (p<0.001) than the pre-intervention group, and atypical antibiotic DOT was reduced by 2.8 days (p<0.001). More patients in the post-intervention group were initiated on antibiotics based on criteria consistent with our guideline (68% versus 87%, p=0.001). There were no differences between groups in terms of clinical outcomes.Conclusion: Following the implementation of a guideline outlining recommendations for initiating and discontinuing antibiotics for CABP among COVID-19 inpatients, we observed a reduction in antibiotic prescribing and DOT. The guideline also resulted in a significant increase in the rate of guideline-congruent empiric antibiotic initiation.

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Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults

Journal of Pharmacy Practice ◽

10.1177/0897190020980616 ◽

2020 ◽

pp. 089719002098061

Author(s):

Calley M. Paulson ◽

Jillian F. Handley ◽

Thomas J. Dilworth ◽

Dan Persells ◽

Rachael Y. Prusi ◽

...

Keyword(s):

Antibiotic Therapy ◽

Median Duration ◽

Intervention Group ◽

Empiric Therapy ◽

Group Differences ◽

Post Intervention ◽

Time Out ◽

Intra Abdominal Infection ◽

The Impact ◽

Post Intervention Group

Introduction: Antibiotic time-outs (ATO) are a recommended antimicrobial stewardship action, but data assessing their impact are lacking. This study investigated the impact of a systematic, pharmacist initiated ATO intervention. Methods: This pre-post study included inpatients on hospitalist and intensivist services receiving empiric antibiotics for ≥48 hours. The ATO was initiated by pharmacists after 48 hours of empiric therapy and the outcome was documented including antibiotic indication, plan, and duration. An electronic medical record (EMR) alert facilitated ATO completion and pharmacists and prescribers received education prior to implementation. The primary outcome was EMR documentation of an antibiotic plan by 72 hours. Secondary outcomes included antibiotic utilization and antibiotic therapy modifications by 2 hours. Results: 399 patients were included, 199 pre- and 200 post-intervention. The most common indications were pneumonia (32%), intra-abdominal infection (20%) and urinary tract infection (19%), with no between-group differences. EMR documentation of an antibiotic plan significantly improved in the post-intervention group (19% vs. 79%, p<0.0001) as did modifications to antibiotic therapy. The median duration of in-hospital antibiotic therapy was similar between groups (4.0 vs. 4.0 days, p = 0.2499). Approximately 45% of patients in each group received discharge antibiotics and median duration of discharge antibiotic therapy prescribed was reduced (7 vs. 5 days in the pre- and post-intervention groups, respectively; p = 0.0140). Discussion: Implementation of pharmacist initiated ATO was associated with improvements in supporting EMR documentation and antibiotic therapy modifications. These findings highlight an important role in which pharmacists can serve as part of a collaborative antibiotic stewardship team.

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1981. Implementation of an Antifungal Stewardship Bundle Focused on Candidemia in an Indian Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1661 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S663-S663

Author(s):

Merlin Moni ◽

Vidya Menon ◽

Sangita Sudhir ◽

Dipu T.S. ◽

Jeslyn Philip ◽

...

Keyword(s):

Clinical Outcomes ◽

Antifungal Therapy ◽

Tertiary Care ◽

Intervention Group ◽

Southern India ◽

Care Bundle ◽

Post Intervention ◽

Historical Cohort ◽

The Impact ◽

Post Intervention Group

Abstract Background In India, Candida bloodstream infections have a reported incidence of 1–12 per 1,000 admissions and a mortality rate of up to 60%. Antimicrobial stewardship programs (ASP) can improve quality of care and clinical outcomes. This study evaluates the impact of a comprehensive candidemia ASP bundle in a hospital in southern India with an established stewardship program. Methods A single-center, pre-post quasi-experimental study was conducted at a tertiary-care center in southern India to analyze the impact of an ASP care bundle for the management of adults with candidemia. During the intervention period (October 2017–December 2018), the ASP provided recommendations to providers in accordance with the 2016 IDSA Guidelines for the Management of Candidemia, which included the following bundle: (1) appropriate selection and dosing of antifungal therapy; (2) repeat blood cultures every 48 hours until clearance; (3) removal of central venous catheters and other potential removable foci of infection; (4) echocardiogram; (5) ophthalmologic evaluation; and (6) appropriate duration of therapy. The primary outcome was initiation of appropriate antifungal therapy. Additional clinical outcomes were also compared with a historical cohort. Results One hundred and four patients with candidemia were included: 52 in the pre-intervention and 52 in the post-intervention group. Overall, baseline demographics were similar between the two groups (Table 1). Candida tropicalis (26.9%) and Candida parapsilosis (29.8%) were the most common causes of candidemia in the cohort. Following intervention, administration of appropriate antifungal therapy improved by 40.4% (28.8% pre vs. 69.2% post, P < 0.01). Average time to effective treatment initiation following culture positivity decreased from 57.6 hours to 12 hours in the post-intervention group (P < 0.01). Thirty-day all-cause mortality was similar between the two groups (34.6% 38.4%, P = 0.84). Conclusion Implementation of a comprehensive candidemia care bundle by the ASP significantly improved the use and timing of initiation of appropriate antifungal therapy. Disclosures All authors: No reported disclosures.

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2103. Emergency Department (ED) Stewardship: Stratifying ED Sepsis Order Sets by Penicillin (PCN) Allergy Severity

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1783 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S711-S712

Author(s):

Mary L Staicu ◽

Maryrose R Laguio-Vila ◽

Allison Ramsey ◽

Kelly M Conn ◽

Kristin Woodring

Keyword(s):

Intervention Group ◽

Hospital Length Of Stay ◽

Antibiotic Prescribing ◽

Hypersensitivity Reactions ◽

Post Intervention ◽

Days Of Therapy ◽

Order Sets ◽

The Impact ◽

Post Intervention Group ◽

Order Set

Abstract Background The Surviving Sepsis Campaign Guidelines recommends administration of broad-spectrum antibiotics within 1 hour of sepsis diagnosis; electronic order sets drive antibiotic selection with pre-populated regimens based on the suspected infectious indication. Given the low rate of cephalosporin cross-reactivity in patients with a PCN allergy, we modified our ED sepsis order set (Images 1 and 2) to include cephalosporin options in patients with reported mild-to-moderate PCN reaction histories. This was a single-center, retrospective analysis evaluating the impact of this change on antibiotic prescribing and associated outcomes. Methods An electronic medical record (EMR) report identified patients ≥18 years of age with a documented PCN allergy that received antibiotics via the ED sepsis order set from December 30, 2012 to September 28, 2013 (pre-intervention) and January 3, 2014 to July 18, 2015 (post-intervention). The primary objective was to compare antibiotic days of therapy (DOT) and length of therapy (LOT) between the pre- and post-groups. The secondary objectives included 30-day readmission and mortality, hospital length of stay (LOS), incidence of C. difficile within 6 months and documented hypersensitivity reactions. Bivariate analyses, with chi-square, Mann–Whitney U, and Poisson means test, were used. Results A total of 180 patients (90 pre- and 90 post-intervention) were included. Demographics were similar between groups, with the exception of congestive heart failure (CHF) which was more prevalent in the post-intervention group (P = 0.039). Aztreonam, vancomycin, aminoglycoside, and fluoroquinolone DOTs were significantly reduced (P < 0.001) while cephalosporin DOTs significantly increased (P < 0.001) in the post-intervention group. There were no statistical differences in antibiotic LOT, 30-day readmission and mortality, hospital LOS, or incidence of C. difficile infection. For those patients that received cephalosporin antibiotics, there were no hypersensitivity reactions documented in the EMR. Conclusion Stratifying ED sepsis order sets by PCN allergy history severity is a safe and effective intervention that reduces second-line antibiotics in PCN allergic patients presenting to the ED with suspected sepsis. Disclosures All authors: No reported disclosures.

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87. Utilization of Methicillin-Sensitive/Resistant Staphylococcus aureus Nares Screen to Decrease Vancomycin and Linezolid Use in Hospitalized Patients with Respiratory Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.132 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S60-S60

Author(s):

Noor F Zaidan ◽

Rachel S Britt ◽

David Reynoso ◽

R Scott Ferren

Keyword(s):

Staphylococcus Aureus ◽

Respiratory Infections ◽

Intervention Group ◽

Kidney Injury ◽

Post Intervention ◽

Gram Positive ◽

Stewardship Program ◽

Screening Protocol ◽

The Impact ◽

Post Intervention Group

Abstract Background Pharmacist-driven protocols for utilization of methicillin-resistant Staphylococcus aureus (MRSA) nares screenings have shown to decrease duration of empiric gram-positive therapy and rates of acute kidney injury (AKI) in patients with respiratory infections. This study evaluated the impact of a pharmacist-driven MRSA nares screening protocol on duration of vancomycin or linezolid therapy (DT) in respiratory infections. Methods Patients aged 18 years and older with a medication order of vancomycin or linezolid for respiratory indication(s) were included. The MRSA nares screening protocol went into effect in October 2019. The protocol allowed pharmacists to order an MRSA nares polymerase chain reaction (PCR) for included patients, while the Antimicrobial Stewardship Program (ASP) made therapeutic recommendations for de-escalation of empiric gram-positive coverage based on negative MRSA nares screenings, if clinically appropriate. Data for the pre-intervention group was collected retrospectively for the months of October 2018 to March 2019. The post-intervention group data was collected prospectively for the months of October 2019 to March 2020. Results Ninety-seven patients were evaluated within both the pre-intervention group (n = 50) and post-intervention group (n = 57). Outcomes for DT (38.2 hours vs. 30.9 hours, P = 0.601) and AKI (20% vs. 14%, P = 0.4105) were not different before and after protocol implementation. A subgroup analysis revealed a significant reduction in DT within the pre- and post-MRSA PCR groups (38.2 hours vs. 24.8 hours, P = 0.0065) when pharmacist recommendations for de-escalation were accepted. Conclusion A pharmacist-driven MRSA nares screening protocol did not affect the duration of gram-positive therapy for respiratory indications. However, there was a reduction in DT when pharmacist-driven recommendations were accepted. Disclosures All Authors: No reported disclosures

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110. Impact of Diagnostic and Antimicrobial Stewardship on Time-to-Appropriate Therapy and Clinical Outcomes in Multi-Drug Resistant Pseudomonas Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.155 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S69-S70

Author(s):

Katie A McCrink ◽

Kailynn DeRonde ◽

Adriana Jimenez ◽

Gemma Rosello ◽

Yoichiro Natori ◽

...

Keyword(s):

Clinical Outcomes ◽

Antimicrobial Stewardship ◽

Patient Survival ◽

Intervention Group ◽

Culture Collection ◽

Drug Resistant ◽

Intervention Period ◽

Post Intervention ◽

Appropriate Therapy ◽

Post Intervention Group

Abstract Background Timely effective therapy in multi-drug resistant (MDR) Pseudomonas (PsA) infections has a direct impact on patient survival. We aimed to determine the impact of diagnostic and antimicrobial stewardship (AMS) on time-to-appropriate therapy (TAP) and clinical outcomes of patients with MDR PsA infections utilizing novel beta-lactam/beta-lactamase inhibitors (BL/BLIs). Methods Retrospective cohort study of adult patients with MDR PsA infections at a 1,500-bed University-affiliated public hospital in Miami, Florida who received ≥72 hours of ceftazidime-avibactam (C/A) or ceftolozane-tazobactam (C/T). During the pre-intervention period (12/2017-12/2018), additional susceptibilities for C/A and C/T were performed upon providers’ request. In the post intervention period (01/2019 – 12/2019), we implemented automatic reflex algorithms (Figure 1) for faster identification and susceptibilities for MDR PsA, including carbapenemase producers. Results were communicated in real-time to the AMS team. Figure 1. Reflex Testing Algorithm for MDR Pseudomonas Isolates from Any Source Results Seventy-six patients were included; median age was 56 years (IQR 37.5–67.0), 40 (52.6%) were in an intensive care unit at time of culture collection; median APACHE II score was 20 (IQR 15.0 – 26.0). Three isolates were carbapenemase producers (VIM = 2; KPC = 1). The most common infections were pneumonia (56.6%) and bacteremia (18.4%). We found a significant decrease in median TAP (120.1 [IQR 82.5–164.6] vs 75.9 [IQR 51.3–101.7] hours, p = 0.003). Median time from culture collection to final susceptibility results was shorter in the post-intervention group (122.2 vs 90.5 hours; p < 0.001). Median length-of-stay after culture collection was numerically lower in the post-intervention group (26.0 [11.6–59.4] vs 19.7 [12.9–37.8] days; p = 0.33). Controlling for ICU admission, our intervention was not associated with decreased 30-day inpatient mortality (OR = 1.62, 95% CI 0.45–5.79). Conclusion Our study identified an improvement in TAP in MDR PsA infections with implementation of diagnostic and AMS initiatives. In an adequately powered study, our intervention could potentially impact patient survival through timely initiation of effective therapy with novel BL/BLIs. Disclosures All Authors: No reported disclosures

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P39 Start smart: improving the quality of empiric antimicrobial prescribing at a tertiary paediatric hospital

Archives of Disease in Childhood ◽

10.1136/archdischild-2017-314585.48 ◽

2018 ◽

Vol 103 (2) ◽

pp. e2.43-e2

Author(s):

Michelle Kirrane ◽

Rob Cunney ◽

Roisin McNamara ◽

Ike Okafor

Keyword(s):

Antibiotic Therapy ◽

Drug Effects ◽

Empiric Antibiotic Therapy ◽

Antibiotic Prescribing ◽

Monday Morning ◽

Paediatric Hospital ◽

Antimicrobial Prescribing ◽

National Quality ◽

Empiric Antibiotic

Appropriate choice of empiric antibiotic therapy, in line with local guidelines, improves outcome for children with infection, while reducing adverse drug effects, cost, and selection of antimicrobial resistance. Data from national point prevalence surveys showed compliance with local prescribing guidelines at our hospital was suboptimal. A team with representatives from the pharmacy, microbiology and emergency departments collaborated with prescribers to improve the quality of empiric antibiotic prescribing. The project aim was, using the ‘Model for Improvement’, to ensure ≥90% of children admitted via the Emergency Department (ED) and commenced on antibiotic therapy, have a documented indication and a choice of therapy in line with local antimicrobial guidelines.MethodResults of weekly audits of the first ten children admitted via ED and started on antibiotics were fed back to prescribers. Front line ownership techniques were used to develop ideas for change, including; regular antibiotic prescribing discussion at Monday morning handover meeting, antibiotic ‘spot quiz’ for prescribers, updates to prescribing guidelines (along with improved access and promotion of prescribing app), printed ID badge guideline summary cards, reminders and guideline summaries at point of prescribing in ED.Collection of audit data initially proved challenging, but was resolved through a series of rapid PDSA cycles. Initial support from ED consultants and other ED staff facilitated establishment of the project. Presentation of weekly run charts to prescribers fostered considerable support among consultants and non-consultant doctors (NCHDs). We saw a shift in perspective from ‘how is your project going?’ to ‘How are we doing?’.ResultsDocumentation of indication and guideline compliance increased from a median of 30% in December 2014/January 2015 to 100% consistently from February 2015 to the present. It is felt that a change in approach to antimicrobial prescribing is now embedded in our hospital culture as this improvement has remained constant through three NCHD changeovers. A comparison of 2014 Antimicrobial expenditure to 2015 figures shows a reduction in expenditure of €101,078.44.ConclusionThis project has inspired other departments to develop local QIPs and has encouraged the surgical teams to lead their own audits in antimicrobial stewardship. An improvement in other areas of antimicrobial prescribing has also been noted e.g. documentation of review date.The initiative has been shared with other hospitals throughout Ireland via presentations at the National Patient Safety Conference, Antimicrobial Awareness day and the Irish Antimicrobial Pharmacist’s Group meeting. It has also been shared at both European and international conferences. The project was a shortlisted finalist for a national healthcare excellence award and has been rolled out as part of a national quality improvement collaborative.

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Antibiotic Prescribing Evaluation in an Outpatient Hemodialysis Clinic

Journal of Pharmacy Technology ◽

10.1177/875512250201800303 ◽

2002 ◽

Vol 18 (3) ◽

pp. 128-132 ◽

Cited By ~ 3

Author(s):

Harold J Manley ◽

Michael A Huke ◽

Mark A Dykstra ◽

Angela V Bedenbaugh

Keyword(s):

Antibiotic Therapy ◽

Empiric Therapy ◽

Prescribing Patterns ◽

Empiric Antibiotic Therapy ◽

Antibiotic Prescribing ◽

Gram Positive ◽

Hospital Infection Control ◽

Empiric Antibiotic ◽

Control And Prevention ◽

Gram Negative Organisms

Background Empiric vancomycin treatment is frequently used in hemodialysis (HD) patients because of ease of administration when methicillin-resistant Staphylococcus aureus (MRSA) infection is suspected. Differing rates of MRSA indicate that empiric antibiotic treatment should be based on a center-specific antibiogram. Objective To develop a center-specific antibiogram, evaluate antibiotic prescribing patterns, and determine areas of improvement in infection treatment. Methods The antibiogram was constructed from culture and susceptibility (C&S) data from January through December 1999. Evaluation of prescribing habits was based on 3 criteria: (1) Hospital Infection Control Practices Advisory Committee and Centers for Disease Control and Prevention guidelines; (2) vancomycin for 1 dose followed by appropriate antibiotic based on C&S results; and (3) C&S obtained with more than 1 dose of antibiotic. Results HD was provided to 161 patients during the study period. Antibiotics were empirically prescribed 104 times in 62 different patients. Cultures were obtained 122 times, and 67 different isolates were identified. Gram-positive organisms and gram-negative organisms accounted for 77.6% and 22.4% of isolates, respectively. Gram-positive organisms were identified as Staphylococcus spp. (53.8%); 17.9% of the staphylococcal isolates were MRSA strains. No isolates of vancomycin-resistant enterococcus were identified. Based on the antibiogram, empiric antibiotic therapy within our center should be 1 dose each of vancomycin and an aminoglycoside. Empiric vancomycin was used 71 times. When criterion I is used, 12 prescriptions (16.9%) were considered appropriate. When criterion II and adjustment for MRSA reported for our center were used, 46 (64.8%) vancomycin prescriptions were considered appropriate. Forty-one patients had more than 1 dose of antibiotic therapy, and 18 (43.9%) of those patients did not have C&S data obtained as prescribed by criterion III. Areas of prescribing improvement include obtaining a C&S in all suspected infections prior to empiric therapy and a more aggressive antibiotic switch based on C&S results. Conclusions Antibiograms can be used to determine appropriate empric antibiotic therapy and identify areas of improvement.

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Assessment of Direct Oral Anticoagulant Prescribing and Monitoring Pre- and Post-Implementation of a Pharmacy Protocol at a Community Teaching Hospital

Hospital Pharmacy ◽

10.1310/hpj5203-207 ◽

2017 ◽

Vol 52 (3) ◽

pp. 207-213 ◽

Cited By ~ 6

Author(s):

Christina Miele ◽

Mary Taylor ◽

Aditi Shah

Keyword(s):

Teaching Hospital ◽

Vitamin K Antagonists ◽

Intervention Group ◽

Adult Patients ◽

Patient Specific ◽

Post Intervention ◽

Appropriate Prescribing ◽

The Impact ◽

Post Intervention Group ◽

Community Teaching

Background Direct oral anticoagulants (DOACs) have become popular alternatives to vitamin K antagonists for the treatment and prevention of thromboembolic diseases; however, there are limited data regarding the appropriate use of DOACs in clinical practice. To ensure safety and efficacy of these medications, it is important that decisions regarding their use in patients rely on the available evidence. Objective The purpose of this study was to evaluate the appropriateness of DOAC prescribing in adult patients before and after the implementation of a pharmacist-driven DOAC protocol. Methods Data were collected on adult patients admitted to a community teaching hospital who received DOAC therapy for at least 2 days between January and March 2015 (pre-intervention group) and between January and March 2016 (post-intervention group). These data were analyzed to measure inappropriately prescribed DOACs, defined based on DOAC indication, renal function, drug interactions, and other pertinent patient-specific factors. Prior to the start of data collection for the post-intervention group, a pharmacist-driven protocol was developed and implemented. DOAC education was provided to pharmacists, including an evidence-based prescribing table to guide appropriate DOAC therapy. Comparisons were made between the pre-intervention and post-intervention groups to determine the impact of the pharmacist-driven service on appropriate DOAC prescribing. Results Fifty patients were analyzed in the pre-intervention group compared with 85 patients in the post-intervention group, with a total of 333 and 816 doses administered, respectively. Of the total doses administered, 32.4% were considered inappropriate in the pre-intervention group compared with 13.8% in the post-intervention group (adjusted odds ratio [OR], 0.42, 95% CI, 0.19-0.96; p = 0.039). Conclusions Implementing a pharmacist-driven DOAC service significantly improved appropriate prescribing of these agents. Provider education regarding DOAC use is essential to further increase appropriate prescribing of DOACs, optimize patients' therapy, and prevent adverse drug events.

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