A Retrospective Case Series of Concomitant Carbapenem and Valproic Acid Use: Are Best Practice Advisories Working?

Background: A Best Practice Advisory (BPA) warns clinicians of an interaction between carbapenems and valproic acid (VPA) that can cause significant declines in VPA levels leading to serious consequences for patients treated for seizure disorder and unknown implications for alternative indications. Objective: The goal of this study was to assess BPA efficacy in avoiding concomitant VPA/carbapenems, and to characterize use of these agents, clinical implications, and potential alternative therapeutic options. Methods: Retrospective chart review was performed on all patients over the course of 1 year who were concomitantly prescribed a carbapenem and VPA at Hartford Hospital, Hartford, CT. Data collected included: level of care, duration of concomitant therapy, indications, VPA levels during or surrounding overlap, documentation of the interaction, and therapeutic implications. Results: Carbapenems and VPA were administered to 591 and 625 patients, respectively; the BPA fired 126 times in 24 patients, and 15 patients were initiated on these agents concomitantly. Eight (53%) patients received VPA for seizures. The remaining seven (47%) received VPA for alternative indications. Eight of nine VPA levels were sub-therapeutic during carbapenem therapy and polypharmacy was administered in all patients receiving VPA for non-convulsive indications. Conclusion: Co-prescribing of these drugs was rare; however, the BPA was ineffective in 63% of instances. Reductions in VPA efficacy for any indication should be expected with concomitant carbapenem administration. Antibiotics other than carbapenems should be considered when coverage of multidrug resistant Gram-negative pathogens is required in patients whose VPA treatment cannot be interrupted or switched to a therapeutic alternative.

Antiseizure Medication Withdrawal in Seizure-Free Patients: Practice Advisory Update Summary

ObjectiveTo update a 1996 American Academy of Neurology practice parameter.MethodsThe authors systematically reviewed literature published from January 1991 to March 2020.ResultsThe long-term (24–60 months) risk of seizure recurrence is possibly higher among adults who have been seizure-free for 2 years and taper antiseizure medications (ASMs) vs those who do not taper ASMs (15% vs 7% per the 1 Class I article addressing this issue). In pediatric patients, there is probably no significant difference in seizure recurrence between those who begin tapering ASMs after 2 years vs 4 years of seizure freedom, and there is insufficient evidence of significant difference in risk of seizure recurrence between those who taper ASMs after 18 months of seizure freedom and those tapering after 24 months. There is insufficient evidence that the rate of seizure recurrence with ASM withdrawal following epilepsy surgery after 1 year of seizure freedom vs after 4 years is not significantly different than maintaining patients on ASMs. An epileptiform EEG in pediatric patients increases the risk of seizure recurrence. ASM withdrawal possibly does not increase the risk of status epilepticus in adults. In seizure-free adults, ASM weaning possibly does not change quality of life. Withdrawal of ASMs at 25% every 10 days to 2 weeks is probably not significantly different from withdrawal at 25% every 2 months in children who are seizure-free in more than 4 years of follow-up.RecommendationsFourteen recommendations were developed.

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

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

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

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

Impact of Automated Best Practice Advisories on Provider Response to CYP2C19 Genotyping Results for Patients on Clopidogrel

Objective The study objective was to examine provider acceptance and genotyping responses to a best practice advisory (BPA) concerning clopidogrel and CYP2C19 intermediate and poor metabolizers within the context of a new pharmacogenomics program at a Midwestern health system . Other secondary objectives analyzed included appropriate BPA firing, the distribution of alleles in study population, indications for clopidogrel use, and impact of indication on therapy change. Methods: In this study, the progress of this program was assessed by quantifying how providers respond to BPAs generated in the electronic medical record (EMR), in the context of a single representative gene–drug–outcome relationship. Patient data was pulled via reports yielding patients with genotyped information in the EMR and cross-referenced with a report evaluating BPA firing occurrences. Results: By capturing antiplatelet therapy changes in response to CYP2C19 genotyping results, 37 patients were found that had 73 BPAs fire. Nine of those patients had alternative antiplatelet therapy ordered. Of these, 6 alternative antiplatelet therapies were ordered from the BPA. Conclusion: Providers utilized BPAs, but responded differently based on individual knowledge of genotypes and indications. Information obtained from this study can be used for provider education and as reference for future design and wording of BPAs.

Leveraging American College of Obstetricians and Gynecologists Guidelines for Point-of-Care Decision Support in Obstetrics

Background The American College of Obstetricians and Gynecologists (ACOG) provides numerous narrative documents containing formal recommendations and additional narrative guidance within the text. These guidelines are not intended to provide a complete “care pathway” for patient management, but these elements of guidance can be useful for clinical decision support (CDS) in obstetrical and gynecologic care and could be exposed within electronic health records (EHRs). Unfortunately, narrative guidelines do not easily translate into computable CDS guidance. Objective This study aimed to describe a method of translating ACOG clinical guidance into clear, implementable items associated with specific obstetrical problems for integration into the EHR. Methods To translate ACOG clinical guidance in Obstetrics into implementable CDS, we followed a set of steps including selection of documents, establishing a problem list, extraction and classification of recommendations, and assigning tasks to those recommendations. Results Our search through ACOG clinical guidelines produced over 500 unique documents. After exclusions, and counting only sources relevant to obstetrics, we used 245 documents: 38 practice bulletins, 113 committee opinions, 16 endorsed publications, 1 practice advisory, 2 task force and work group reports, 2 patient education, 2 obstetric care consensus, 60 frequently asked questions (FAQ), 1 women's health care guidelines, 1 Prolog series, and 9 others (non-ACOG). Recommendations were classified as actionable (n = 576), informational (n = 493), for in-house summary (n = 124), education/counseling (n = 170), policy/advocacy (n = 33), perioperative care (n = 4), delivery recommendations (n = 50), peripartum care (n = 13), and non-ACOG (n = 25). Conclusion We described a methodology of translating ACOG narrative into a semi-structured format that can be more easily applied as CDS in the EHR. We believe this work can contribute to developing a library of information within ACOG that can be continually updated and disseminated to EHR systems for the most optimal decision support. We will continue documenting our process in developing executable code for decision support.

Narrative Review of Surgery for Myasthenia Gravis

Myasthenia Gravis (MG) is a rare autoimmune disorder characterized by antibody mediated blockade of neuromuscular transmission. Up until the last decade, evidence suggesting benefit of thymectomy for myasthenia gravis has been based on non-randomized control studies. Our paper serves as an expert narrative review of new literature pertaining to surgical management of myasthenia gravis based on review of articles from PubMed and Cochrane database from date of inception through June 14, 2021. We used the MeSH search terms: “myasthenia gravis”; “thymectomy”; “thymoma”; and “surgery” to identify any new relevant articles for inclusion in our review. The results of these studies are summarized below. We reviewed multiple articles including two randomized control trials. As a result of these studies over the past decade, the American Academy of Neurology’s most recent practice advisory, published online March 25, 2020, gives a level ‘B’ recommendation for thymectomy for MG in patients with acetylcholine receptor antibody-positive generalized MG age 18-65 years old. They additionally noted the need for further discussion surrounding the benefits and risks of surgery and whether minimally invasive approaches to thymectomy would provide the same benefits as the traditional transsternal approach. Evidence recommending thymectomy during pregnancy remains limited due to lack of available data. Emerging evidence suggests that performance of video-assisted or robotic-assisted thymectomy is feasible, but further study is needed due to a lack of randomized control trials.

Evaluation of a Pharmacist-Led Diabetes Collaborative Drug Therapy Management Service

Objective: To evaluate the pharmacist-led diabetes collaborative drug therapy management services in a family medicine and internal medicine clinic. Design: Mixed methods of evaluation based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Results: Reach: 71.3% of patients who were independently consulted (n = 184/258) and 1.6% (n = 11/680) of patients who triggered a best practice advisory (BPA) were enrolled. Effectiveness: 27.7% of patients (n = 54/195) enrolled were lost to follow-up. Adoption: 55% of eligible providers (n = 77/140) have placed a consult. Implementation: Providers independently choose to refer patients and are also prompted to place consults by a BPA that triggers for patients with an HbA1c ≥ 9%. Common reasons providers did not place a consult include: alignment with workflow, patient refusal, and patients followed by other services. Regarding patient perceptions, patients valued the service. Patients reported increased accountability with disease state maintenance and increased self-efficacy. Regarding how to improve the service, patients wanted more information on expectations before engaging with the pharmacist. Patients suggested to replicate this service for pain, cancer, and blood pressure management. Maintenance: 96.7% of providers (n = 30/31) reported they were very likely/likely to place a consult in the future and 60% of providers (n = 18/30) reported they were very likely/likely to place a consult when prompted by the BPA. Conclusion: These results can be utilized to make improvements to the pharmacist-led diabetes collaborative drug therapy management service to ensure sustainability. This study also provides lessons learned and strategies for future adoption, implementation, and maintenance of similar services for other disease states.