Microbiological profiles of tracheostomy patients: a single-center experience

Background: This study compared the prevalence of common microorganisms in obstructed and non-obstructed cases across the four quarters on the first post-tracheostomy year.Methods: A retrospective chart review of the microbiological profiles of all adult patients who underwent a tracheostomy was conducted between June 2015 and September 2019 at our hospital. Based on the tracheostomy indications, patients were allocated to obstructed or non-obstructed group. Any patient with at least one positive sample was followed up quarterly for a year. The first culture result obtained was recorded at least one month following the last antibiotic dose in each quarter.Results: Out of the 65 tracheal aspirate results obtained from 58 patients (mean age, 57.5±16.48 years), the most common procedure and indications were surgical tracheostomy (72.4%) and non-obstructed causes (74.1%), respectively. Moreover, 47.7% of the culture results indicated Pseudomonas aeruginosa, which showed significantly different proportions across the quarters (p=0.006). Among obstructed patients, P. aeruginosa was the most common (35%), followed by methicillin-resistant Staphylococcus aureus (MRSA; 23.5%).Conclusions: The most common post-tracheostomy microorganism was P. aeruginosa. MRSA showed a strong association with tracheostomy for obstructive indications.

143. Use of First-Generation Cephalosporins in Patients with Serious Penicillin Allergies

Background Penicillin allergies have a negative impact on patient outcomes due to utilization of second-line agents. Newer data suggests cephalosporins are well tolerated in penicillin allergies; however, none have solely evaluated anaphylactic penicillin allergies with first-generation cephalosporins. The purpose of this study was to evaluate the risk of any allergic reaction to first-generation cephalosporins compared to aztreonam in patients reporting anaphylaxis to an agent in the penicillin class. Methods This was a retrospective cohort study with patients who reported “anaphylaxis” to a penicillin agent and received cefazolin, cephalexin, or aztreonam. The final analysis included 220 patients: aztreonam (n=81), cefazolin (n=81), and cephalexin (n=58) (Figure 1). IgE-mediated reactions (within six hours of antibiotic administration) were defined as any one of the following: anaphylaxis, angioedema, urticarial rash, hypotension, immediate airway compromise, or receipt of epinephrine, hydrocortisone, or diphenhydramine. Non-IgE mediated reactions (within thirty days of antibiotic administration) included delayed hypersensitivity reactions and other dermatologic reactions. Figure 1: Patient Enrollment Patients admitted between January 1, 2013 to September 1, 2020 with a reported allergy of “anaphylaxis” to an agent in the penicillin class who received at least one dose of cefazolin, cephalexin, or aztreonam were screened for inclusion. Patients were excluded if the allergy was deleted from the electronic health record prior to antibiotic administration. All first-generation cephalosporin patients were included. Aztreonam patients were included in chronological order and limited to the number of included cefazolin patients. Results There were less allergic reactions in the first-generation cephalosporin group compared to the aztreonam group, but this was not statistically significant (7% vs. 14%, p=0.077). There were fewer IgE-mediated reactions in the cephalosporin group (6% vs. 14%, p=0.046). No difference in allergic reactions was observed when comparing those who received a single antibiotic dose versus multiple doses within the cephalosporin and aztreonam groups, respectively (3% vs. 11%, p=0.082, 20% vs. 12%, p=0.451). Because cephalexin has a similar R1 side chain to aminopenicillins, five patients with an aminopenicillin allergy who received cephalexin were evaluated separately; none had an allergic reaction (Table 1, Table 2, Figure 2). Table 1: Baseline Characteristics The median age was higher in the aztreonam group, and the majority of patients were female and Caucasian. There were significantly more pregnant females in the cephalosporin group, and the majority of patients reported a natural penicillin allergy. Table 2: Outcomes There were less allergic reactions (IgE or non-IgE mediated) in the first-generation cephalosporin group compared to the aztreonam group, but this was not statistically significant. Also, there were fewer IgE-mediated reactions in the cephalosporin group. There was no difference in allergic reactions in patients with two or more reported drug allergies compared to less than two drug allergies. No difference in allergic reactions was observed when comparing those who received a single antibiotic dose versus multiple doses within the cephalosporin and aztreonam groups. Of the five patients who received cephalexin and reported an aminopenicillin anaphylactic allergy, none had an allergic reaction. Additionally, there were not any patients readmitted within 30 days for delayed hypersensitivity reactions and no antibiotics were discontinued due to other documented adverse reactions. Figure 2: Occurrence of Allergic Reactions Of the patients who had allergic reactions in the cephalosporin and aztreonam groups, these included immediate airway compromise, hypotension with one patient in the aztreonam group receiving vasopressors within the pre-defined time frame, receipt of the non-standing rescue medication of diphenhydramine, and drug rash. Conclusion There was no difference in the incidence of allergic reactions between the aztreonam and first-generation cephalosporin group, and fewer serious allergic reactions occurred in the cephalosporin group. This study suggests that cefazolin and cephalexin can safely be used in patients who report anaphylaxis to an agent in the penicillin class. Disclosures Janessa Smith, PharmD, Merck & Co. (Employee)

CARBAPENEM ANTIBIOTIC DOSE MODE FOR PEDIATRIC PATIENT AT CAN THO CHILDREN’S HOSPITAL

Objective: Analyzing the dose regimen of carbapenem antibiotics used in pediatric patients at Can Tho Children’s Hospital.Objects and methods: retrospective-descriptive study on 140 medical records of patients being treated at departments of Can Tho Children’s Hospital during the period from June 1st, 2020 toDecember 31st, 2020. Results: Regarding the dosage regimen characteristics of meropenem showed that 20.3% and 10.8%of meropenem’s indications for the dose of meropenem for non-central nervous system infections and meningitis treament was appropriate according to the recommendations. Meanwhile, up to63.5% of the dose was higher than the recommended dose and 5.5% of the treatment dose was lower than the recommended dose. Regarding imipenem dosage regimen characteristics from the resultsshowed that 71.2% of the dose of imipenem for the treatment of infections non-central nervous system complied with recommendations according to the literature. However, more than 20% of the recommended dose for patients was lower than recommended dose. Conclusion: The meropenem dose regimen was consistent with the recommendation was low. The imipenem dose regimen was consistent with the relatively high recommendation.

THE REASONABLENESS OF USING DRUGS TO TREAT PNEUMONIA

Objective: To investigate the reasonableness of using drugs to treat pneumonia at Can Tho Children’s Hospital. Subjects and methods: a retrospective-descriptive study on 384 inpatient medical records at Can Tho Children’s Hospital from January 2019 to December 2019 was diagnosed pneumonia. Results: The percentage of the initial treatment regimen that was not reasonable with the recommended antibiotic regimen was relatively high at 84.11%. The proportion of antibiotics with inappropriate dose was only 1.71% of the total number of surveyed cases. The appropriate rate of antibiotic dose was 98.29%. The proportion of adjuvants with high appropriate doses such as Salbutamol, Hydrocortison and Prednisolon accounted for 100%. The rate of taking antibiotics in accordance with recommendations accounted for 94.67%. The rate of adjuvanvt drug delivery was very high, there were only a few cases that did not comply with recommendations such as Ibuprofen with 14 cases, accounting for 37.84%, Acetylcysteine ​​and Hydrocortison accounted for 14.58% with 7 cases, and Prednisolon and Budesonid accounted for the very low percentage. Conclusion: The proportion of the initial treatment regimen that was not compatible with the antibiotic regimen was relatively high. The appropriate rate of antibiotic dose was high. The proportion of adjuvants with suitable doses was high such as Salbutamol, Hydrocortison and Prednisolon. The antibiotic delivery rate was consistent with recommendations. The rate of adjuvant delivery was very high.

MO417NEPHROLOGIST INTERVENTION TO AVOID KIDNEY REPLACEMENT THERAPY IN ACUTE KIDNEY INJURY

Background and Aims Based on the pathophysiology of acute kidney injury (AKI) it is plausible that certain early interventions by the nephrologist could influence its trajectory. In this study, we investigated the impact of 5 early nephrology interventions on starting kidney replacement therapy (KRT), AKI progression and death. Method In a prospective cohort at Hospital Civil of Guadalajara, we followed-up for 10 days AKI patients in whom a nephrology consultation was requested. We analyzed 5 early interventions of the nephrology team (fluid adjustment, nephrotoxic withdrawal, antibiotic dose adjustment, nutritional adjustment and removal of hyperchloremic solutions) after propensity score and multivariate analysis for the risk of starting KRT (primary objective), AKI progression to stage 3 and death (secondary objectives). Results From 2017 to 2020 we analyzed 288 AKI patients. The mean age was 55.3 years, 60.7% were male, AKI KDIGO stage 3 was present in 50.5% of them, sepsis was the main etiology 50.3%, and 72 (25%) patients started KRT. The overall survival was 84.4%. Fluid adjustment was the only intervention associated with a decreased risk for starting KRT (OR 0.58, 95% CI 0.48-0.70, p = <0.001) and AKI progression to stage 3 (OR 0.59, 95% CI 0.49-0.71, p = <0.001). Receiving vasopressors and KRT were associated with mortality, but neither of these interventions reduced these risks. Conclusion In this prospective cohort study of AKI patients, we found for the first time that early nephrologist intervention and fluid prescription adjustment was associated with a reduction in the risk of starting KRT and progression to AKI stage 3.

Urinary tract infection pocket card effect on preferred antimicrobial prescribing for cystitis among patients discharged from the emergency department

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To evaluate the impact of a urinary tract infection (UTI) pocket card on preferred antibiotic prescribing for patients discharged from the emergency department (ED) with a diagnosis of cystitis. Methods A multicenter, retrospective, pre-post study was conducted to compare outcomes following the introduction of a UTI pocket card. The primary outcome was prescribing rates for institutional first-line preferred antibiotics (cephalexin and nitrofurantoin) versus other antimicrobials for cystitis. Secondary outcomes included prescriber adherence to recommended therapy in regards to discharge dose, frequency, duration, and healthcare utilization rates. Results The study included 915 patients in total, 407 in the preintervention group and 508 in the postintervention group. The frequency of preferred antibiotic prescribing was significantly increased after the introduction of a UTI pocket card compared to prior to its introduction (81.7% vs 72.0%, P = 0.001). Significant increases in prescribing of an appropriate antibiotic dose (78.0% vs 66.8%, P < 0.0001) and frequency (64.2% vs 47.4%, P < 0.0001) were also found post intervention. No significant differences were seen between the pre- and postintervention groups with regards to healthcare utilization rates. Conclusion A UTI pocket card increased preferred antibiotic prescribing for cystitis in the ED. This study provides data on a successful antimicrobial stewardship intervention in the ED setting.

Evaluating the Addition of a Clinical Pharmacist Service to a Midlevel Provider-Driven Culture Follow-up Program in a Community Emergency Department

Background: The impact that an antimicrobial stewardship program can have on an inpatient setting has been well documented, but there are limited data on the use of an antimicrobial stewardship program in the emergency department (ED). Objective: The objective of this study was to assess the impact of adding a pharmacist service to a midlevel provider-driven culture follow-up program in the ED on achieving optimal therapy. Methods: This was a quasi-experimental study with designations of pre- and post-interventions conducted at a large community hospital with the pre-intervention phase occurring from June 1, 2019, to August 31, 2019, and the post-intervention phase occurring from January 1, 2020, to March 31, 2020. The primary outcome was optimal antimicrobial therapy: a composite of optimal antibiotic, dose, and duration, prescribed after the culture resulted. Secondary outcomes included optimal antibiotic, dose, duration, and return to the ED within 30 days due to infection. Results: Optimal antimicrobial therapy received after the culture resulted occurred in 59 patients (26.81%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase ( P = .003). For the secondary outcomes, optimal antibiotic choice occurred in 115 patients (52.27%) in the pre-implementation phase and 66 patients (72.53%) in the implementation phase ( P = .001). Optimal antibiotic dose occurred in 113 patients (51.36%) in the pre-implementation phase and 65 patients (71.43%) in the implementation phase ( P = .001). Optimal antibiotic duration occurred in 65 patients (29.55%) in the pre-implementation phase and 40 patients (43.96%) in the implementation phase ( P = .014). Conclusions: The addition of a clinical pharmacist service in a midlevel provider-driven ED culture callback program resulted in an increased rate of achieving optimal antimicrobial therapy.

Alternative Therapies

Antibiotic resistance is one of the leading public health concerns across the globe. Antibiotics are losing their effectiveness, leading to uncertainty in available treatment options to clinicians. Resistance to antibiotics is at an all-time high, and there is a pressing demand to look for alternative antimicrobial candidates other than antibiotics. Alternative therapies include use of bacteriophages, lytic proteins, nanoparticles, phytochemicals, quorum quenchers, and other antibacterial or antivirulent agents that can eradicate bacterial infection alone or in conjunction with antibiotics. Alternative therapies can replace or lower the effective antibiotic dose, which can help to tackle antibiotic resistance as well as counter its side effects. For sustainable development of antimicrobials against drug resistant bugs, novel alternative strategies need to be explored in the near future. Alternative therapies can help researchers to construct a toolbox containing a variety of antimicrobial agents, which can be used alone, in combination with other agents, or in rotation.

Cefiderocol Retains Anti-Biofilm Activity in Multi-Drug Resistant Gram-Negative Pathogens

Cefiderocol is a siderophore cephalosporin with potent antibacterial activity against a broad range of Gram-negative pathogens, including multi-drug resistant strains. Siderophore antibiotics bind ferric iron and utilize iron transporters to cross the cell membrane. In the biofilm setting, where antibiotic resistance is high but iron scavenging is important, cefiderocol may have advantageous antimicrobial properties. In this study, we compared the antimicrobial activity of cefiderocol to seven commonly used antibiotics in well-characterized multi-drug resistant pathogens, then determined their efficacy in the biofilm setting. MIC90 values were consistently lower for cefiderocol in all strains tested compared to other antibiotics (ceftolozane-tazobactam, ceftazidime-avibactam, ceftazidime, piperacillin-tazobactam, imipenem, tobramycin, clarithromycin). Cefiderocol treatment displayed a superior reduction in Pseudomonas aeruginosa biofilm (93%, p<0.0001) compared to other antibiotics (49-82%). Cefiderocol was generally as effective or superior in reducing biofilm in other pathogens depending on the pathogen-antibiotic combination. There was a trend towards greater biofilm reduction when the antibiotic dose was increased or with increased frequency of antibiotic treatment. We conclude that cefiderocol effectively reduces biofilm and is a potent inhibitor of planktonic growth across a range of Gram-negative medically important pathogens.