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Tang KM, Lee P, Anosike BI, Asas K, Cassel-Choudhury G, Devi T, Gennarini L, Raizner A, Rhim HJH, Savva J, Shah D, Philips K. Decreasing Prescribing Errors in Antimicrobial Stewardship Program-Restricted Medications. Hosp Pediatr 2024; 14:281-290. [PMID: 38482585 DOI: 10.1542/hpeds.2023-007548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVES Antimicrobial stewardship programs (ASPs) restrict prescribing practices to regulate antimicrobial use, increasing the risk of prescribing errors. This quality improvement project aimed to decrease the proportion of prescribing errors in ASP-restricted medications by standardizing workflow. METHODS The study took place on all inpatient units at a tertiary care children's hospital between January 2020 and February 2022. Patients <22 years old with an order for an ASP-restricted medication course were included. An interprofessional team used the Model for Improvement to design interventions targeted at reducing ASP-restricted medication prescribing errors. Plan-Do-Study-Act cycles included standardizing communication and medication review, implementing protocols, and developing electronic health record safety nets. The primary outcome was the proportion of ASP-restricted medication orders with a prescribing error. The secondary outcome was time between prescribing errors. Outcomes were plotted on control charts and analyzed for special cause variation. Outcomes were monitored for a 3-month sustainability period. RESULTS Nine-hundred ASP-restricted medication orders were included in the baseline period (January 2020-December 2020) and 1035 orders were included in the intervention period (January 2021-February 2022). The proportion of prescribing errors decreased from 10.9% to 4.6%, and special cause variation was observed in Feb 2021. Mean time between prescribing errors increased from 2.9 days to 8.5 days. These outcomes were sustained. CONCLUSIONS Quality improvement methods can be used to achieve a sustained reduction in the proportion of ASP-restricted medication orders with a prescribing error throughout an entire children's hospital.
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Affiliation(s)
- Katherine M Tang
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Philip Lee
- Children's Hospital at Montefiore, Bronx, New York
| | - Brenda I Anosike
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Kathleen Asas
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Gina Cassel-Choudhury
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Tanvi Devi
- Children's Hospital at Montefiore, Bronx, New York
| | - Lisa Gennarini
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Aileen Raizner
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Hai Jung H Rhim
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Dhara Shah
- Children's Hospital at Montefiore, Bronx, New York
| | - Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
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Reyes RE, López MJ, Pérez JE, Martínez G. Description of changes in clinical outcomes following the implementation of an antibiotic stewardship program in a level IV hospital. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:244-251. [PMID: 37433162 PMCID: PMC10540980 DOI: 10.7705/biomedica.6748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 05/09/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Inadequate prescription of antibiotics has been recognized as a public health problem by the World Health Organization. In this context, antibiotic stewardship programs have been implemented as a tool to mitigate its impact. OBJETIVE To describe the changes in clinical outcomes after the implementation of an antibiotic stewardship program in a level IV hospital. MATERIALS AND METHODS We conducted a unique cohort study of patients hospitalized for infectious pathologies that were treated with antibiotics in an advanced medical facility. We collected the clinical history before the implementation of the antibiotic stewardship program (2013 to 2015) and then we compared it to the records from 2018 to 2019 collected after the implementation of the program. We evaluated changes in clinical outcomes such as overall mortality, and hospital stay, among others. RESULTS We analyzed 1,066 patients: 266 from the preimplementation group and 800 from the post-implementation group. The average age was 59.2 years and 62% of the population was male. Statistically significant differences were found in overall mortality (29% vs 15%; p<0.001), mortality due to infectious causes (25% vs 9%; p<0.001), and average hospital stay (45 days vs 21 days; p<0.001); we also observed a tendency to decrease hospital readmission at 30 days for infectious causes (14% vs 10%; p=0.085). CONCLUSIONS The antibiotic stewardship program implemented was associated with a decrease in overall mortality and mortality due to infectious causes, as well as in average hospital stay. Our results evidenced the importance of interventions aimed at mitigating the impact of inadequate prescription of antibiotics.
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Affiliation(s)
- Raúl Eduardo Reyes
- Servicio de Medicina Interna, Hospital Militar Central, Bogotá, D.C., Colombia.
| | - María José López
- Servicio de Infectología, Hospital Militar Central, Bogotá, D.C., Colombia.
| | | | - Gustavo Martínez
- Servicio de Medicina Interna, Hospital Militar Central, Bogotá, D.C., Colombia.
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3
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Wang Q, Zhang X, Zheng F, Wang L, Yu T. Clinicians' Intention to Submit Microbiological Pathogenic Test Before Antibiotics Use and Its Influencing Factors: New Evidence from the Perspective of Hospital Management. Infect Drug Resist 2022; 15:3013-3023. [PMID: 35720253 PMCID: PMC9199522 DOI: 10.2147/idr.s366892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Antimicrobial resistance (AR) is a global public health problem, improving clinicians’ intention to submit microbiological pathogenic test (submission intention) can effectively increase the value for rational use antibiotics to curb AR. However, there are few studies on the factors influencing improvement of the submission intention, especially from the perspective of hospital management. This study will fill the gap and provide evidence that can continuously support improvement of antibiotics prescribing rationally. Patients and Methods A cross-sectional survey of clinicians was conducted in all public hospitals in Hubei, China. Dependent variables were submission intention of non-restricted-use, restricted-use and special-use antibiotics which were measured submission, not sure submission, no submission. Independent variables were frequency of training and publicity on submission, and hospital with or without submission performance assessment, guideline, information decision system and laboratory items, including bacterial culture item, fungal culture item and so on. Clinicians’ demographics were applied as control variables. Multinomial logistic regression was performed to model independent variables influencing submission intention. Results For non-restricted-use antibiotics, guideline (OR = 0.263; 95% CI = [0.188, 0.369]) (OR = 0.526; 95% CI = [0.375, 0.738]) and bacterial culture item (OR = 0.141; 95% CI = [0.074, 0.268]) (OR = 0.520; 95% CI = [0.292, 0.927]) are key factors that positively affect clinicians’ intention on submission and not sure submission; For restricted-use and special-use antibiotics, training frequency and bacterial culture item (OR = 0.155; 95% CI = [0.076, 0.315]) (OR = 0.092; 95% CI = [0.036, 0.232]) (OR = 0.106; 95% CI = [0.046, 0.248]) (OR = 0.027; 95% CI = [0.006, 0.117]) are key factors that positively affect clinicians’ intention on submission and not sure submission. Conclusion This study found that bacterial culture item, guideline, and training frequency are key factors that affect clinicians’ intention on submission and not sure submission, but various factors exist different effects level on different types of antibiotics. Consequently, a focus should be placed on the construction and implementation of management factors, as well as reformation of antimicrobial stewardship in hospitals according to the types of antibiotics.
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Affiliation(s)
- Qianning Wang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Xinping Zhang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Feiyang Zheng
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Lu Wang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Tiantian Yu
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
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4
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Recent Updates in Antimicrobial Stewardship in Outpatient Parenteral Antimicrobial Therapy. Curr Infect Dis Rep 2021; 23:24. [PMID: 34776793 PMCID: PMC8577634 DOI: 10.1007/s11908-021-00766-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/11/2022]
Abstract
Purpose of Review Antimicrobial stewardship within acute care is common and has been expanding to outpatient areas. Some inpatient antimicrobial stewardship tactics apply to outpatient parenteral antimicrobial therapy (OPAT) and complex outpatient antimicrobial therapy (COpAT) management, but differences do exist. Recent Findings OPAT/COpAT is a growing area of practice and research with its own unique considerations for antimicrobial stewardship. Potential ideas for antimicrobial stewardship in the OPAT/COpAT setting include redesigning the regimen to COpAT instead of OPAT, ensuring the use of the shortest effective duration of antimicrobial therapy; using antimicrobials dosed less frequently, such as long-acting glycopeptides; optimizing antimicrobial susceptibility testing reporting for common OPAT/COpAT drugs; and establishing routine laboratory and safety monitoring. Future consensus is needed to determine validated OPAT program metrics and outcomes. Summary As more focus is placed on outpatient antimicrobial stewardship, clinicians practicing in OPAT should publish more data regarding OPAT program methods and outcomes as they relate to antimicrobial stewardship. These can involve patient clinical outcomes, OPAT readmission rates, OPAT therapy completion, and central line-related complications.
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5
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Kimball JM, Deri CR, Nesbitt WJ, Nelson GE, Staub MB. Development of the Three Antimicrobial Stewardship E's (TASE) framework and Association between Stewardship Interventions and intended Results (ASIR) analysis to identify key facility-specific interventions and strategies for successful antimicrobial stewardship. Clin Infect Dis 2021; 73:1397-1403. [PMID: 33983389 DOI: 10.1093/cid/ciab430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Successful antimicrobial stewardship (AS) interventions have been described previously. Currently, a uniform operational approach to planning and implementing successful AS interventions does not exist. From 2015 to 2019, concomitant vancomycin and piperacillin-tazobactam use (CVPTU) for >48 hours at Vanderbilt University Medical Center (VUMC) significantly decreased through AS efforts. We analyzed the interventions that led to this change and created a model to inform future intervention planning and development. METHODS VUMC adult admissions from January 2015 to August 2019 were evaluated for CVPTU. Percentage of admissions receiving CVPTU >48 hours, the primary outcome, was evaluated using statistical process control charts. We created the Three Antimicrobial Stewardship E's (TASE) framework and Association between Stewardship Interventions and intended Results (ASIR) analysis to assess potential intensity and impact of interventions associated with successful change during this time period and to identify guiding principles for development of future initiatives. RESULTS The mean percentage of admissions receiving CVPTU per month declined from 4.2% to 0.7%. Over 8 time periods, we identified 4 high, 3 moderate and 1 low intervention intensity periods. Continuous provider-level AS education was present throughout. Creation and dissemination of division and department algorithms and reinforcement via computerized provider order entry sets preceded the largest reduction in CVPTU and sustained prescribing practice changes. CONCLUSIONS The TASE framework and ASIR analysis successfully identified pivotal interventions and strategies needed to effect and sustain change at VUMC. Further research is needed to validate its effectiveness as a stewardship intervention planning tool at our institution and others.
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Affiliation(s)
- Joanna M Kimball
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Connor R Deri
- Antimicrobial Stewardship and Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Whitney J Nesbitt
- Antimicrobial Stewardship and Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - George E Nelson
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Milner B Staub
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
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6
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Salzo A, Ripabelli G, Sammarco ML, Mariano A, Niro C, Tamburro M. Healthcare-Associated Infections and Antibiotics Consumption: A Comparison of Point Prevalence Studies and Intervention Strategies. Hosp Top 2021; 99:140-150. [PMID: 33792522 DOI: 10.1080/00185868.2021.1902758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study compares healthcare-associated infections (HAIs) prevalence and antimicrobial consumption (AMC) from surveys conducted in 2016 and 2019 in an Italian hospital for acute care. HAIs prevalence was 7.1% in both surveys, while patients were under antibiotic treatment slightly increased from 2016 to 2019, from 42.6% to 43.7%, respectively. In the survey of 2016, HAIs risk factors were fatal McCabe score and hospitalization longer than two weeks, while CVC and urinary catheter in that conducted in 2019. In both surveys, CVC and peripheral venous catheter resulted associated to AMC. HAIs and AMC remained stable although the hospital undergone a complexity reduction in the second survey, remarking that critical actions are strictly required implementing infection control practices and antimicrobial stewardship.
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Affiliation(s)
- Angelo Salzo
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Giancarlo Ripabelli
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Michela Lucia Sammarco
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Andrea Mariano
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Cristina Niro
- Molise Regional Health Authority, "Antonio Cardarelli" Hospital, Campobasso, Italy
| | - Manuela Tamburro
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
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7
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Ozkaynak M, Metcalf N, Cohen DM, May LS, Dayan PS, Mistry RD. Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments. Appl Clin Inform 2020; 11:589-597. [PMID: 32906153 DOI: 10.1055/s-0040-1715893] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions. METHODS Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis. RESULTS Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing. DISCUSSION The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization). CONCLUSION Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Noel Metcalf
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Larissa S May
- Department of Emergency Medicine, UC Davis Health, Davis, California, United States
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D Mistry
- Department of Pediatrics and Emergency Medicine, Section of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
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8
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Gregoriano C, Heilmann E, Molitor A, Schuetz P. Role of procalcitonin use in the management of sepsis. J Thorac Dis 2020; 12:S5-S15. [PMID: 32148921 DOI: 10.21037/jtd.2019.11.63] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Important aspects of sepsis management include early diagnosis as well as timely and specific treatment in the first few hours of triage. However, diagnosis and differentiation from non-infectious causes often cause uncertainties and potential time delays. Correct use of antibiotics still represents a major challenge, leading to increased risk for opportunistic infections, resistances to multiple antimicrobial agents and toxic side effects, which in turn increase mortality and healthcare costs. Optimized procedures for reliable diagnosis and management of antibiotic therapy has great potential to improve patient care. Herein, biomarkers have been shown to improve infection diagnosis, help in early risk stratification and provide prognostic information which helps optimizing therapeutic decisions ("antibiotic stewardship"). In this context, the use of the blood infection marker procalcitonin (PCT) has gained much attention. There is still no gold standard for the detection of sepsis and use of conventional diagnostic approaches are restricted by some limitations. Therefore, additional tests are necessary to enable early and reliable diagnosis. PCT has good discriminatory properties to differentiate between bacterial and viral inflammations with rapidly available results. Further, PCT adds to risk stratification and prognostication, which may influence appropriate use of health-care resources and therapeutic options. PCT kinetics over time also improves the monitoring of critically ill patients with sepsis and thus influences decisions regarding de-escalation of antibiotics. Most importantly, PCT helps in guiding antibiotic use in patients with respiratory infection and sepsis by limiting initiation and by shortening treatment duration. To date, PCT is the best studied biomarker regarding antibiotic stewardship. Still, further research is needed to understand optimal use of PCT, also in combination with other remerging diagnostic tests for most efficient sepsis care.
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Affiliation(s)
- Claudia Gregoriano
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Eva Heilmann
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Alexandra Molitor
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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9
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Nace DA, Fridkin SK. Are Antibiograms Ready for Prime Time in the Nursing Home? J Am Med Dir Assoc 2020; 21:8-11. [PMID: 31888866 PMCID: PMC11040279 DOI: 10.1016/j.jamda.2019.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Scott K Fridkin
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA
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10
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Palavecino EL, Williamson JC, Ohl CA. Collaborative Antimicrobial Stewardship: Working with Microbiology. Infect Dis Clin North Am 2019; 34:51-65. [PMID: 31836331 PMCID: PMC7127374 DOI: 10.1016/j.idc.2019.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There have been tremendous advances in methodologies available for detection and identification of organisms causing infections. Providers can now obtain identification results and antimicrobial susceptibility results in a shorter period of time. However, declining health care resources highlight the importance of selecting the right test at the right time to maximize diagnostic benefits. Therefore, the role of the antimicrobial stewardship team in the clinical microbiology laboratory has expanded to include diagnostic stewardship and provision of guidance on test selection for diagnosis and management of infection. This review focuses on the experience of our group in collaborative stewardship, emphasizing successes and challenges.
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Affiliation(s)
| | - John C Williamson
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC, USA; Department of Internal Medicine, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Christopher A Ohl
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest Baptist Health, Winston-Salem, NC, USA.
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11
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Abstract
Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.
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12
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Ostrowsky B, Banerjee R, Bonomo RA, Cosgrove SE, Davidson L, Doron S, Gilbert DN, Jezek A, Lynch JB, Septimus EJ, Siddiqui J, Iovine NM. Infectious Diseases Physicians: Leading the Way in Antimicrobial Stewardship. Clin Infect Dis 2019; 66:995-1003. [PMID: 29444247 DOI: 10.1093/cid/cix1093] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/16/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Belinda Ostrowsky
- Montefiore Medical Center, Albert Einstein Medical Center, Bronx, New York
| | - Ritu Banerjee
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert A Bonomo
- Research and Medical Services Veterans Affairs Medical Center, Ohio.,Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Case Western Reserve University, Ohio.,Cleveland Geriatric Research Education and Clinical Center, Case Western Reserve University-Cleveland Veterans Affairs Medical Center, Center for Antimicrobial Resistance and Epidemiology, Ohio
| | - Sara E Cosgrove
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | - Lisa Davidson
- Carolinas Health Care System, Charlotte, North Carolina
| | | | - David N Gilbert
- Providence-Portland Medical Center, Portl.,Oregon Health Sciences University, Portl
| | - Amanda Jezek
- Infectious Diseases Society of America, Arlington, Virginia
| | - John B Lynch
- Harborview Medical Center, University of Washington, Seattle
| | - Edward J Septimus
- HCA Healthcare, Nashville, Tennessee.,Texas A&M College of Medicine, Houston
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13
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Tran CAT, Zschaebitz JV, Spaeder MC. Epidemiology of Blood Culture Utilization in a Cohort of Critically Ill Children. J Pediatr Intensive Care 2019; 8:144-147. [PMID: 31402991 PMCID: PMC6687448 DOI: 10.1055/s-0038-1676993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/26/2018] [Indexed: 12/23/2022] Open
Abstract
Blood culture acquisition is integral in the assessment of patients with sepsis, though there exists a lack of clarity relating to clinical states that warrant acquisition. We investigated the clinical status of critically ill children in the timeframe proximate to acquisition of blood cultures. The associated rates of systemic inflammatory response syndrome (72%) and sepsis (57%) with blood culture acquisition were relatively low suggesting a potential overutilization of blood cultures. Efforts are needed to improve decision making at the time that acquisition of blood cultures is under consideration and promote percutaneous blood draws over indwelling lines.
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Affiliation(s)
| | - Jenna Verena Zschaebitz
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, United States
| | - Michael Campbell Spaeder
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, United States
- Center for Advanced Medical Analytics, University of Virginia, Charlottesville, Virginia, United States
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14
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Abstract
Biomarkers are increasingly used in patients with serious infections in the critical care setting to complement clinical judgment and interpretation of other diagnostic and prognostic tests. The main purposes of such blood markers are (1) to improve infection diagnosis (i.e., differentiation between bacterial vs. viral vs. fungal vs. noninfectious), (2) to help in the early risk stratification and thus provide prognostic information regarding the risk for mortality and other adverse outcomes, and (3) to optimize antibiotic tailoring to individual needs of patients ("antibiotic stewardship").Especially in critically ill patients, in whom sepsis is a major cause of morbidity and mortality, rapid diagnosis is desirable to start timely and specific treatment.Besides some biomarkers, such as procalcitonin, which is well established and has shown positive effects in regard to utilization of antimicrobials and clinical outcomes, there is a growing number of novel markers from different pathophysiological pathways, where the final proof of an added value to clinical judgment and ultimately clinical benefit to patients is still lacking.Without a doubt, the addition of blood biomarkers to clinical medicine has had a strong impact on the way we care for patients today. Recent trials show that as an adjunct to other clinical and laboratory parameters these markers provide important information about risks for bacterial infection and resolution of infection. Moreover, biomarkers can help to optimize management of patients with serious illness in the intensive care unit, thereby offering more individualized treatment courses with overall improvements in clinical outcomes.
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Affiliation(s)
- Eva Heilmann
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Claudia Gregoriano
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Switzerland
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15
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Ripabelli G, Salzo A, Mariano A, Sammarco ML, Tamburro M. Healthcare-associated infections point prevalence survey and antimicrobials use in acute care hospitals (PPS 2016–2017) and long-term care facilities (HALT-3): a comprehensive report of the first experience in Molise Region, Central Italy, and targeted intervention strategies. J Infect Public Health 2019; 12:509-515. [DOI: 10.1016/j.jiph.2019.01.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 01/08/2019] [Accepted: 01/17/2019] [Indexed: 11/29/2022] Open
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16
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Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input. Methods A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting. Results The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use. Conclusions Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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Greene DJ, Gill BC, Hinck B, Nyame YA, Almassi N, Krishnamurthi V, Noble M, Sivalingam S, Monga M. American Urological Association Antibiotic Best Practice Statement and Ureteroscopy: Does Antibiotic Stewardship Help? J Endourol 2018; 32:283-288. [DOI: 10.1089/end.2017.0796] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Daniel J. Greene
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley C. Gill
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bryan Hinck
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Yaw A. Nyame
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nima Almassi
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Venkatesh Krishnamurthi
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mark Noble
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sri Sivalingam
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manoj Monga
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio
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Clemmons AB, Alexander M, DeGregory K, Kennedy L. The Hematopoietic Cell Transplant Pharmacist: Roles, Responsibilities, and Recommendations from the ASBMT Pharmacy Special Interest Group. Biol Blood Marrow Transplant 2017; 24:914-922. [PMID: 29292057 DOI: 10.1016/j.bbmt.2017.12.803] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/26/2017] [Indexed: 12/14/2022]
Abstract
Pharmacists are increasingly recognized as an essential member of the multidisciplinary team for hematopoietic cell transplant (HCT) patients. However, until recently, their educational background, required training, and potential roles have not been well described. Therefore, the purpose of this manuscript is to provide supporting evidence for the HCT Clinical Pharmacist Role Description, which has been endorsed by several organizations including the American Society for Blood and Marrow Transplantation. This document provides justification for the various roles pharmacists fulfill with respect to medication management, transitions of care, patient and provider education, policy development, quality improvement, and research. Furthermore, evidence supporting the value, financially and otherwise, HCT pharmacists provide is reviewed. Pharmacists in the HCT setting are encouraged to report on novel practice models and potential impact of their services to increase awareness and utilization of HCT pharmacists.
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Affiliation(s)
- Amber B Clemmons
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, Georgia; Department of Pharmacy, Augusta University (AU) Medical Center, Augusta, Georgia.
| | - Maurice Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Kathlene DeGregory
- Department of Pharmacy, University of Virginia Health System, Charlottesville, Virginia
| | - LeAnne Kennedy
- Department of Pharmacy, Wake Forest Baptist Health, Winston Salem, North Carolina
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Conway EL, Sellick JA, Horey A, Fodero K, Ott MC, Krajewski MP, Mergenhagen KA. Decreased mortality in patients prescribed vancomycin after implementation of antimicrobial stewardship program. Am J Infect Control 2017; 45:1194-1197. [PMID: 28739223 DOI: 10.1016/j.ajic.2017.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/06/2017] [Accepted: 06/08/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The impact of an antimicrobial stewardship program (ASP) on 30-day mortality rates was evaluated in patients prescribed vancomycin in a Veterans Affairs hospital. METHODS A retrospective chart review of patients receiving a minimum of 48 hours of vancomycin during October 2006-July 2014. A multivariate logistic regression analysis was used to determine predictors of mortality. Interventions of the ASP consist of appropriate antibiotic selection, dosing, microbiology, and treatment duration. RESULTS Death occurred in 12.4% of 453 patients. Of the 56 deaths, 64.3% occurred during prestewardship versus 35.7% during stewardship (P = .021). Increased mortality was associated with pre-ASP (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.13-4.27), age (unit OR, 1.08; 95% CI, 1.05-1.12), nephrotoxicity (OR, 3.24; 95% CI, 1.27-8.01), and hypotension (OR, 3.28; 95% CI, 1.42-7.44). Patients treated in the intensive care unit were associated with increased mortality. Patients in the stewardship group experienced lower rates of mortality, which may be caused by interventions initiated by the stewardship team, including minimizing nephrotoxicity and individualized chart review. CONCLUSIONS Mortality in patients treated with vancomycin was decreased after antimicrobial stewardship was implemented. As anticipated, older age, hypotension, nephrotoxicity, and intensive care unit admission were associated with an increased incidence of mortality.
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Affiliation(s)
- Erin L Conway
- Veterans Affairs Western New York Healthcare System, Buffalo, NY
| | - John A Sellick
- Veterans Affairs Western New York Healthcare System, Buffalo, NY; Division of Infectious Diseases, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Amy Horey
- Veterans Affairs Western New York Healthcare System, Buffalo, NY
| | - Kristen Fodero
- Veterans Affairs Western New York Healthcare System, Buffalo, NY
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20
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Lockwood AR, Bolton NS, Winton MD, Carter JT. Formalization of an antimicrobial stewardship program in a small community hospital. Am J Health Syst Pharm 2017; 74:S52-S60. [DOI: 10.2146/ajhp160609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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21
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Shah KB, Rimawi RH, Mazer MA, Cook PP. Can a collaborative subspecialty antimicrobial stewardship intervention have lasting effects? Infection 2017; 45:645-649. [PMID: 28726037 DOI: 10.1007/s15010-017-1047-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We previously demonstrated the benefit of direct, daily collaboration between infectious disease (ID) and critical care practitioners (CCP) on guideline adherence and antibiotic use in the medical intensive care unit (MICU). In this post-intervention review, we sought to establish whether the effect on antibiotic use and guideline adherence was sustainable. DESIGN A retrospective review of 87 patients, admitted to the 24-bed MICU, was done 3 (n = 45) and 6 months (n = 42) after the intervention. MEASUREMENTS Data included demographics, severity indicators, admitting pathology, infectious diagnosis, clinical outcomes [mechanical ventilation days (MVD) and MICU length of stay (LOS), antibiotic days of therapy (DOT), in-hospital mortality], and antibiotic appropriateness based on current guidelines. RESULTS In the 3-month (3-PI) and 6-month post-intervention (6-PI), there were no significant differences in the APACHE II score, MVD, LOS, DOT, or total antibiotic use at 3 (p = 0.59) and 6-PI (p = 0.87). There was no change in the mean use of extended-spectrum penicillins, cephalosporin, and carbapenems. While there were significant differences in vancomycin usage at 3-PI [3.1 DOT vs. 4.3 DOT (p = 0.007)], this finding was not seen after 6 months [3.1 DOT vs. 3.4 DOT (p = 0.08)]. When compared to the intervention period, the inappropriateness of antibiotic use at 3 (p = 1.00) and 6-PI (p = 0.30) did not change significantly. CONCLUSIONS There were no significant differences in either total antibiotic use or inappropriate antibiotic use at the 6-PI time period. Continuous, daily, direct collaboration between ID and CCP, once implemented, can have lasting effects even at 6 months after the interaction has been discontinued.
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Affiliation(s)
- Kaushal B Shah
- Division of Infectious Diseases, Department of Internal Medicine, The Brody School of Medicine at East Carolina University, Doctor's Park 6A, Mail Stop 715, Greenville, NC, 27834, USA.
| | - Ramzy H Rimawi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University, Brody School of Medicine, Greenville, NC, 27834, USA
| | - Mark A Mazer
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University, Brody School of Medicine, Greenville, NC, 27834, USA
| | - Paul P Cook
- Division of Infectious Diseases, Department of Internal Medicine, The Brody School of Medicine at East Carolina University, Doctor's Park 6A, Mail Stop 715, Greenville, NC, 27834, USA
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Current State of Antimicrobial Stewardship in Children's Hospital Emergency Departments. Infect Control Hosp Epidemiol 2017; 38:469-475. [PMID: 28173888 DOI: 10.1017/ice.2017.3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) effectively optimize antibiotic use for inpatients; however, the extent of emergency department (ED) involvement in ASPs has not been described. OBJECTIVE To determine current ED involvement in children's hospital ASPs and to assess beliefs and preferred methods of implementation for ED-based ASPs. METHODS A cross-sectional survey of 37 children's hospitals participating in the Sharing Antimicrobial Resistance Practices collaboration was conducted. Surveys were distributed to ASP leaders and ED medical directors at each institution. Items assessed included beliefs regarding ED antibiotic prescribing, ED prescribing resources, ASP methods used in the ED such as clinical decision support and clinical care guidelines, ED participation in ASP activities, and preferred methods for ED-based ASP implementation. RESULTS A total of 36 ASP leaders (97.3%) and 32 ED directors (86.5%) responded; the overall response rate was 91.9%. Most ASP leaders (97.8%) and ED directors (93.7%) agreed that creation of ED-based ASPs was necessary. ED resources for antibiotic prescribing were obtained via the Internet or electronic health records (EHRs) for 29 hospitals (81.3%). The main ASP activities for the ED included production of antibiograms (77.8%) and creation of clinical care guidelines for pneumonia (83.3%). The ED was represented on 3 hospital ASP committees (8.3%). No hospital ASPs actively monitored outpatient ED prescribing. Most ASP leaders (77.8%) and ED directors (81.3%) preferred implementation of ED-based ASPs using clinical decision support integrated into the EHR. CONCLUSIONS Although ED involvement in ASPs is limited, both ASP and ED leaders believe that ED-based ASPs are necessary. Many children's hospitals have the capability to implement ED-based ASPs via the preferred method: EHR clinical decision support. Infect Control Hosp Epidemiol 2017;38:469-475.
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Metcalfe J, Lam A, Lam SSH, de Clifford JM, Schramm P. Impact of the introduction of computerised physician order entry (CPOE) on the surveillance of restricted antimicrobials and compliance with policy. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2016. [DOI: 10.1002/jppr.1227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Julie Metcalfe
- Antimicrobial Stewardship/Infectious Diseases Pharmacist; Pharmacy Department; Frankston Hospital; Frankston Australia
| | - Alice Lam
- Senior Clinical Pharmacist; Pharmacy Department; Frankston Hospital; Frankston Australia
| | - Skip S. H. Lam
- Director of Pharmacy; Peninsula Health; Frankston Australia
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Avent ML, Hall L, Davis L, Allen M, Roberts JA, Unwin S, McIntosh KA, Thursky K, Buising K, Paterson DL. Antimicrobial stewardship activities: a survey of Queensland hospitals. AUST HEALTH REV 2016; 38:557-63. [PMID: 25376911 DOI: 10.1071/ah13137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 08/20/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. METHODS The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. RESULTS The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. CONCLUSIONS Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. WHAT IS KNOWN ABOUT THE TOPIC?: The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. WHAT DOES THE PAPER ADD?: This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.
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Affiliation(s)
- Minyon L Avent
- Infection and Immunity Theme, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Royal Brisbane and Women's Hospital, Herston, Qld 4006, Australia.
| | - Lisa Hall
- Centre for Healthcare Related Infection Surveillance and Prevention, Communicable Diseases Unit, Queensland Health, Herston, Qld 4006, Australia.
| | - Louise Davis
- Centre for Healthcare Related Infection Surveillance and Prevention, Communicable Diseases Unit, Queensland Health, Herston, Qld 4006, Australia.
| | - Michelle Allen
- Centre for Healthcare Related Infection Surveillance and Prevention, Communicable Diseases Unit, Queensland Health, Herston, Qld 4006, Australia.
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Qld 4029, Australia.
| | - Sean Unwin
- Princess Alexandra Hospital, Woolloongabba, Qld 4102, Australia.
| | - Kylie A McIntosh
- Department of Health, 50 Lonsdale Street, Melbourne, Victoria 3000.
| | - Karin Thursky
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Melbourne, Vic. 3000, Australia.
| | - Kirsty Buising
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Melbourne, Vic. 3000, Australia.
| | - David L Paterson
- Infection and Immunity Theme, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Royal Brisbane and Women's Hospital, Herston, Qld 4006, Australia.
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Early procalcitonin kinetics and appropriateness of empirical antimicrobial therapy in critically ill patients. J Crit Care 2016; 34:50-5. [DOI: 10.1016/j.jcrc.2016.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 12/20/2022]
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Spaeder MC, Soyer R. Risk Model of Bacterial Coinfection in Children with Severe Viral Bronchiolitis. J Pediatr Intensive Care 2016; 6:103-108. [PMID: 31073432 DOI: 10.1055/s-0036-1584810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022] Open
Abstract
Background Among children with respiratory failure from viral lower respiratory tract infection (LRTI), up to 39% will develop pulmonary bacterial coinfection, yet nearly all will receive antibiotics. We sought to identify patients with viral LRTI requiring mechanical ventilation at low risk of bacterial coinfection through the use of a risk prediction model. Methods We performed a retrospective cohort study identifying all patients admitted to the intensive care unit with laboratory-confirmed viral LRTI requiring invasive mechanical ventilation over a 2-year period and partitioned data in experimental and validation datasets. A multivariate probit regression model was constructed including variables associated with bacterial coinfection in the experimental dataset. Model was validated and recalibrated using the validation dataset. Model discrimination was assessed using receiver operating characteristic curve analysis. Results There were 126 patients included in the analysis. Variables associated with bacterial coinfection included tracheostomy in situ, Gram-stained smear white blood cells, and bacteria. The final recalibrated model discriminating between no coinfection and coinfection had an area under the curve of 0.8696. Conclusion Our prediction model identifies patients with viral LRTI requiring mechanical ventilation at very low risk of bacterial coinfection and has the potential to decrease antibiotic utilization without negatively impacting clinical outcome.
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Affiliation(s)
- Michael C Spaeder
- Division of Pediatric Critical Care, University of Virginia School of Medicine, Charlottesville, Virginia, United States
| | - Refik Soyer
- Department of Decision Science, The George Washington University School of Business, Washington, District of Columbia, United States
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del Pozo-Ruiz J, Martín-Pérez E, Malafarina V. Pharmacoeconomic and clinical aspect of a sequential intravenous to oral therapy plan in an acute geriatric ward. Eur Geriatr Med 2016. [DOI: 10.1016/j.eurger.2015.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Fodero KE, Horey AL, Krajewski MP, Ruh CA, Sellick JA, Mergenhagen KA. Impact of an Antimicrobial Stewardship Program on Patient Safety in Veterans Prescribed Vancomycin. Clin Ther 2016; 38:494-502. [PMID: 26831569 DOI: 10.1016/j.clinthera.2016.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/04/2015] [Accepted: 01/05/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE This study aimed to determine the safety impact of an antimicrobial stewardship program (ASP) on vancomycin-associated nephrotoxicity and to examine risk factors contributing to the development of toxicity. METHODS This was a retrospective chart review of data from 453 veterans receiving vancomycin in the VA Western New York Healthcare System between October 2006 and July 2014. Nephrotoxicity was defined as an increase in serum creatinine of ≥ 0.5 mg/dL or by 50% of baseline for 2 consecutive days. FINDINGS Patients receiving vancomycin after the implementation of the ASP were less likely to develop nephrotoxicity (odds ratio [OR] = 2.06; 95% CI, 1.02-4.28). Nephrotoxicity occurred in 6.84% of patients from the pre-ASP cohort and in 3.75% of patients after the implementation of the ASP. Predictors of nephrotoxicity included hospital service (surgical service, OR = 2.29; 95% CI, 1.13-4.64), elevated maximum trough concentration (unit OR = 1.15; 95% CI, 1.10-1.20), and concurrent piperacillin/tazobactam therapy (OR = 3.21; 95% CI, 1.43-7.96). The number of vancomycin trough concentration measurements per patient did not vary between the pre-ASP and ASP groups. IMPLICATIONS ASPs represent an important aspect of a patient-safety initiative in order to reduce vancomycin-associated nephrotoxicity. Concurrent piperacillin/tazobactam therapy, surgical service, and elevated maximum trough concentration were risk factors for nephrotoxicity.
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Affiliation(s)
- Kristen E Fodero
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York
| | - Amy L Horey
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York
| | - Michael P Krajewski
- Department of Pharmacy Practice, The State University of New York, Buffalo, New York
| | - Christine A Ruh
- Department of Pharmacy Practice, The State University of New York, Buffalo, New York
| | - John A Sellick
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York; Department of Medicine, University at Buffalo, Buffalo, New York
| | - Kari A Mergenhagen
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York.
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Pan IW, Kuo GM, Luerssen TG, Lam SK. Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients. Neurosurg Focus 2015; 39:E10. [DOI: 10.3171/2015.9.focus15385] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
This study explored antibiotic prophylaxis (AP) in pediatric patients undergoing intrathecal baclofen pump (ITBP) surgery and factors associated with perioperative AP compliance with clinical guidelines.
METHODS
Data were obtained from the Pediatric Health Information System. The study cohort comprised patients who underwent ITBP surgery within 3 days of admission, between July 1, 2004, and March 31, 2014, with a minimum prior screening period and follow-up of 180 days. Exclusion criteria were prior infection, antibiotic use within 30 days of admission, and/or missing financial data. Chi-square tests and multivariate logistic regressions were used to determine factors associated with compliance with AP guidelines in ITBP surgeries.
RESULTS
A total of 1,534 patients met the inclusion criteria; 91.5% received AP and 37.6% received dual coverage or more. Overall bundled compliance comprised 2 components: 1) perioperative antibiotic administration and 2) < 24-hour postoperative antibiotic course. The most frequently used antibiotics in surgery were cefazolin (n = 873, 62.2%) and vancomycin (n = 351, 25%). Documented bundled AP compliance rates were 70.2%, 62.0%, 66.0%, and 55.2% in West, South, Midwest, and Northeast regions of the US, respectively. Compared with surgeries in the Northeast, procedures carried out in the West (OR 2.0, 95% C11.4-2.9, p < 0.001), Midwest (OR 1.6, 95% C11.1-2.3, p = 0.007), and South (OR 1.5, 95% C11.1-2.0, p = 0.021) were more likely to have documented AP compliance. Black (OR 0.74, 95% CI 0.55-1.00, p = 0.05) and Hispanic (OR 0.63, 95% CI 0.47-0.86, p = 0.004) patients were less likely to have documented AP compliance in ITBP surgeries than white patients. There were no significant differences in compliance rate by age, sex, type of insurance, and diagnosis. AP process measures were associated with shorter length of stay, lower hospitalization costs, and lower 6-month rates of surgical infection/complication. One of the 2 noncompliance subgroups, missed preoperative antibiotic administration, was correlated with a significantly higher 6-month surgical complication/infection rate (27.03%) compared with bundled compliance (20.00%, p = 0.021). For the other subgroup, prolonged antibiotic use > 24 hours postoperatively, the rate was insignificantly higher (22.00%, p = 0.368). Thus, of direct relevance to practicing clinicians, missed preoperative antibiotics was associated with 48% higher risk of adverse complication/infection outcome in a 6-month time frame. Adjusted hospitalization costs associated with baclofen pump surgery differed significantly (p < 0.001) with respect to perioperative antibiotic practices: 22.83, 29.10, 37.66 (× 1000 USD) for bundled compliance, missed preoperative antibiotics, and prolonged antibiotic administration, respectively.
CONCLUSIONS
Significant variation in ITBP antibiotic prophylaxis was found. Documented AP compliance was associated with higher value of care, showing favorable clinical and financial outcomes. Of most impact to clinical outcome, missed preoperative antibiotics was significantly associated with higher risk of 6-month surgical complication/infection. Prolonged antibiotic use was associated with significantly higher hospital costs compared with those with overall bundled antibiotic compliance. Future research is warranted to examine factors associated with practice variation and how AP compliance is associated with outcomes and quality, aiming for improving delivery of care to pediatric patients undergoing ITBP procedures.
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Affiliation(s)
- I-Wen Pan
- 1Department of Neurosurgery, Baylor College of Medicine, and
- 2Division of Pediatric Neurosurgery, Texas Children’s Hospital, Houston, Texas; and
| | - Grace M. Kuo
- 3Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Thomas G. Luerssen
- 1Department of Neurosurgery, Baylor College of Medicine, and
- 2Division of Pediatric Neurosurgery, Texas Children’s Hospital, Houston, Texas; and
| | - Sandi K. Lam
- 1Department of Neurosurgery, Baylor College of Medicine, and
- 2Division of Pediatric Neurosurgery, Texas Children’s Hospital, Houston, Texas; and
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Chow ALP, Lye DC, Arah OA. Mortality Benefits of Antibiotic Computerised Decision Support System: Modifying Effects of Age. Sci Rep 2015; 5:17346. [PMID: 26617195 PMCID: PMC4663624 DOI: 10.1038/srep17346] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/27/2015] [Indexed: 11/09/2022] Open
Abstract
Antibiotic computerised decision support systems (CDSSs) are shown to improve antibiotic prescribing, but evidence of beneficial patient outcomes is limited. We conducted a prospective cohort study in a 1500-bed tertiary-care hospital in Singapore, to evaluate the effectiveness of the hospital’s antibiotic CDSS on patients’ clinical outcomes, and the modification of these effects by patient factors. To account for clustering, we used multilevel logistic regression models. One-quarter of 1886 eligible inpatients received CDSS-recommended antibiotics. Receipt of antibiotics according to CDSS’s recommendations seemed to halve mortality risk of patients (OR 0.54, 95% CI 0.26–1.10, P = 0.09). Patients aged ≤65 years had greater mortality benefit (OR 0.45, 95% CI 0.20–1.00, P = 0.05) than patients that were older than 65 (OR 1.28, 95% CI 0.91–1.82, P = 0.16). No effect was observed on incidence of Clostridium difficile (OR 1.02, 95% CI 0.34–3.01), and multidrug-resistant organism (OR 1.06, 95% CI 0.42–2.71) infections. No increase in infection-related readmission (OR 1.16, 95% CI 0.48–2.79) was found in survivors. Receipt of CDSS-recommended antibiotics reduced mortality risk in patients aged 65 years or younger and did not increase the risk in older patients. Physicians should be informed of the benefits to increase their acceptance of CDSS recommendations.
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Affiliation(s)
- Angela L P Chow
- Department of Clinical Epidemiology, Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore.,Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, United States
| | - David C Lye
- Department of Infectious Diseases, Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, United States.,Center for Health Policy Research, University of California, Los Angeles (UCLA), Los Angeles, United States
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Indications and Types of Antibiotic Agents Used in 6 Acute Care Hospitals, 2009-2010: A Pragmatic Retrospective Observational Study. Infect Control Hosp Epidemiol 2015; 37:70-9. [PMID: 26456803 DOI: 10.1017/ice.2015.226] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND To design better antimicrobial stewardship programs, detailed data on the primary drivers and patterns of antibiotic use are needed. OBJECTIVE To characterize the indications for antibiotic therapy, agents used, duration, combinations, and microbiological justification in 6 acute-care US facilities with varied location, size, and type of antimicrobial stewardship programs. DESIGN, PARTICIPANTS, AND SETTING Retrospective medical chart review was performed on a random cross-sectional sample of 1,200 adult inpatients, hospitalized (>24 hrs) in 6 hospitals, and receiving at least 1 antibiotic dose on 4 index dates chosen at equal intervals through a 1-year study period (October 1, 2009-September 30, 2010). METHODS Infectious disease specialists recorded patient demographic characteristics, comorbidities, microbiological and radiological testing, and agents used, dose, duration, and indication for antibiotic prescriptions. RESULTS On the index dates 4,119 (60.5%) of 6,812 inpatients were receiving antibiotics. The random sample of 1,200 case patients was receiving 2,527 antibiotics (average: 2.1 per patient); 540 (21.4%) were prophylactic and 1,987 (78.6%) were therapeutic, of which 372 (18.7%) were pathogen-directed at start. Of the 1,615 empirical starts, 382 (23.7%) were subsequently pathogen-directed and 1,231 (76.2%) remained empirical. Use was primarily for respiratory (27.6% of prescriptions) followed by gastrointestinal (13.1%) infections. Fluoroquinolones, vancomycin, and antipseudomonal penicillins together accounted for 47.1% of therapy-days. CONCLUSIONS Use of broad-spectrum empirical therapy was prevalent in 6 US acute care facilities and in most instances was not subsequently pathogen directed. Fluoroquinolones, vancomycin, and antipseudomonal penicillins were the most frequently used antibiotics, particularly for respiratory indications. Infect. Control Hosp. Epidemiol. 2015;37(1):70-79.
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Chow ALP, Lye DC, Arah OA. Patient and physician predictors of patient receipt of therapies recommended by a computerized decision support system when initially prescribed broad-spectrum antibiotics: a cohort study. J Am Med Inform Assoc 2015; 23:e58-70. [PMID: 26342216 DOI: 10.1093/jamia/ocv120] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/06/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Antibiotic computerized decision support systems (CDSSs) were developed to guide antibiotic decisions, yet prescriptions of CDSS-recommended antibiotics have remained low. Our aim was to identify predictors of patients' receipt of empiric antibiotic therapies recommended by a CDSS when the prescribing physician had an initial preference for using broad-spectrum antibiotics. METHODS We conducted a prospective cohort study in a 1 500-bed tertiary-care hospital in Singapore. We included all patients admitted from October 1, 2011 through September 30, 2012, who were prescribed piperacillin-tazobactam or carbapenem for empiric therapy and auto-triggered to receive antibiotic recommendations by the in-house antibiotic CDSS. Relevant data on the patient, prescribing and attending physicians were collected via electronic linkages of medical records and administrative databases. To account for clustering, we used multilevel logistic regression models to explore factors associated with receipt of CDSS-recommended antibiotic therapy. RESULTS One-quarter of the 1 886 patients received CDSS-recommended antibiotics. More patients treated for pneumonia (33.2%) than sepsis (12.1%) and urinary tract infections (7.1%) received CDSS-recommended antibiotic therapies. The prescribing physician - but not the attending physician or clinical specialty - accounted for some (13.3%) of the variation. Prior hospitalization (odds ratio [OR] 1.32, 95% CI, 1.01-1.71), presumed pneumonia (OR 6.77, 95% CI, 3.28-13.99), intensive care unit (ICU) admission (OR 0.38, 95% CI, 0.21-0.66), and renal impairment (OR 0.70, 95% CI, 0.52-0.93) were factors associated with patients' receipt of CDSS-recommended antibiotic therapies. CONCLUSIONS We observed that ICU admission and renal impairment were negative predictors of patients' receipt of CDSS-recommended antibiotic therapies. Patients admitted to ICU and those with renal impairment might have more complex clinical conditions that require a physician's assessment in addition to antibiotic CDSS.
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Affiliation(s)
- Angela L P Chow
- Department of Clinical Epidemiology, Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, United States
| | - David C Lye
- Department of Infectious Diseases, Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, United States Center for Health Policy Research, University of California, Los Angeles (UCLA), Los Angeles, United States
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Loh JA, Darby JD, Daffy JR, Moore CL, Battye MJ, Poy Lorenzo YS, Stanley PA. Implementation of an antimicrobial stewardship program in an Australian metropolitan private hospital: lessons learned. ACTA ACUST UNITED AC 2015. [DOI: 10.1071/hi15015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
OBJECTIVEWe found previously that inappropriate inpatient antimicrobial use was often attributable to erroneous diagnoses. Here, we detail diagnostic errors and their relationship to inappropriate antimicrobial courses.DESIGNRetrospective cohort studySETTINGVeterans Affairs hospitalPATIENTSA cohort of 500 randomly selected inpatients with an antimicrobial courseMETHODSBlinded reviewers judged the accuracy of the initial provider diagnosis for the condition that led to an antimicrobial course and whether the course was appropriate.RESULTSThe diagnoses were correct in 291 cases (58%), incorrect in 156 cases (31%), and of indeterminate accuracy in 22 cases (4%). In the remaining 31 cases (6%), the diagnosis was a sign or symptom rather than a syndrome or disease. The odds ratio of a correct diagnosis was 4.3 (95% confidence interval [CI], 2.2–8.5) if the index condition was related to the reason for admission. When the diagnosis was correct, 181 of 292 courses (62%) were appropriate, compared with only 10 of 208 (5%) when the diagnosis was incorrect or indeterminate or when providers were treating a sign or symptom rather than a syndrome or disease (P<.001). Among the 309 cases in which antimicrobial courses were not appropriate, reasons varied by diagnostic accuracy; in 81 of 111 cases (73%) with a correct diagnosis, incorrect antimicrobial(s) were selected; in 166 of 198 other cases (84%), antimicrobial therapy was not indicated.CONCLUSIONSDiagnostic accuracy is important for optimal inpatient antimicrobial use. Antimicrobial stewardship strategies should help providers avoid diagnostic errors and know when antimicrobial therapy can be withheld safely.Infect Control Hosp Epidemiol 2015;36(8):949–956
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Rush J, Postelnick M, Schulz L. Use of Electronic Health Record Clinical Decision Support Tools in Antimicrobial Stewardship Activities. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0042-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McGowan JE. Antimicrobial Stewardship—the State of the Art in 2011 Focus on Outcome and Methods. Infect Control Hosp Epidemiol 2015; 33:331-7. [DOI: 10.1086/664755] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Antimicrobial stewardship programs attempt to optimize prescribing of these drugs to benefit both current and future patients. Recent regulatory and other incentives have led to widespread adoption of such programs. Measurements of the success of these programs have focused primarily on process measures. However, evaluation of outcome measures will be needed to ensure sustainability of these efforts. Outcome efforts to date provide some evidence for improved care of individual patients, some evidence for minimizing emergence of resistance, and ample evidence for cost reduction. Attention to evaluation methods must be increased to provide convincing evidence for the continuation of such programs.
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Filice GA, Drekonja DM, Thurn JR, Rector TS, Hamann GM, Masoud BT, Leuck AM, Nordgaard CL, Eilertson MK, Johnson JR. Use of a Computer Decision Support System and Antimicrobial Therapy Appropriateness. Infect Control Hosp Epidemiol 2015; 34:558-65. [DOI: 10.1086/670627] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To determine whether antimicrobial (AM) courses ordered with an antimicrobial computer decision support system (CDSS) were more likely to be appropriate than courses ordered without the CDSS.Design.Retrospective cohort study. Blinded expert reviewers judged whether AM courses were appropriate, considering drug selection, route, dose, and duration.Setting.A 279-bed university-affiliated Department of Veterans Affairs (VA) hospital.Patients.A 500-patient random sample of inpatients who received a therapeutic AM course between October 2007 and September 2008.Intervention.An optional CDSS, available at the point of order entry in the VA computerized patient record system.Results.CDSS courses were significantly more likely to be appropriate (111/254, 44%) compared with non-CDSS courses (81/246, 33%, P = .013). Courses were more likely to be appropriate when the initial provider diagnosis of the condition being treated was correct (168/273, 62%) than when it was incorrect, uncertain, or a sign or symptom rather than a disease (24/227, 11%, P< .001). In multivariable analysis, CDSS-ordered courses were more likely to be appropriate than non-CDSS-ordered courses (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.13–2.98). Courses were also more likely to be judged appropriate when the initial provider diagnosis of the condition being treated was correct than when it was incorrect, uncertain, or a sign or symptom rather than a disease (OR, 3.56; 95% CI, 1.4-9.0).Conclusions.Use of the CDSS was associated with more appropriate AM use. To achieve greater improvements, strategies are needed to improve provider diagnoses of syndromes that are infectious or possibly infectious.
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Implementation of Hospital’s Antibiotic Policy Decreases Antimicrobial Use in the General Pediatric Ward. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 857:67-74. [DOI: 10.1007/5584_2015_124] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Radošević Quadranti N, Popović B, Škrobonja I, Skočibušić N, Vlahović-Palčevski V. Assessment of adherence to printed guidelines for antimicrobial drug use in a university hospital. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2014-000533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Almirante B, Garnacho-Montero J, Pachón J, Pascual Á, Rodríguez-Baño J. Scientific evidence and research in antimicrobial stewardship. Enferm Infecc Microbiol Clin 2014; 31 Suppl 4:56-61. [PMID: 24129291 DOI: 10.1016/s0213-005x(13)70134-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Evaluating the impact of antibiotic stewardship programs is challenging. There is evidence that they are effective in terms of reducing the consumption and cost of antibiotics, although establishing their impact on antimicrobial resistance (beyond restrictive policies in outbreaks caused by specific antimicrobial resistant organisms) and clinical outcomes is more difficult. Proper definitions of exposure and outcome variables, the use of advanced and appropriate statistical analyses and well-designed quasi-experimental studies would more accurately support the conclusions. Cluster randomized trials should be used whenever possible and appropriate, although the limitations of this approach should also be acknowledged. These issues are reviewed in this paper. We conclude that there are good research opportunities in the field of antibiotic stewardship.
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Affiliation(s)
- Benito Almirante
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Red Española de Investigación en Patología Infecciosa, Instituto de Salud Carlos III, Madrid, Spain
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Schreiber R, Peters K, Shaha SH. Computerized provider order entry reduces length of stay in a community hospital. Appl Clin Inform 2014; 5:685-98. [PMID: 25298809 DOI: 10.4338/aci-2014-04-ra-0029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Does computerized provider order entry (CPOE) improve clinical, cost, and efficiency outcomes as quantified in shortened hospital length of stay (LOS)? Most prior studies were done in university settings with home-grown electronic records, and are now 20 years old. This study asked whether CPOE exerts a downward force on LOS in the current era of HITECH incentives, using a vendor product in a community hospital. METHODS The methodology retrospectively evaluated correlation between CPOE and LOS on a perpatient, per-visit basis over 22 consecutive quarters, organized by discipline. All orders from all areas were eligible, except verbals, and medication orders in the emergency department which were not available via CPOE. These results were compared with quarterly case mix indices organized by discipline. Correlational and regression analyses were cross-checked to ensure validity of R-square coefficients, and data were smoothed for ease of display. Standard models were used to calculate the inflection point. RESULTS Gains in CPOE adoption occurred iteratively house-wide, and in each discipline. LOS decreased in a sigmoid shaped curve. The inflection point shows that once CPOE adoption approaches 60%, further lowering of LOS accelerates. Overall there was a 20.2% reduction in LOS correlated with adoption of CPOE. Case mix index increased during the study period showing that reductions in LOS occurred despite increased patient complexity and resource utilization. CONCLUSIONS There was a 20.2% reduction in LOS correlated with rising adoption of CPOE. CPOE contributes to improved clinical, cost, and efficiency outcomes as quantified in reduced LOS, over and above other processes introduced to lower LOS. CPOE enabled a reduction in LOS despite an increase in the case mix index during the time frame of this study.
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Affiliation(s)
| | - K Peters
- Holy Spirit Hospital , Camp Hill, PA ; Vibra Healthcare , Mechanicsburg, PA
| | - S H Shaha
- Center for Public Policy & Admin , Salt Lake City, UT ; Allscripts , Chicago, IL
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Ohl CA, Luther VP. Health Care Provider Education as a Tool to Enhance Antibiotic Stewardship Practices. Infect Dis Clin North Am 2014; 28:177-93. [DOI: 10.1016/j.idc.2014.02.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hum RS, Cato K, Sheehan B, Patel S, Duchon J, DeLaMora P, Ferng YH, Graham P, Vawdrey DK, Perlman J, Larson E, Saiman L. Developing clinical decision support within a commercial electronic health record system to improve antimicrobial prescribing in the neonatal ICU. Appl Clin Inform 2014; 5:368-87. [PMID: 25024755 DOI: 10.4338/aci-2013-09-ra-0069] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 02/19/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool. METHODS Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool. RESULTS The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%). DISCUSSION During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved. CONCLUSION To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges.
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Affiliation(s)
- R S Hum
- Department of Pediatrics, Columbia University , NY, NY
| | - K Cato
- School of Nursing, Columbia University , NY, NY
| | - B Sheehan
- Faculty Practice Organization, Columbia University , NY, NY
| | - S Patel
- Department of Pediatrics, Northwestern University , Chicago, IL
| | - J Duchon
- Department of Pediatrics, Columbia University , NY, NY
| | - P DeLaMora
- Department of Pediatrics, Weill Cornell Medical College , NY, NY
| | - Y H Ferng
- School of Nursing, Columbia University , NY, NY
| | - P Graham
- Department of Pediatrics, Columbia University , NY, NY ; Department of Quality and Patient Safety, NewYork-Presbyterian Hospital , NY, NY ; Department of Infection Prevention & Control, NewYork-Presbyterian Hospital , NY, NY
| | - D K Vawdrey
- Department of Biomedical Informatics, Columbia University , NY, NY
| | - J Perlman
- Department of Pediatrics, Weill Cornell Medical College , NY, NY
| | - E Larson
- School of Nursing, Columbia University , NY, NY ; School of Nursing and Mailman School of Public Health, Columbia University , NY, NY
| | - L Saiman
- Department of Pediatrics, Columbia University , NY, NY ; Department of Infection Prevention & Control, NewYork-Presbyterian Hospital , NY, NY
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Prevention of Clostridium difficile infection in rural hospitals. Am J Infect Control 2014; 42:311-5. [PMID: 24406257 DOI: 10.1016/j.ajic.2013.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/28/2013] [Accepted: 09/04/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Prevention of Clostridium difficile infection (CDI) remains challenging across the spectrum of health care. There are limited data on prevention practices for CDI in the rural health care setting. METHODS An electronic survey was administered to 21 rural facilities in Wisconsin, part of the Rural Wisconsin Health Cooperative. Data were collected on hospital characteristics and practices to prevent endemic CDI. RESULTS Fifteen facilities responded (71%). Nearly all respondent facilities reported regular use of dedicated patient care items, use of gown and gloves, private patient rooms, hand hygiene, and room cleaning. Facilities in which the infection preventionist thought the support of his/her leadership to be "Very good" or "Excellent" employed significantly more CDI practices (13.3 ± 2.4 [standard deviation]) compared with infection preventionists who thought there was less support from leadership (9.8 ± 3.0, P = .033). Surveillance for CDI was highly variable. The most frequent barriers to implementation of CDI prevention practices included lack of adequate resources, lack of a physician champion, and difficulty keeping up with new recommendations. CONCLUSION Although most rural facilities in our survey reported using evidence-based practices for prevention of CDI, surveillance practices were highly variable, and data regarding the impact of these practices on CDI rates were limited. Future efforts that correlate CDI prevention initiatives and CDI incidence will help develop evidence-based practices in these resource-limited settings.
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Maripuu H, Aldeyab MA, Kearney MP, McElnay JC, Conlon G, Magee FA, Scott MG. An audit of antimicrobial treatment of lower respiratory and urinary tract infections in a hospital setting. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2013-000394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Crader MF. Development of antimicrobial competencies and training for staff hospital pharmacists. Hosp Pharm 2014; 49:32-40. [PMID: 24421561 DOI: 10.1310/hpj4901-32] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Antimicrobial stewardship is an important component in health care outcomes of all patients. Many institutions are seeking the best methods to incorporate antimicrobial stewardship strategies into their hospitals including pharmacy services. Multiple factors should be considered when beginning or expanding an antimicrobial stewardship program. The purpose of this article is to discuss the development of basic antibiotic competencies and training for staff pharmacists in a community hospital. The article includes an assessment of pharmacists' knowledge pre education and post education, perception of benefits from an antibiotic education program, and learning needs and preferences.
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Affiliation(s)
- Marsha F Crader
- Associate Professor of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, 4301 W. Markham Street, Slot #522, Little Rock, AR 72205; phone: 870-207-4463; e-mail:
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Abstract
The incidence and severity of Clostridium difficile infection (CDI) have dramatically increased in the Western world in recent years. In contrast, CDI is rarely reported in China, possibly due to under-diagnosis. This article briefly summarizes CDI incidence, management and preventive strategies. The authors intend to raise awareness of this disease among Chinese physicians and health workers, in order to minimize the medical and economic burden of a potential epidemic in the future.
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Affiliation(s)
- Xinhua Chen
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Pasupuleti LV, Sifri ZC, Mohr AM. Is extended antibiotic prophylaxis necessary after penetrating trauma to the thoracolumbar spine with concomitant intraperitoneal injuries? Surg Infect (Larchmt) 2013; 15:8-13. [PMID: 24116741 DOI: 10.1089/sur.2012.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prolonged courses of broad-spectrum antibiotics are often cited as standard care for the prevention of infectious complications in thoracolumbar or sacral (TLS) fractures following penetrating abdominal trauma. Perforation of a hollow viscus in addition to a TLS fracture is believed to be associated with a high incidence of spine infection. Because over use of antibiotics is associated with an increasing prevalence of multi-drug-resistant organisms, this study seeks to define the actual risk of infection of the spine and need for antibiotics in patients with TLS fractures and intraperitoneal injuries following penetrating trauma. METHODS A retrospective review of 67 patients with penetrating abdominal trauma and concomitant TLS fracture was performed. Demographics, level of TLS fracture, associated spinal cord injury (SCI), need for operative intervention, presence of concomitant hollow viscus injury, and type and duration of antibiotic coverage were collected. In addition, associated infectious complications were reviewed. Spine infections were defined as spinal or paraspinal abscess, osteomyelitis of the spine, or meningitis. Intraabdominal infections were defined with imaging studies or positive peritoneal cultures. RESULTS Sixty-seven patients (mean age of 27 ± 9 years) had an exploratory laparotomy and one or more TLS fractures. Four patients died within 24 h and were excluded from further study. Thirty-eight patients (60%) had one or more hollow viscus injuries, 13 (21%) had solid organ injuries alone and 12 (19%) had a non-therapeutic laparotomy. All patients received perioperative antibiotics; 92% received 48 h or less of antibiotic prophylaxis and 62% received only 24 h of antibiotics. In one patient with an isolated solid organ injury there was a spine infection (1%). CONCLUSIONS In this study, 92% of patients received antibiotics for 48 h or less with no increased incidence of spine infections. Bacterial colonization of the vertebrae was not higher in patients with penetrating gastrointestinal injury. There is insufficient evidence to support the use of prolonged antibiotic prophylaxis to prevent spine infection in patients with penetrating abdominal trauma and TLS fracture.
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Affiliation(s)
- Latha V Pasupuleti
- Department of Surgery, Division of Trauma, Rutgers New Jersey Medical School , Newark, New Jersey
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Using procalcitonin-guided algorithms to improve antimicrobial therapy in ICU patients with respiratory infections and sepsis. Curr Opin Crit Care 2013; 19:453-60. [DOI: 10.1097/mcc.0b013e328363bd38] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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