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Brown AW, Jovevski JJ, Naville-Cook CA, Roberts JL, Triboletti MD, Williams MJ, Smith CR. Cost analysis of one-time intravenous antibiotic doses in the emergency department. J Am Pharm Assoc (2003) 2024; 64:102114. [PMID: 38705468 DOI: 10.1016/j.japh.2024.102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/12/2024] [Accepted: 02/23/2020] [Indexed: 05/07/2024]
Abstract
BACKGROUND Research shows that one-time doses of intravenous (IV) antibiotics do not improve resolution of infection. However, providers continue to use them-especially in the emergency department (ED). Very few studies have aimed to quantify the cost of this practice. OBJECTIVES The primary objective was to evaluate the difference in average total cost of ED stay between patients who received a one-time dose of IV antibiotics in the ED before discharging on oral antibiotics and patients who were just discharged on oral antibiotics. Secondary objectives were to evaluate the differences in durations of stay between the 2 groups, as well as the differences in adverse drug effects and need for health care contact after discharge. METHODS Chart review was conducted to identify patients who received and did not receive a one-time dose of IV antibiotics in the ED between April 30, 2020, and April 30, 2022. A microcosting approach was used to determine ED-associated costs per patient. Comparisons in primary and secondary outcomes were performed using statistical inferential tests. RESULTS A total of 102 patients were analyzed in each group. Patients who received a one-time dose of IV antibiotics in the ED before being discharged on oral antibiotics had an average length of stay of 4.55 hours, as opposed to patients who did not receive a one-time dose of IV antibiotics before being discharged on oral antibiotics who had an average length of stay of 2.82 hours (absolute difference 1.73 hours, P < 0.001). One-time dosing of IV antibiotics in the ED incurred an additional cost of approximately $556 per patient, totaling to more than $56,000 in our study cohort. CONCLUSION The use of one-time IV antibiotics in the ED did not confer any additional benefits to patients. The use of one-time doses resulted in statistically significant reduced throughput in the ED and statistically significant increased health care costs.
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Schuchter K, Shuler Truoccolo DM, Wilson WS, Anton G. Descriptive evaluation of patients receiving one-time intravenous vancomycin doses at a large academic medical center emergency department. Am J Emerg Med 2024; 77:177-182. [PMID: 38157592 DOI: 10.1016/j.ajem.2023.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 11/14/2023] [Accepted: 11/25/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Intravenous (IV) vancomycin is commonly used to treat a variety of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). The practice of administering a single dose of IV vancomycin prior to emergency department (ED) discharge may be clinically ineffective and foster antimicrobial resistance. Furthermore, this practice introduces an unnecessary infection risk along with preventable adverse effects while potentially increasing ED length of stay (LOS). There is a paucity of literature identifying patient characteristics and objective findings in this patient population, which may foster future antimicrobial stewardship initiatives in the ED. METHODS This was a single-center, retrospective, descriptive analysis of adult patients seen in the ED between January 2020 and January 2023 who received a single dose of IV vancomycin and were subsequently discharged from the ED without hospital admission. Information was collected on patient demographics and select comorbidities, vancomycin indication and dosing, ED LOS, initial vitals and labs, concomitant antibiotics administered, culture results, 30-day return ED visits and admissions, and antibiotics prescribed at ED discharge. RESULTS A total of 295 patients met inclusion criteria. A total of 32.1% of patients met SIRS criteria. The most commonly selected order indication for IV vancomycin was "skin and skin structure infection" (41%). A total of 86.1% of patients received concomitant antibiotics in the ED and only 54.6% of patients were prescribed oral antibiotics at ED discharge. A total of 80% of patients had at least one culture obtained during the ED visit. In those who had at least one culture obtained, 78.4% of patients had negative cultures and 4.2% of patients had MRSA positive cultures, with MRSA skin cultures being the most common (3.1%). Return ED visits and admissions within 30 days were not statistically significantly different between patients who did and did not receive oral antibiotics at ED discharge. CONCLUSIONS Despite a lack of clinical efficacy reported in prior literature and the potential risks, administration of a one-time dose of IV vancomycin prior to ED discharge is commonly encountered in clinical practice. There are opportunities for enhanced antimicrobial stewardship related to IV vancomycin use in the ED. Areas of future focus include the utilization of oral antimicrobials when clinically appropriate, particularly for skin and soft tissue infections, and clarification of antibiotic allergies.
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Affiliation(s)
- Kyle Schuchter
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA; Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | | | - William S Wilson
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Greta Anton
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
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Jorgensen SCJ, Murray KP, Lagnf AM, Melvin S, Bhatia S, Shamim MD, Smith JR, Brade KD, Simon SP, Nagel J, Williams KS, Ortwine JK, Veve MP, Truong J, Huang DB, Davis SL, Rybak MJ. A Multicenter Evaluation of Vancomycin-Associated Acute Kidney Injury in Hospitalized Patients with Acute Bacterial Skin and Skin Structure Infections. Infect Dis Ther 2020; 9:89-106. [PMID: 31983021 PMCID: PMC7054514 DOI: 10.1007/s40121-019-00278-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Indexed: 12/21/2022] Open
Abstract
Background We sought to determine the real-world incidence of and risk factors for vancomycin-associated acute kidney injury (V-AKI) in hospitalized adults with acute bacterial skin and skin structure infections (ABSSSI). Methods Retrospective, observational, cohort study at ten U.S. medical centers between 2015 and 2019. Hospitalized patients treated with vancomycin (≥ 72 h) for ABSSSI and ≥ one baseline AKI risk factor were eligible. Patients with end-stage kidney disease, on renal replacement therapy or AKI at baseline, were excluded. The primary outcome was V-AKI by the vancomycin guidelines criteria. Results In total, 415 patients were included. V-AKI occurred in 39 (9.4%) patients. Independent risk factors for V-AKI were: chronic alcohol abuse (aOR 4.710, 95% CI 1.929–11.499), no medical insurance (aOR 3.451, 95% CI 1.310–9.090), ICU residence (aOR 4.398, 95% CI 1.676–11.541), Gram-negative coverage (aOR 2.926, 95% CI 1.158–7.392) and vancomycin duration (aOR 1.143, 95% CI 1.037–1.260). Based on infection severity and comorbidities, 34.7% of patients were candidates for oral antibiotics at baseline and 39.3% had non-purulent cellulitis which could have been more appropriately treated with a beta-lactam. Patients with V-AKI had significantly longer hospital lengths of stay (9 vs. 6 days, p = 0.001), higher 30-day readmission rates (30.8 vs. 9.0%, p < 0.001) and increased all-cause 30-day mortality (5.1 vs. 0.3%, p = 0.024) Conclusions V-AKI occurred in approximately one in ten ABSSSI patients and may be largely prevented by preferential use of oral antibiotics whenever possible, using beta-lactams for non-purulent cellulitis and limiting durations of vancomycin therapy. Electronic supplementary material The online version of this article (10.1007/s40121-019-00278-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah C J Jorgensen
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA
| | | | - Abdalhamid M Lagnf
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA
| | - Sarah Melvin
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA
| | - Sahil Bhatia
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA
| | - Muhammad-Daniayl Shamim
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA
| | - Jordan R Smith
- Fred Wilson School of Pharmacy, High Point University, High Point, NC, USA.,Cone Health, Greensboro, NC, USA
| | | | | | | | | | | | - Michael P Veve
- College of Pharmacy, University of Tennessee Health Sciences Center, Knoxville, TN, USA.,University of Tennessee Medical Center, Knoxville, TN, USA
| | | | - David B Huang
- Motif BioSciences, Princeton, NJ, USA.,Rutgers New Jersey Medical School, Trenton, NJ, USA
| | - Susan L Davis
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA.,Henry Ford Health-System, Detroit, MI, USA
| | - Michael J Rybak
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA. .,Detroit Medical Center, Detroit, MI, USA. .,School of Medicine, Wayne State University, Detroit, MI, USA.
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Abstract
PURPOSE OF REVIEW Skin and soft tissue infections (SSTIs) are the most frequent infectious cause of referrals to emergency departments and hospital admissions in developed world, contributing to significant morbidity and healthcare expenditures. We sought to review recent literature covering epidemiology and management of SSTIs. RECENT FINDINGS Incidence trends of SSTIs were increasing worldwide with Staphylococcus aureus and streptococci predominating and methicillin-resistant S. aureus (MRSA) posing additional challenges, because of high rates of treatment failure and relapse. Development of new antimicrobials was associated with an appraisal of regulatory definitions and endpoints. Prediction of clinical response can be very tricky, because of variable risk factors for recurrence or treatment failure, depending mostly on the host. Precise indications for new antimicrobials should be established; their integration into clinical practice algorithms may serve reduction of unnecessary admissions, overtreatment and total costs. SUMMARY New antimicrobials with activity against MRSA have been recently launched. Long-acting agents, mainly oritavancin and dalbavancin, provide the opportunity of single-dose treatment and early discharge. Further outpatient treatment options include new per os antibiotics such as oxazolidinones. Validated assessment tools are urgently needed to support decision-making toward rational resource utilization and delivery of optimal treatment.
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Abstract
The literature contains robust evidence on the positive impact of antimicrobial stewardship programs (ASP) in the inpatient setting. With national policies shifting toward provisions of quality health care, the impetus to expand ASP services becomes an important strategy for institutions. However data on stewardship initiatives in other settings are less characterized. For organizations with an established ASP team, it is rational to consider expanding these services to the emergency department (ED). The ED serves as an interface between the inpatient and community settings. It is often the first place where patients present for medical care, including for common infections. Challenges inherent to the fast-paced nature of the environment must be recognized for successful ASP implementation in the ED. Based on the current literature, a combination of strategies for initiating ASP services in the ED will be described. Furthermore, common scenarios and management approaches are proposed for respiratory tract, skin and soft tissue, and urinary tract infections. Expansion of ASP services across the health care continuum may improve patient outcomes with a potential associated decrease in health care costs while preventing adverse effects including the development of antibiotic resistance.
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