1
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Claeys KC, Morgan DJ, Johnson MD. The importance of pharmacist engagement in diagnostic stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e43. [PMID: 38628377 PMCID: PMC11019581 DOI: 10.1017/ash.2024.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 04/19/2024]
Abstract
Diagnostic stewardship is increasingly recognized as a powerful tool to improve patient safety. Given the close relationship between diagnostic testing and antimicrobial misuse, antimicrobial stewardship (AMS) pharmacists should be key members of the diagnostic team. Pharmacists practicing in AMS already frequently engage with clinicians to improve the diagnostic process and have many skills needed for the implementation of diagnostic stewardship initiatives. As diagnostic stewardship becomes more broadly used, all infectious disease clinicians, including pharmacists, must collaborate to optimize patient care.
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Affiliation(s)
- Kimberly C. Claeys
- Associate Professor Infectious Diseases, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Veterans’ Affairs Maryland Healthcare System, Baltimore, MD, USA
| | - Melissa D. Johnson
- Professor in Medicine, Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA
- Liaison Clinical Pharmacist, Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC, USA
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2
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Karpen R, Murphy C, Reed E, Gerlach AT, Cape K, Mellett J, Atyia SA. Evaluation of an Automated, Pharmacist-Driven, Antimicrobial Patient Acuity Scoring System for Hospitalized Bacteremic Patients. Hosp Pharm 2024; 59:32-38. [PMID: 38223862 PMCID: PMC10786048 DOI: 10.1177/00185787231182567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Purpose: The implementation of an automated, pharmacist-driven, scoring system within the EMR has been shown to improve patient care in patients with Staphylococcus aureus bacteremia by increasing the adherence to disease specific quality-of-care measures. However, there are a lack of studies evaluating the incorporation of blood culture review into standard, non-antimicrobial stewardship pharmacist workflow. Our institution implemented an automated, pharmacist-driven, antimicrobial scoring system in the electronic medical record (EMR) on August 6, 2019. Methods: This was a retrospective, single-center, quasi-experimental study of hospitalized, non-critically ill adult (18-89 years of age) patients with bacteremia between July 6, 2018 and July 5, 2019 (pre-implementation group) and September 6, 2019 and September 5, 2020 (post-implementation group). The primary outcome was time to directed antibiotic therapy in patients with positive blood cultures. Secondary outcomes included hospital length-of-stay, days of therapy (DOT) while inpatient, time to effective therapy, 30-day all-cause mortality, and rates of Clostridioides difficile infections documented within 3 months of positive culture results. Results: Implementation of the antimicrobial scoring system did not result in a significant change in time to directed antibiotic therapy (32.5 hours vs 37.4 hours; P = .757). There was also no difference found for time to effective antibiotic therapy (-12.6 hours vs -14.2 hours; P =.905) and no difference found for all other secondary outcomes. Conclusion: The implementation of the antimicrobial scoring system did not lead to an improvement in clinical outcomes. Further research is needed to better define a patient population that may benefit from this system.
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Affiliation(s)
- Riley Karpen
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Claire Murphy
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Erica Reed
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Kari Cape
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John Mellett
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sara A. Atyia
- The Ohio State University Wexner Medical Center East Hospital, Columbus, OH, USA
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3
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Jhaveri TA, Weiss ZF, Winkler ML, Pyden AD, Basu SS, Pecora ND. A decade of clinical microbiology: top 10 advances in 10 years: what every infection preventionist and antimicrobial steward should know. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e8. [PMID: 38415089 PMCID: PMC10897726 DOI: 10.1017/ash.2024.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 02/29/2024]
Abstract
The past 10 years have brought paradigm-shifting changes to clinical microbiology. This paper explores the top 10 transformative innovations across the diagnostic spectrum, including not only state of the art technologies but also preanalytic and post-analytic advances. Clinical decision support tools have reshaped testing practices, curbing unnecessary tests. Innovations like broad-range polymerase chain reaction and metagenomic sequencing, whole genome sequencing, multiplex molecular panels, rapid phenotypic susceptibility testing, and matrix-assisted laser desorption ionization time-of-flight mass spectrometry have all expanded our diagnostic armamentarium. Rapid home-based testing has made diagnostic testing more accessible than ever. Enhancements to clinician-laboratory interfaces allow for automated stewardship interventions and education. Laboratory restructuring and consolidation efforts are reshaping the field of microbiology, presenting both opportunities and challenges for the future of clinical microbiology laboratories. Here, we review key innovations of the last decade.
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Affiliation(s)
- Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - Zoe Freeman Weiss
- Division of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
- Division of Geographic Medicine & Infectious Disease, Tufts Medical Center, Boston, MA, USA
| | - Marisa L. Winkler
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexander D. Pyden
- Division of Pathology and Laboratory Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
- Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA, USA
| | - Sankha S. Basu
- Division of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | - Nicole D. Pecora
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
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4
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Heil EL, Justo JA, Bork JT. Improving the Efficiency of Antimicrobial Stewardship Action in Acute Care Facilities. Open Forum Infect Dis 2023; 10:ofad412. [PMID: 37674632 PMCID: PMC10478156 DOI: 10.1093/ofid/ofad412] [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: 06/01/2023] [Accepted: 07/28/2023] [Indexed: 09/08/2023] Open
Abstract
Inpatient antimicrobial stewardship (AS) programs are quality improvement programs tasked with improving antibiotic practices by augmenting frontline providers' antibiotic prescription. Prospective audit and feedback (PAF) and preauthorization (PRA) are essential activities in the hospital that can be resource intensive for AS teams. Improving efficiency in AS activities is needed when there are limited resources or when programs are looking to expand tasks beyond PAF and PRA, such as broad education or guideline development. Guidance on the creation and maintenance of alerts for the purpose of PAF reviews, modifications of antibiotic restrictions for PRA polices, and overall initiative prioritization strategies are reviewed. In addition, daily prioritization tools, such as the tiered approach, scoring systems, and regression modeling, are available for stewards to prioritize their daily workflow. Using these tools and guidance, AS programs can be productive and impactful in the face of resource limitation or competing priorities in the hospital.
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Affiliation(s)
- Emily L Heil
- Department of Practice, Sciences and Health Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, South Carolina, USA
| | - Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology, Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland, USA
- Veterans Affairs (VA) Maryland Health Care System, Baltimore, Maryland, USA
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5
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Cole JC, Jankowski CA, Verdecia JL, Isache CL, Ravi MS, McCarter YS, Casapao AM. The Time for Action Is Now: The Impact of Timing of Infectious Disease Consultation for Staphylococcus aureus Bacteremia. Clin Infect Dis 2023; 76:2007-2009. [PMID: 36869697 DOI: 10.1093/cid/ciad110] [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: 12/12/2022] [Revised: 02/13/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
This retrospective cohort study was performed to compare clinical outcomes between patients with Staphylococcus aureus bacteremia who received an early versus late infectious disease consultation. Early consultation resulted in significantly greater adherence to quality care indicators and shorter hospital stays.
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Affiliation(s)
- J Chase Cole
- Department of Pharmacy, University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Christopher A Jankowski
- Department of Pharmacy, University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Jorge L Verdecia
- Department of Medicine, Division of Infectious Disease, University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Carmen L Isache
- Department of Medicine, Division of Infectious Disease, University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Malleswari S Ravi
- Department of Medicine, Division of Infectious Disease, University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Yvette S McCarter
- Department of Pathology and Laboratory Medicine, University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Anthony M Casapao
- Department of Pharmacy, University of Florida Health Jacksonville, Jacksonville, Florida, USA
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Jacksonville, Florida
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6
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White BP, Barber KE, Chastain DB. Variation Among Infectious Diseases Pharmacists for the Treatment of Staphylococcus aureus Bacteremia. J Pharm Pract 2023; 36:295-302. [PMID: 34399064 DOI: 10.1177/08971900211038864] [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] [Indexed: 11/15/2022]
Abstract
Introduction: Staphylococcus aureus bacteremia (SAB) remains complex, in that optimal treatment for patients, including complicated or persistent infection, remains unclear. Two recent surveys have demonstrated practice variations in SAB among infectious diseases (ID) physicians. Objectives: The purpose of this survey was to examine practice variations in SAB among ID pharmacists. Methods: A thirty-five-question survey was electronically distributed to the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (IDPRN) in Fall 2019 to determine differences in SAB management. Data were analyzed utilizing Pearson's Chi-Square or Fisher's Exact Test. Results: A total of 106 ID pharmacists responded. Only 28% of pharmacists practiced at hospitals with mandatory ID consultation for SAB. A majority (75%) had rapid diagnostic technology (RDT) for identifying SABSI, but 32% of those facilities with RDT did not notify pharmacy with results. Anti-staphylococcal penicillins were preferred for MSSA blood stream infections (BSI) in patients with central nervous system infection and endocarditis, whereas cefazolin was favored for other MSSA BSI. For persistent MRSA BSI, 34% selected daptomycin alone while 38% elected to combine daptomycin and ceftaroline. Pharmacists at hospitals less than 500 beds were more likely to use daptomycin, while those at larger hospitals were more likely to use daptomycin and ceftaroline for persistent MRSA BSI (P < .05). Conclusions: A survey of ID pharmacists showed variation in the management of SABs, as well as the definition and treatment of persistent SAB. Mandatory ID consultation and RDT use to improve SAB management have not been optimized.
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Affiliation(s)
- Bryan P White
- Department of Pharmacy, 6195OU Medical Center, Oklahoma City, OK, USA
- College of Medicine, Infectious Diseases Section, 12308University of Oklahoma, Oklahoma City, OK, USA
| | - Katie E Barber
- College of Pharmacy, 15516University of Mississippi, Jackson, MS, USA
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Claeys KC, Johnson MD. Leveraging diagnostic stewardship within antimicrobial stewardship programmes. Drugs Context 2023; 12:dic-2022-9-5. [PMID: 36843619 PMCID: PMC9949764 DOI: 10.7573/dic.2022-9-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
Novel diagnostic stewardship in infectious disease consists of interventions that modify ordering, processing, and reporting of diagnostic tests to provide the right test for the right patient, prompting the right action. The interventions work upstream and synergistically with traditional antimicrobial stewardship efforts. As diagnostic stewardship continues to gain public attention, it is critical that antimicrobial stewardship programmes not only learn how to effectively leverage diagnostic testing to improve antimicrobial use but also ensure that they are stakeholders and leaders in developing new diagnostic stewardship interventions within their institutions. This review will discuss the need for diagnostic and antimicrobial stewardship, the interplay of diagnostic and antimicrobial stewardship, evidence of benefit to antimicrobial stewardship programmes, and considerations for successfully engaging in diagnostic stewardship interventions. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.
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Affiliation(s)
- Kimberly C Claeys
- University of Maryland School of Pharmacy, Department of Practice Science and Health Outcomes Research, Baltimore, MD, USA
| | - Melissa D Johnson
- Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA,Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center Durham, NC, USA
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8
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Xu J, Huang J, Yu Y, Zhou D, Wang Y, Xue S, Shang E, Sun J, Ding X, Shi L, Duan L, Tang L, Zhou Q, Li X. The Impact of a Multifaceted Pharmacist-Led Antimicrobial Stewardship Program on Antibiotic Use: Evidence From a Quasi-Experimental Study in the Department of Vascular and Interventional Radiology in a Chinese Tertiary Hospital. Front Pharmacol 2022; 13:832078. [PMID: 35295325 PMCID: PMC8919369 DOI: 10.3389/fphar.2022.832078] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: The objective of the study was to assess the impact of multifaceted clinical pharmacist-led antimicrobial stewardship (AMS) program on the rational use of antibiotics for patients who receive vascular and interventional radiology therapies. Methods: A quasi-experimental retrospective intervention design with a comparison group was applied to the practice of antibiotic use in the department of vascular and interventional radiology in a Chinese tertiary hospital. We used difference-in-differences (DID) analysis to compare outcomes before and after the AMS intervention between the intervention group and control group, to determine whether intervention would lead to changes in irrationality of antibiotic prescribing, antibiotic utilization, cost of antibiotics, and length of hospital stay. Results: The DID results showed that the intervention group was associated with a reduction in the average consumption of antibiotics (p = 0.017) and cost of antibiotics (p = 0.006) and cost per defined daily dose (DDD) (p = 0.000). There were no significant differences in the mean change of total costs and length of stay between the two groups (p > 0.05). The average inappropriate score of perioperative antimicrobial prophylaxis in the intervention group declined by 0.23, while it decreased by 0.02 in the control group [0.21 (95% CI, -0.271 to -0.143); p = 0.000]. The average inappropriate score of non-surgical antimicrobial prophylaxis in the intervention group declined by 0.14, while it increased by 0.02 in the control group [0.16 (95% CI, -0.288 to -0.035); p = 0.010]. The average inappropriate score of the therapeutic use of antibiotics in the intervention group declined by 0.07, while it decreased by 0.01 in the control group [0.06 (95% CI, -0.115 to -0.022); p = 0.003]. Conclusions: This study provides evidence that implementation of AMS interventions was associated with a marked reduction of antibiotic use, cost of antibiotics, and irrationality of antibiotic prescribing in China.
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Affiliation(s)
- Jinhui Xu
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Jian Huang
- Department of Vascular and Interventional Radiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - YanXia Yu
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Dayong Zhou
- Department of Vascular and Interventional Radiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Ying Wang
- Department of Education and Training, The First Affiliated Hospital of SooChow University, SuZhou, China
| | - Sudong Xue
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Erning Shang
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Jiantong Sun
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Xinyuan Ding
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Lu Shi
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Lufen Duan
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Lian Tang
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Qin Zhou
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Xin Li
- Department of Clinical Pharmacy, School of Pharmacy, Nanjing Medical University, Nanjing, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
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Lai WM, Islahudin FH, Ambaras Khan R, Chong WW. Pharmacists’ Perspectives of Their Roles in Antimicrobial Stewardship: A Qualitative Study among Hospital Pharmacists in Malaysia. Antibiotics (Basel) 2022; 11:antibiotics11020219. [PMID: 35203822 PMCID: PMC8868356 DOI: 10.3390/antibiotics11020219] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/29/2022] [Accepted: 01/30/2022] [Indexed: 12/10/2022] Open
Abstract
Antimicrobial resistance has negatively impacted patient outcomes and increased healthcare costs. Antimicrobial stewardship (AMS) includes all activities and policies to promote the judicious use of antimicrobials. Pharmacists are key players in AMS models worldwide. However, there is a research gap in the role of pharmacists as antimicrobial stewards in Malaysia. This study aimed to explore hospital pharmacists’ perspectives on their roles in, and barriers and facilitators to the implementation of AMS strategies. Individual, semi-structured interviews were conducted with 16 hospital pharmacists involved in AMS activities from 13 public hospitals in Kuala Lumpur and Selangor. Audio-taped interviews were transcribed verbatim and imported into NVivo software version 10.0 (QSR). A thematic analysis method was used to identify themes from the qualitative data until theme saturation was reached. Respondents perceived pharmacists as having important roles in the implementation of AMS strategies, in view of the multiple tasks they were entrusted with. They described their functions as antimicrobial advisors, antimicrobial guardians and liaison personnel. The lack of resources in terms of training, manpower and facilities, as well as attitudinal challenges, were some barriers identified by the respondents. Administrative support, commitment and perseverance were found to be facilitators to the role of pharmacists in AMS. In conclusion, pharmacists in public hospitals play important roles in AMS teams. This study has provided insights into the support that AMS pharmacists in public hospitals require to overcome the barriers they face and to enhance their roles in the implementation of AMS strategies.
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Affiliation(s)
- Wan Mae Lai
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia; (W.M.L.); (F.H.I.)
- Pharmacy Department, Serdang Hospital, Ministry of Health, Kajang 43000, Malaysia
| | - Farida Hanim Islahudin
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia; (W.M.L.); (F.H.I.)
| | - Rahela Ambaras Khan
- Pharmacy Department, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur 50586, Malaysia;
| | - Wei Wen Chong
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia; (W.M.L.); (F.H.I.)
- Correspondence: ; Tel.: +6(03)-9289-8038
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10
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Cook CA, Vakayil V, Pribyl K, Yerxa D, Kriz J, Case A, Meisel S, Ho T, Harmon JV. A Pharmacist-Driven Glycemic Control Protocol to Reduce the Rate of Severe Hypoglycemia in High-Risk Patients. Hosp Pharm 2022; 57:45-51. [PMID: 35521019 PMCID: PMC9065522 DOI: 10.1177/0018578720973891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Purpose: Hospital pharmacists contribute to patient safety and quality initiatives by overseeing the prescribing of antidiabetic medications. A pharmacist-driven glycemic control protocol was developed to reduce the rate of severe hypoglycemia events (SHE) in high-risk hospitalized patients. Methods: We retrospectively analyzed the rates of SHE (defined as blood glucose ≤40 mg/dL), before and after instituting a pharmacist-driven glycemic control protocol over a 4-year period. A hospital glucose management team that included a lead Certified Diabetes Educator Pharmacist (CDEP), 5 pharmacists trained in diabetes, a lead hospitalist, critical care and hospital providers established a process to first identify patients at risk for severe hypoglycemia and then implement our protocol. Criteria from the American Diabetes Association and the American Association of Clinical Endocrinologists was utilized to identify and treat patients at risk for SHE. We analyzed and compared the rate of SHE and physician acceptance rates before and after protocol initiation. Results: From January 2015 to March 2019, 18 297 patients met criteria for this study; 139 patients experienced a SHE and approximately 80% were considered high risk diabetes patients. Physician acceptance rates for the new protocol ranged from 77% to 81% from the year of initiation (2016) through 2018. The absolute risk reduction of SHE was 9 events per 1000 hospitalized diabetic patients and the relative risk reduction was 74% SHE from the start to the end of the protocol implementation. Linear regression analysis demonstrated that SHE decreased by 1.5 events per 1000 hospitalized diabetic patients (95% confidence interval, -1.54 to -1.48, P < .001) during the 2 years following the introduction of the protocol. This represents a 15% relative reduction of SHE per year. Conclusion: The pharmacist-driven glycemic control protocol was well accepted by our hospitalists and led to a significant reduction in SHE in high-risk diabetes patient groups at our hospital. It was cost effective and strengthened our physician-pharmacist relationship while improving diabetes care.
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Affiliation(s)
- Colleen A. Cook
- M Health Fairview Ridges Hospital, Burnsville, MN, USA,Colleen A. Cook, Department of Pharmacy, Hospital Pharmacist, M Health Fairview, Fairview Ridges Hospital, 201 E Nicollet Blvd, Burnsville, MN 55337, USA.
| | | | - Kyle Pribyl
- University of Minnesota, Minneapolis, MN, USA
| | - Derek Yerxa
- University of Minnesota, Minneapolis, MN, USA
| | - John Kriz
- M Health Fairview Ridges Hospital, Burnsville, MN, USA
| | - Angie Case
- M Health Fairview Ridges Hospital, Burnsville, MN, USA
| | - Steven Meisel
- M Health Fairview Ridges Hospital, Burnsville, MN, USA
| | - Tammy Ho
- University of Minnesota, Minneapolis, MN, USA
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11
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Berger NJ, Wright ME, Pouliot JD, Green MW, Armstrong DK. The Impact of a Pharmacist-Driven Staphylococcus aureus Bacteremia Initiative in a Community Hospital: A Retrospective Cohort Analysis. PHARMACY 2021; 9:pharmacy9040191. [PMID: 34941623 PMCID: PMC8703297 DOI: 10.3390/pharmacy9040191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose: Staphylococcus aureus is a leading cause of bacteremia with a 30-day mortality of 20%. This study evaluated outcomes after implementation of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) initiative in a community hospital. Methods: This retrospective cohort analysis compared patients admitted with SAB between May 2015 and April 2018 (intervention group) to those admitted between May 2012 and April 2015 (historical control group). Pharmacists were notified of and responded to blood cultures positive for Staphylococcus aureus by contacting provider(s) with a bundle of recommendations. Components of the SAB bundle included prompt source control, selection of appropriate intravenous antibiotics, appropriate duration of therapy, repeat blood cultures, echocardiography, and infectious diseases consult. Demographics (age, gender, and race) were collected at baseline. Primary outcome was in-hospital mortality. Compliance with bundle components was also assessed. Results: Eighty-three patients in the control group and 110 patients in the intervention group were included in this study. Demographics were similar at baseline. In-hospital mortality was lower in the intervention group (3.6% vs. 15.7%; p = 0.0033). Bundle compliance was greater in the intervention group (69.1% vs. 39.8%; p < 0.0001). Conclusions: We observed a significant reduction in in-hospital mortality and increased treatment bundle compliance in the intervention cohort with implementation of a pharmacist-driven SAB initiative. Pharmacists’ participation in the care of SAB patients in the form of recommending adherence to treatment bundle components drastically improved clinical outcomes. Widespread adoption and implementation of similar practice models at other institutions may reduce in-hospital mortality for this relatively common and life-threatening infection.
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Affiliation(s)
- Nate J. Berger
- Department of Pharmacy, Williamson Medical Center, Franklin, TN 37067, USA; (M.E.W.); (J.D.P.); (M.W.G.); (D.K.A.)
- Department of Pharmacy, Methodist Health System, Dallas, TX 75203, USA
- Correspondence: or
| | - Michael E. Wright
- Department of Pharmacy, Williamson Medical Center, Franklin, TN 37067, USA; (M.E.W.); (J.D.P.); (M.W.G.); (D.K.A.)
| | - Jonathon D. Pouliot
- Department of Pharmacy, Williamson Medical Center, Franklin, TN 37067, USA; (M.E.W.); (J.D.P.); (M.W.G.); (D.K.A.)
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Lipscomb University, Nashville, TN 37204, USA
| | - Montgomery W. Green
- Department of Pharmacy, Williamson Medical Center, Franklin, TN 37067, USA; (M.E.W.); (J.D.P.); (M.W.G.); (D.K.A.)
- Department of Pharmacy Practice, College of Pharmacy, Belmont University, Nashville, TN 37212, USA
| | - Deborah K. Armstrong
- Department of Pharmacy, Williamson Medical Center, Franklin, TN 37067, USA; (M.E.W.); (J.D.P.); (M.W.G.); (D.K.A.)
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12
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Brower KI, Hecke A, Mangino JE, Gerlach AT, Goff DA. Duration of Antibiotic Therapy for General Medicine and General Surgery Patients Throughout Transitions of Care: An Antibiotic Stewardship Opportunity for Noninfectious Disease Pharmacists. Hosp Pharm 2021; 56:532-536. [PMID: 34720157 DOI: 10.1177/0018578720928265] [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] [Indexed: 12/18/2022]
Abstract
Background Overuse of antibiotics from the inpatient to outpatient setting is an antibiotic stewardship initiative where noninfectious disease (ID) pharmacists can have a large impact. Our purpose was to evaluate antibiotic durations across transitions of care from the inpatient to outpatient setting. Methods This is a single-center, retrospective cohort analysis evaluating antibiotic durations from the inpatient and outpatient setting in adult patients admitted to general surgery and medicine services at an academic medical center between January 1, 2017 and September 20, 2017. The primary outcome was to assess total antibiotic duration for patients with uncomplicated and complicated urinary tract infections (UTI, cUTI), community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP). Outpatient electronic discharge prescriptions were used to calculate intended antibiotic duration upon transitions of care. Excessive duration of therapy was defined as >3 days-UTI, >5 days-CAP, and >7 days-cUTI or HAP. Results One hundred and one patients met inclusion criteria. Overall, most of the patients (81%) had antibiotics longer than recommended with only 3% receiving less than the recommended duration. Median total duration of therapy compared with recommended duration specified in national guidelines was UTI: 10 days [7 -10], cUTI: 12 days [7.5-12.5], CAP: 7 days [7 -9], HAP: 10 days [8 -12]. The median antibiotic duration was shorter in patients with no cultures or culture negative results compared with patients with positive cultures for all indications (UTI: 10.3 vs 10.8 days, cUTI: 9 vs 12 days, CAP: 8 vs 9.1 days, HAP: 10.5 vs 19.8 days). Overall, the recommended duration of antibiotics was completed while inpatient in 34.7%, but varied by infection. More patients with UTI or cUTI completed recommended duration of therapy while inpatient vs for CAP or HAP (53.8% vs 28%, P = .03). Eighty percent of those with UTI, 18.2% with cUTI, 25.6% with CAP, and 31.2% with HAP had already received the recommended duration of treatment, or more, on day of hospital discharge. Conclusions The median duration of antibiotic therapy for all indications evaluated was longer than recommended in national guidelines. Opportunities for stewardship by non-ID pharmacists to impact postdischarge antimicrobial use at transitions of care have been identified.
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Affiliation(s)
| | | | - Julie E Mangino
- The Ohio State University Wexner Medical Center, Columbus, USA
| | | | - Debra A Goff
- The Ohio State University Wexner Medical Center, Columbus, USA
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Kufel WD, Mastro KA, Steele JM, Wang D, Riddell SW, Paolino KM, Thomas SJ. Impact of a pharmacist-facilitated, evidence-based bundle initiative on Staphylococcus aureus bacteremia management. Diagn Microbiol Infect Dis 2021; 101:115535. [PMID: 34634714 DOI: 10.1016/j.diagmicrobio.2021.115535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/22/2021] [Accepted: 08/29/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate a pharmacist-facilitated evidence-based bundle (EBB) initiative with infectious disease consultation (IDC) for Staphylococcus aureus bacteremia (SAB). METHODS This was a before-and-after quasi-experimental study of adult patients with SAB before and after the pharmacist-facilitated EBB initiative, which included IDC, timely definitive antibiotics, source control, echocardiography, and repeat blood cultures. RESULTS Ninety and 111 patients were included in pre- and post-intervention cohorts, respectively. We observed significant increases in adherence to all 5 (4.4% vs 68.5%, P < 0.001) and 4 (10.0% vs 76.6%, P < 0.001) EBB elements. Time to definitive antibiotics (48 vs 16 hours, P < 0.001), time to IDC (43.5 vs 32 hours, P < 0.001), SAB duration (95 vs 66 hours, P = 0.009), persistent SAB (18.9% vs 9.0%, P = 0.041), and length of stay (14 vs 13 days, P = 0.027) also improved. No statistically significant differences for SAB-related readmission or all-cause mortality were observed. CONCLUSIONS Our pharmacist-facilitated SAB initiative was associated with improved EBB adherence and clinical outcomes.
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Affiliation(s)
- Wesley D Kufel
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA; State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA.
| | - Keri A Mastro
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA; State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey M Steele
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Dongliang Wang
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Scott W Riddell
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Kristopher M Paolino
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Stephen J Thomas
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
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Willekens R, Puig-Asensio M, Suanzes P, Fernández-Hidalgo N, Larrosa MN, González-López JJ, Rodríguez-Pardo D, Pigrau C, Almirante B. "Mortality in Staphylococcus aureus bacteraemia remains high despite adherence to quality indicators: secondary analysis of a prospective cohort study". J Infect 2021; 83:656-663. [PMID: 34626700 DOI: 10.1016/j.jinf.2021.10.001] [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] [Received: 06/25/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the association between compliance with previously published quality indicators (QIs) for the management of Staphylococcus aureus bacteraemia (SAB) and 30-day mortality. METHODS We conducted a post hoc analysis of all adult patients with SAB who were hospitalized at a Spanish university hospital between 2013 and 2018. We evaluated the compliance with 7 QIs of SAB management (i.e., Infectious Diseases consultation, follow-up blood cultures, early source control, echocardiography, early cloxacillin or cefazolin, vancomycin monitoring, and appropriate treatment duration). The QIs compliance rate was considered good if ≥75% of the QIs recommended in each patient were performed. We studied the impact of different risk factors (including QIs compliance) on 30-day all-cause mortality adjusting by multivariable modeling and propensity-matched analysis. RESULTS We included 441 patients with SAB. The QIs compliance rate was ≥75% in 361 patients (81.9%). A total of 95 patients (21.5%) died within 30 days after the index blood culture. In the multivariable model, the variables associated with 30-day mortality were: age (OR, 1.1; 95% CI, 1.0-1.1), Charlson comorbidity index (OR, 1.2; 95% CI, 1.1-1.4), persistent bacteraemia >72 h (OR, 6.0; 95% CI, 3.2-11.5), infective endocarditis (OR, 2.8; 95% CI, 1.2-6.7), and SAB of unknown source (OR, 3.3; 95% CI, 1.5-7.1). We did not find an association between a global QIs compliance rate of ≥75% or any individual QI with 30-day mortality. CONCLUSIONS SAB 30-day mortality remains high despite good adherence to previously published QIs for the management of SAB. Future research should focus on additional factors to further improve SAB-related mortality.
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Affiliation(s)
- Rein Willekens
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Paula Suanzes
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Research Institute, Barcelona, Spain
| | - Nuria Fernández-Hidalgo
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Maria N Larrosa
- Spanish Network for the Study of Infectious Diseases (REIPI), Spain; Department of Microbiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Juan J González-López
- Spanish Network for the Study of Infectious Diseases (REIPI), Spain; Department of Microbiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Dolors Rodríguez-Pardo
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Carles Pigrau
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Benito Almirante
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
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15
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Brotherton AL, Rab S, Kandiah S, Kriengkauykiat J, Wong JR. The impact of an automated antibiotic stewardship intervention for the management of Staphylococcus aureus bacteraemia utilizing the electronic health record. J Antimicrob Chemother 2021; 75:1054-1060. [PMID: 31942636 DOI: 10.1093/jac/dkz518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Staphylococcus aureus bacteraemia (SAB) management bundles have been shown to improve performance measures and clinical outcomes. SAB bundles often require direct intervention by infectious diseases (ID) physicians or antibiotic stewardship programme (ASP) members or pharmacists. The purpose of this study was to evaluate an automated, real-time ASP intervention utilizing clinical decision support (CDS) in the electronic health record (EHR) for the management of SAB. METHODS A retrospective, single-centre quasi-experimental study of hospitalized patients with known SAB was conducted. The intervention was the implementation of a hard-stop best practice advisory (BPA) alert that would prompt physicians to use an electronic order set, on identification of SAB, with management recommendations, including ID consultation. The primary outcome was overall adherence to six institutional ASP SAB bundle elements. Secondary outcomes included both clinical and process outcomes. RESULTS A total of 227 patients were included, 111 in the pre-intervention and 116 in the post-intervention period. Completion of all six bundle elements improved by 27.2% in the post-intervention group (29.7% versus 56.9%, P < 0.001). BPA activation and order-set utilization occurred in 95.7% and 57.8% in the post-intervention group, respectively. Composite outcome of 30 day mortality or 90 day readmission with SAB complication decreased in the post-intervention group by 9.6% (24.3% versus 14.7%, P = 0.092). CONCLUSIONS Optimization of CDS within the EHR, using real-time BPA alert and order set, demonstrated an immediate, sustainable intervention that improved adherence to institutional performance measures for SAB management without direct prospective audit with intervention and feedback.
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Affiliation(s)
- Amy L Brotherton
- Department of Pharmacy, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA
| | - Saira Rab
- Department of Pharmacy and Drug Information, Grady Health System, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
| | - Sheetal Kandiah
- Department of Medicine Division of Infectious Diseases, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Jane Kriengkauykiat
- Department of Pharmacy and Drug Information, Grady Health System, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
| | - Jordan R Wong
- Department of Pharmacy and Drug Information, Grady Health System, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
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Meredith J, Onsrud J, Davidson L, Medaris LA, Kowalkowski M, Fischer K, Priem J, Leonard M, McCurdy L. Successful Use of Telemedicine Infectious Diseases Consultation With an Antimicrobial Stewardship-Led Staphylococcus aureus Bacteremia Care Bundle. Open Forum Infect Dis 2021; 8:ofab229. [PMID: 34189171 PMCID: PMC8231364 DOI: 10.1093/ofid/ofab229] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/30/2021] [Indexed: 11/20/2022] Open
Abstract
Background Telemedicine (TM) programs can be implemented to deliver specialty care through virtual platforms and overcome geographic/resource constraints. Few data exist to describe outcomes associated with TM-based infectious diseases (ID) management. The purpose of this study was to compare outcomes associated with TM and onsite standard-of-care (SOC) ID consultation after implementation of an antimicrobial stewardship (AMS)-led Staphylococcus aureus bacteremia (SAB) bundle. Methods A retrospective cohort study was conducted on the effects of a SAB bundle comparing ID consult delivery (SOC or TM) at 10 US hospitals within Atrium Health in adult patients admitted from September 2016 through December 2017. The type of ID consult provided was based on the admitting hospital; no hospital had both modalities. Bundle components included the following: (1) ID consult, (2) appropriate antibiotics, (3) repeat blood cultures until clearance, (4) echocardiogram obtainment, and (5) appropriate antibiotic duration. The AMS facilitated bundle initiation and compliance. The primary outcome was bundle adherence between groups. Differences in clinical outcomes were also assessed. Results We evaluated 738 patients with SAB (576 with SOC, 162 with TM ID). No differences were observed in overall bundle adherence (SOC 86% vs TM 89%, P = .33). In addition, no significant differences resulted between groups for hospital mortality, 30-day SAB-related readmission, persistent bacteremia, and culture clearance. Groups did not differ in 30-day mortality when controlling for demographics, bacteremia source, and physiological measures with multivariable logistic regression. Conclusions Our findings provide evidence to support effective use of TM ID consultation and AMS-led care bundles for SAB management in resource-limited settings.
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Affiliation(s)
- Jacqueline Meredith
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer Onsrud
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina, USA
| | - Lisa Davidson
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
| | - Leigh Ann Medaris
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
| | - Marc Kowalkowski
- Centers for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Kristin Fischer
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer Priem
- Centers for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Michael Leonard
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
| | - Lewis McCurdy
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
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17
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Fukuda T, Tanuma K, Iio S, Saito J, Komura M, Yamatani A. Impact of a Pharmacist-Led Antimicrobial Stewardship Program on the Number of Days of Antimicrobial Therapy for Uncomplicated Gram-Negative Bacteremia in a Community Hospital. Cureus 2021; 13:e14635. [PMID: 34046272 PMCID: PMC8140741 DOI: 10.7759/cureus.14635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction The need for pharmacist-led antimicrobial stewardship programs (ASP) is increasing. Objective We performed a retrospective study to assess whether pharmacist-led ASPs can decrease the duration of treatment for uncomplicated gram-negative bacteremia among patients admitted in a community hospital. Methods This research was conducted at a 325-bed regional general hospital in Japan, from January 2013 to June 2015. There are no infectious diseases specialists affiliated with the hospital. The outcomes of the pharmacist-led ASP group, who received pharmacist intervention, and the control group, who did not receive pharmacist intervention, were compared. The study included patients aged 18 years or older who were diagnosed with gram-negative bacteremia. The pharmacist performed an antimicrobial time-out at 72 hours after blood culture collection and optimized treatment based on the patient's clinical response and test results. The primary outcome was the duration of antibiotic treatment. Results In total, 34 patients in the pharmacist-led ASP group and 32 in the control group were included in the final analysis. The median number of days of antimicrobial treatment was 8 (interquartile range [IQR]: 7-14) days in the pharmacist-led ASP group and 14 (IQR: 10-15) days in the control group. The number of days of antimicrobial treatment significantly reduced in the pharmacist-led ASP group (p < 0.001). The de-escalation rates were 11 (32.4%) cases in the pharmacist-led ASP group and 4 (12.5%) cases in the control group. Hence, the trend was higher in the pharmacist-led ASP group than in the control group (p = 0.08). Conclusion The pharmacist-led ASP reduced the number of days of antimicrobial therapy for uncomplicated gram-negative bacteremia among patients admitted in a community hospital without an infectious diseases specialist.
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Affiliation(s)
- Tetsuya Fukuda
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, JPN.,Department of Pharmacy, National Hospital Organization Nishisaitama-Chuo National Hospital, Tokorozawa-shi, JPN
| | - Kentaro Tanuma
- Department of Pharmacy, National Hospital Organization Nishisaitama-Chuo National Hospital, Tokorozawa-shi, JPN
| | - Satoru Iio
- Department of Pharmacy, National Hospital Organization Nishisaitama-Chuo National Hospital, Tokorozawa-shi, JPN
| | - Jumpei Saito
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, JPN
| | - Makoto Komura
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, JPN
| | - Akimasa Yamatani
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, JPN
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Lloyd EC, Martin ET, Dillman N, Nagel J, Chang R, Gandhi TN, Tribble AC. Impact of a Best Practice Advisory for Pediatric Patients With Staphylococcus aureus Bacteremia. J Pediatric Infect Dis Soc 2021; 10:282-288. [PMID: 32531048 DOI: 10.1093/jpids/piaa058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/12/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Infectious diseases (ID) consultation and optimal antibiotic therapy improve outcomes in Staphylococcus aureus bacteremia (SAB). Data on strategies to improve adherence to these practices in children are limited. METHODS This was a quasi-experimental study evaluating the impact of an electronic medical record (EMR)-based best practice advisory (BPA) for SAB, recommending ID consult and optimal antibiotic therapy based on rapid mecA gene detection. Inpatients < 21 years old with SAB before (January 2015-July 2017) and after (August 2017-December 2018) BPA implementation were included. Primary outcome was receipt of ID consult. Secondary outcomes included receipt of optimal therapy, time to ID consult and optimal therapy, recurrent SAB, and 30-day all-cause mortality. ID consultation rates pre- and postimplementation were compared using interrupted time series (ITS) analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) for time to optimal therapy were calculated using Cox regression. RESULTS We included 99 SAB episodes (70 preintervention, 29 postintervention). Preintervention, 48 (68.6%) patients received an ID consult compared to 27 (93.1%) postintervention, but this was not statistically significant on ITS analysis due to a preexisting trend of increasing consultation. Median hours to optimal therapy decreased from 26.1 to 5.5 (P = .03), most notably in patients with methicillin-sensitive S. aureus (MSSA) (42.2 to 10.8; P < .01). On Cox regression, BPA implementation was associated with faster time to optimal therapy (HR, 3.22 [95% CI, 1.04-10.01]). CONCLUSIONS Implementation of an EMR-based BPA for SAB resulted in faster time to optimal antibiotic therapy, particularly for patients with MSSA. ID consultation increased throughout the study period and was not significantly impacted by the BPA.
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Affiliation(s)
- Elizabeth C Lloyd
- Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, Michigan
| | - Emily T Martin
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Nicholas Dillman
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Jerod Nagel
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Robert Chang
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan
| | - Tejal N Gandhi
- Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan
| | - Alison C Tribble
- Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, Michigan
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Birrell MT, Horne K, Rogers BA. Potential interventions for an antimicrobial stewardship bundle for Escherichia coli bacteraemia. Int J Antimicrob Agents 2021; 57:106301. [PMID: 33588016 DOI: 10.1016/j.ijantimicag.2021.106301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 12/06/2020] [Accepted: 02/06/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Escherichia coli is the most commonly identified bacteraemia, and causes a broad spectrum of diseases. The range of clinical conditions associated with E. coli bacteraemia mean that antimicrobial therapy is highly variable. This study aimed to determine the workload, efficiency and potential impact of an antimicrobial stewardship (AMS) bundle approach to E. coli bacteraemia. METHODS An observational cohort study of patients with E. coli bacteraemia was performed, and a review of each case's entire medical record was undertaken. A number of AMS interventions were modelled on this cohort to assess their impact on overall days of antimicrobial therapy and time to optimized antimicrobial therapy. RESULTS In total, 566 episodes of E. coli bacteraemia were identified. A number of AMS interventions were modelled to assess their impact. The strict implementation of guideline-based therapy was found to increase the number of patients receiving ineffective empirical therapy to 38/266 (14.3%) compared with 27/266 (10.2%) patients when w hen non-guideline-adherent therapy was allowed. A scheduled review by an AMS team on day 3 of empirical therapy could lead to a narrower-spectrum intravenous antibiotic in 237/515 (46%) cases, and 386 cases (68.2% of cohort) could have their duration of therapy reduced by a median of 7 days. CONCLUSION This study provides detailed description of a large cohort of patients with E. coli bacteraemia. There remains significant variability in empirical treatment, choice of step-down therapy and antimicrobial duration. A significant opportunity exists for AMS programmes to impact the management of E. coli bacteraemia through a bundled approach.
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Affiliation(s)
- Michael T Birrell
- Department of Infectious Diseases, Monash Health, Clayton, Victoria, Australia.
| | - Kylie Horne
- Department of Infectious Diseases, Monash Health, Clayton, Victoria, Australia; Department of Medicine, Centre for Inflammatory Diseases, Monash University, Clayton, Victoria, Australia
| | - Benjamin A Rogers
- Department of Infectious Diseases, Monash Health, Clayton, Victoria, Australia; Department of Medicine, Centre for Inflammatory Diseases, Monash University, Clayton, Victoria, Australia.
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Reduction of 30-day death rates from Staphylococcus aureus bacteremia by mandatory infectious diseases consultation: Comparative study interventions with and without an infectious disease specialist. Int J Infect Dis 2020; 103:308-315. [PMID: 33278619 DOI: 10.1016/j.ijid.2020.11.199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/12/2020] [Accepted: 11/26/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Most Japanese hospitals need to keep to higher Staphylococcus aureus bacteremia (SAB) quality-of-care indicators (QCIs) and create strategies that can maximize the effect of these QCIs with only a small number of infectious disease specialists. This study aimed to evaluate the clinical outcomes of patients with SAB before and after the enhancement of the mandatory infectious disease consultations (IDCs). METHODS This retrospective study was conducted at a tertiary care hospital in Japan. The primary outcome was the 30-day mortality between each period. A generalized structural equation model was employed to examine the effect of the mandatory IDC enhancement on 30-day mortality among patients with SAB. RESULTS A total of 114 patients with SAB were analyzed. The 30-day all-cause mortality differed significantly between the two periods (17.3% vs. 4.8%, P = 0.02). Age, three-QCI point ≥ 1, and Pitt bacteremia score ≥ 3 were the significant risk factors for 30-day mortality. The intervention was also significantly associated with improved adherence to QCIs. CONCLUSION Mandatory IDCs for SAB improved 30-day mortality and adherence to QCIs after the intervention. In Japan, improving the quality of management in patients with SAB should be an important target.
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Welch SN, Patel RM, Morris LE, Dassner AM, Rozario NL, Forrester JB. Impact of antimicrobial stewardship and rapid diagnostics in children with
Staphylococcus aureus
bacteremia. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Stephanie N. Welch
- Department of Pharmacy Atrium Health Carolinas Medical Center Charlotte North Carolina USA
| | - Rupal M. Patel
- Antimicrobial Support Network Atrium Health Levine Children's Hospital Charlotte North Carolina USA
| | - Lee E. Morris
- Department of Pediatric Infectious Diseases Atrium Health Levine Children's Hospital Charlotte North Carolina USA
| | - Aimee M. Dassner
- Department of Pharmacy Children's Medical Center of Dallas Dallas Texas USA
| | - Nigel L. Rozario
- Center for Outcomes Research and Evaluation Atrium Health Charlotte North Carolina USA
| | - Jeanne B. Forrester
- Antimicrobial Support Network Atrium Health Levine Children's Hospital Charlotte North Carolina USA
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Bouza E, Brenes FJ, Díez Domingo J, Eiros Bouza JM, González J, Gracia D, Juárez González R, Muñoz P, Petidier Torregrossa R, Ribera Casado JM, Ramos Cordero P, Rodríguez Rovira E, Sáez Torralba ME, Serra Rexach JA, Tovar García J, Verdejo Bravo C, Palomo E. The situation of infection in the elderly in Spain: a multidisciplinary opinion document. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2020; 33:327-349. [PMID: 32896115 PMCID: PMC7528417 DOI: 10.37201/req/057.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 11/10/2022]
Abstract
Infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. It is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. In an attempt to give the widest possible focus to this issue, the Health Sciences Foundation has convened experts from different areas to produce this position paper on Infection in the Elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. The format is that of discussion of a series of pre-formulated questions that were discussed by all those present. We begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. We also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. In this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed.
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Affiliation(s)
- E Bouza
- Emilio Bouza, Instituto de Investigación Sanitaria Gregorio Marañón. C/ Dr. Esquerdo, 46 28007 Madrid, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - E Palomo
- Esteban Palomo, Director. Health Sciences Foundation. C/ Severo Ochoa 2 - 28760 Tres Cantos. Madrid. Phone +34 91 3530150
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Inagaki K, Lucar J, Blackshear C, Hobbs CV. Methicillin-susceptible and Methicillin-resistant Staphylococcus aureus Bacteremia: Nationwide Estimates of 30-Day Readmission, In-hospital Mortality, Length of Stay, and Cost in the United States. Clin Infect Dis 2020; 69:2112-2118. [PMID: 30753447 DOI: 10.1093/cid/ciz123] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 02/05/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Information on outcomes of methicillin-susceptible and -resistant Staphylococcus aureus (MSSA and MRSA, respectively) bacteremia, particularly readmission, is scarce and requires further research to inform optimal patient care. METHODS We performed a retrospective analysis using the 2014 Nationwide Readmissions Database, capturing 49.3% of US hospitalizations. We identified MSSA and MRSA bacteremia using International Classification of Diseases, Ninth Revision, Clinical Modification among patients aged ≥18 years. Thirty-day readmission, mortality, length of stay, and costs were assessed using Cox proportional hazards regression, logistic regression, Poisson regression, and generalized linear model with gamma distribution and log link, respectively. RESULTS Of 92 089 (standard error [SE], 1905) patients with S. aureus bacteremia, 48.5% (SE, 0.4%) had MRSA bacteremia. Thirty-day readmission rate was 22% (SE, 0.3) overall with no difference between MRSA and MSSA, but MRSA bacteremia had more readmission for bacteremia recurrence (hazard ratio, 1.17 [95% confidence interval {CI}, 1.02-1.34]), higher in-hospital mortality (odds ratio, 1.15 [95% CI, 1.07-1.23]), and longer hospitalization (incidence rate ratio, 1.09 [95% CI, 1.06-1.11]). Readmission with bacteremia recurrence was particularly more common among patients with endocarditis, immunocompromising comorbidities, and drug abuse. The cost of readmission was $12 425 (SE, $174) per case overall, and $19 186 (SE, $623) in those with bacteremia recurrence. CONCLUSIONS Thirty-day readmission after S. aureus bacteremia is common and costly. MRSA bacteremia is associated with readmission for bacteremia recurrence, increased mortality, and longer hospitalization. Efforts should continue to optimize patient care, particularly for those with risk factors, to decrease readmission and associated morbidity and mortality in patients with S. aureus bacteremia.
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Affiliation(s)
- Kengo Inagaki
- Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Jose Lucar
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Chad Blackshear
- Data Science, University of Mississippi Medical Center, Jackson
| | - Charlotte V Hobbs
- Department of Pediatrics, University of Mississippi Medical Center, Jackson
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Claeys KC, Heil EL, Hitchcock S, Johnson JK, Leekha S. Management of Gram-Negative Bloodstream Infections in the Era of Rapid Diagnostic Testing: Impact With and Without Antibiotic Stewardship. Open Forum Infect Dis 2020; 7:ofaa427. [PMID: 33134414 PMCID: PMC7585329 DOI: 10.1093/ofid/ofaa427] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/09/2020] [Indexed: 12/26/2022] Open
Abstract
Background Verigene Blood-Culture Gram-Negative is a rapid diagnostic test (RDT) that detects gram-negatives (GNs) and resistance within hours from gram stain. The majority of the data support the use of RDTs with antimicrobial stewardship (AMS) intervention in gram-positive bloodstream infection (BSI). Less is known about GN BSI. Methods This was a retrospective quasi-experimental (nonrandomized) study of adult patients with RDT-target GN BSI comparing patients pre-RDT/AMS vs post-RDT/pre-AMS vs post-RDT/AMS. Optimal therapy was defined as appropriate coverage with the narrowest spectrum, accounting for source and co-infecting organisms. Time to optimal therapy was analyzed using Kaplan-Meier and multivariable Cox proportional hazards regression. Results Eight-hundred thirty-two patients were included; 237 pre-RDT/AMS vs 308 post-RDT/pre-AMS vs 237 post-RDT/AMS, respectively. The proportion of patients on optimal antibiotic therapy increased with each intervention (66.5% vs 78.9% vs 83.2%; P < .0001). Time to optimal therapy (interquartile range) decreased with introduction of RDT: 47 (7.9–67.7) hours vs 24.9 (12.4–55.2) hours vs 26.5 (10.3–66.5) hours (P = .09). Using multivariable modeling, infectious diseases (ID) consult was an effect modifier. Within the ID consult stratum, controlling for source and ICU stay, compared with the pre-RDT/AMS group, both post-RDT/pre-AMS (adjusted hazard ratio [aHR], 1.34; 95% CI, 1.04–1.72) and post-RDT/AMS (aHR, 1.28; 95% CI, 1.01–1.64), improved time to optimal therapy. This effect was not seen in the stratum without ID consult. Conclusions With the introduction of RDT and AMS, both proportion and time to optimal antibiotic therapy improved, especially among those with an existing ID consult. This study highlights the beneficial role of RDTs in GN BSI.
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Affiliation(s)
- Kimberly C Claeys
- Department Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Emily L Heil
- Department Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | | | | | - Surbhi Leekha
- University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Kullar R, Nagel J, Bleasdale SC, Sutton SH, Naumovski S, Rodriguez A, Smith C, Leggett J, Goldstein EJC. Going for the Gold: A Description of the Centers of Excellence Designation by the Infectious Diseases Society of America. Clin Infect Dis 2020; 68:1777-1782. [PMID: 30239608 DOI: 10.1093/cid/ciy797] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/10/2018] [Indexed: 12/18/2022] Open
Abstract
Antimicrobial stewardship programs (ASPs) are recommended by the Centers for Disease Control and Prevention and World Health Organization and mandated by the Joint Commission to curb antimicrobial resistance. However, <50% of institutions have optimal ASPs in place. Building on its experience of antimicrobial stewardship (AMS) advocacy, the Infectious Diseases Society of America (IDSA) developed the AMS Centers of Excellence (CoE) program, which will serve as a conduit to share best practices and highlight the standards for other hospitals to achieve in order to advance the field of AMS. A designation of CoE signifies that these institutions deliver high-quality care consistently, serve as the "gold" standard for executing novel AMS principles, and demonstrate commitment to their ASP. Here, we describe the process and purpose of designating institutions as AMS CoEs, provide awareness to clinicians on opportunities available through IDSA with this CoE designation, and discuss the evolution of the program.
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Affiliation(s)
| | - Jerod Nagel
- University of Michigan Health System, College of Pharmacy, University of Michigan, Ann Arbor
| | - Susan C Bleasdale
- Division of Infectious Diseases, College of Medicine, University of Illinois at Chicago
| | - Sarah H Sutton
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Snezana Naumovski
- Department of Pharmacy, Providence Saint Johns' Health Center, Santa Monica, California
| | - Andres Rodriguez
- Clinical Affairs and Practice Guidelines, Infectious Diseases Society of America, Arlington, Virginia
| | - Cheryl Smith
- Clinical Affairs and Practice Guidelines, Infectious Diseases Society of America, Arlington, Virginia
| | - James Leggett
- Providence Portland Medical Center, Oregon Health & Sciences University, Portland.,Division of Infectious Diseases, Oregon Health & Sciences University, Portland
| | - Ellie J C Goldstein
- Infectious Diseases Division, Providence Saint Johns' Health Center.,RM Alden Research Laboratory, Santa Monica, California
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26
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Fernandez JM, Dobrick JB, Jadavji A, Adam RD. Staphylococcus aureus bacteremia at a referral medical center in Kenya: A retrospective review of cases from 2010 to 2018. PLoS One 2020; 15:e0234914. [PMID: 32574220 PMCID: PMC7310726 DOI: 10.1371/journal.pone.0234914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 06/04/2020] [Indexed: 11/18/2022] Open
Abstract
Background Many studies have shown that Staphylococcus aureus is a leading cause of both community onset and hospital onset bloodstream infections. However, relatively little is known about the occurrence and outcome of S. aureus bacteremia in sub-Saharan Africa. A previous report indicated that S. aureus accounts for 16% of community onset and 6% of hospital onset bloodstream infections at Aga Khan University Hospital Nairobi (AKUHN). Data about the etiology of S. aureus bacteremia in sub-Saharan Africa will help optimize recognition and treatment. This study was performed in order to understand the etiologies and risk factors for S. aureus bacteremia in a sub-Saharan location. Materials and methods A review of the electronic record of laboratory results from September 2010 through December 2018 identified 201 patients seen at AKUHN with S. aureus bacteremia. The source and/or focus of infection was identified and in-hospital mortality was determined. Cases with bacteremia after three days of hospitalization were considered hospital acquired. Community onset cases were divided into community acquired and health care associated. Results Most cases (71%; 143/201) were community onset, but only 41% (83/201) of these cases were community acquired. The most commonly identified foci of infection for community acquired bacteremia were musculoskeletal (25%; 21/83) and skin and soft tissue (24%; 20/83). The majority of health care associated (70%; 40/57) and hospital acquired cases (74%; 43/58) were associated with invasive vascular devices, with peripheral IVs being the most common for hospital acquired and dialysis catheters being the most common for health care associated infections. In-hospital mortality rates were 23% (19/83) for community acquired, 19% (11/57) for health care associated and 33% (19/58) for hospital acquired infections. Conclusion Invasive vascular devices were associated with a substantial portion of cases of S. aureus bacteremia and provide an important target for infection control efforts.
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Affiliation(s)
| | - Jenna B Dobrick
- University of Arizona College of Medicine, Tucson, AZ, United States of America
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27
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Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves. Infect Control Hosp Epidemiol 2020; 41:921-925. [PMID: 32539873 DOI: 10.1017/ice.2020.143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation. DESIGN Retrospective cohort study with descriptive and before-and-after analyses. SETTING Tertiary-care academic medical center. PATIENTS All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis. METHODS A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre-post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters. RESULTS Overall, 391 interventions were made in the 20-month period following implementation, including 20 "good saves" avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045). CONCLUSIONS This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.
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28
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Goff DA, Kullar R. Can the Perfect Handshake Hold the Key to Success and Sustainability of Antimicrobial Stewardship Programs? Clin Infect Dis 2020; 70:2333-2335. [DOI: 10.1093/cid/ciz699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/31/2019] [Indexed: 01/11/2023] Open
Affiliation(s)
- Debra A Goff
- The Ohio State University College of Pharmacy, The Ohio State University Wexner Medical Center; Columbus
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29
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Arensman K, Dela-Pena J, Miller JL, LaChance E, Beganovic M, Anderson M, Rivelli A, Wieczorkiewicz SM. Impact of Mandatory Infectious Diseases Consultation and Real-time Antimicrobial Stewardship Pharmacist Intervention on Staphylococcus aureus Bacteremia Bundle Adherence. Open Forum Infect Dis 2020; 7:ofaa184. [PMID: 32548206 PMCID: PMC7288607 DOI: 10.1093/ofid/ofaa184] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/19/2020] [Indexed: 12/22/2022] Open
Abstract
Background The purpose of this study was to evaluate the impact of infectious diseases consultation (IDC) and a real-time antimicrobial stewardship (AMS) review on the management of Staphylococcus aureus bacteremia (SAB). Methods This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at 7 hospitals. Outcomes were compared between 3 time periods: before mandatory IDC and AMS review (period 1), after mandatory IDC and before AMS review (period 2), and after mandatory IDC and AMS review (period 3). The primary outcome was bundle adherence, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary end points included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality. Results A total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n = 241/371), 54% in period 2 (n = 47/87), and 76% in period 3 (n = 92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37–0.93; P = .02) and period 2 (OR, 0.37; 95% CI, 0.20–0.67; P = .0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < .001), source control (34% vs 45% vs 45%; P = .04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = .01). No differences were noted for readmission or mortality. Conclusions The addition of AMS pharmacist review to mandatory IDC was associated with significantly improved quality care bundle adherence.
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Affiliation(s)
- Kellie Arensman
- Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | | | - Jessica L Miller
- Advocate South Suburban Hospital, Hazel Crest, Illinois, USA.,Advocate Trinity Hospital, Chicago, Illinois, USA
| | - Erik LaChance
- Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Maya Beganovic
- Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Morgan Anderson
- Advocate Condell Medical Center, Libertyville, Illinois, USA.,Advocate Good Shepherd Hospital, Barrington, Illinois, USA
| | - Anne Rivelli
- Russel Center for Research and Innovation, Park Ridge, Illinois, USA
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30
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Du Y, Li J, Wang X, Peng X, Wang X, He W, Li Y, Wang X, Yang Q, Zhang X. Impact of a Multifaceted Pharmacist-Led Intervention on Antimicrobial Stewardship in a Gastroenterology Ward: A Segmented Regression Analysis. Front Pharmacol 2020; 11:442. [PMID: 32351389 PMCID: PMC7174747 DOI: 10.3389/fphar.2020.00442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/20/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Irrational use of antimicrobial agents for gastrointestinal diseases deserves attention, but corresponding antimicrobial stewardship programs (ASPs) are generally not a priority for managers. We conducted this study to evaluate the effectiveness of multifaceted pharmacist-led (MPL) interventions in the gastroenterology ward (GW) to provide evidence for the efficacy of ASPs in a non-priority department. METHODS This was an interventional, retrospective study implemented in China. The MPL intervention lasting 1.5 years involved daily ward rounds with physicians, regular review of medical orders, monthly indicator feedback, frequent physician training, and necessary patient education. Data on all hospitalized adults receiving antibiotics was extracted from the hospital information system over a 36-month period from January 2016 to December 2018. Segmented regression analysis of interrupted time series was performed to evaluate the effect of the MPL interventions (started in July 2017) on antibiotic use and length of hospital stay, which was calculated monthly as analytical units. RESULTS A total of 1763 patients receiving antibiotics were enrolled. Segmented regression models showed descending trends from the baseline in the intensity of antibiotic consumption (coefficient = -0.88, p = 0.01), including a significant decline in the level of change of the proportion of patients receiving combined antibiotics (coefficient = -9.91, p = 0.03) and average length of hospital stay (coefficient = -1.79, p = 0.00), after MPL interventions. The MPL interventions led to a temporary increase in the proportion of patients receiving antibiotics (coefficient = 4.95, p = 0.038), but this was part of a declining secular trend (coefficient = -0.45, p = 0.05). CONCLUSION The MPL interventions led a statistically significant decline in the number of patients receiving antibiotics, the antibiotic consumption, and the average hospital stay post-intervention compared to the pre-intervention phase of the study. Health policymakers should actively practice MPL interventions by clinical pharmacists in ASPs in those departments that are not included in priority management.
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Affiliation(s)
- Yaling Du
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Jing Li
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xinchun Wang
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xi Peng
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xiaoyi Wang
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Wenying He
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Yan Li
- First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China
| | - Xuemei Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiuxia Yang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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31
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Bianchini ML, Mercuro NJ, Kenney RM, Peters MA, Samuel LP, Swiderek J, Davis SL. Improving care for critically ill patients with community-acquired pneumonia. Am J Health Syst Pharm 2020; 76:861-868. [PMID: 31361849 DOI: 10.1093/ajhp/zxz068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE The purpose of this study was to improve antimicrobial management and outcomes of critically ill patients with community-acquired pneumonia (CAP) through implementation of a pharmacist-driven bundle for ordering evidence-based diagnostic tests in a medical intensive care unit (MICU). METHODS An inpatient collaborative practice agreement (CPA) was established for MICU pharmacists to order criteria-driven diagnostic testing for CAP from November 2017-March 2018. Adults admitted to the MICU and started on empiric antibiotics for CAP were included. The intervention arm was compared with a standard of care (SOC) group from November 2016-March 2017. RESULTS Ninety-one patients were included in each group. There was no difference in the median antibiotic duration between SOC and CPA, at 7 days (interquartile range [IQR], 6-10) versus 7 days (IQR, 6-8), respectively. The overall use of evidence-based diagnostic tests increased in the CPA group. Patients in the CPA group had more frequent pathogen identification (SOC and CPA, respectively: 31 [34%] versus 46 [51%], p = 0.035) and antimicrobial deescalation (24 [26%] versus 53 [58%], p < 0.001). There was no significant difference in length of intensive care unit stay, at 4 days for SOC (IQR, 2-10) versus 6 days for CPA (IQR, 3-10), and no significant difference in inpatient all-cause mortality (13 [14%] versus 7 [8%]), retreatment 14 [15%] versus 11 [12%]), or 30-day readmission 16 ([18%] versus 13 [14%]) for SOC and CPA, respectively. The CPA was the only variable that was independently associated with antimicrobial deescalation (odds ratio, 4.030; 95% confidence interval, 2.101-7.731) in a multiple logistic regression. CONCLUSION Implementation of a pharmacy-driven pneumonia diagnostic stewardship bundle improved the use of evidence-based diagnostics and increased the frequency of pathogen identification. This intervention was associated with increased antimicrobial deescalation without a negative impact on patient safety outcomes.
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Affiliation(s)
| | - Nicholas J Mercuro
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, and Department of Pharmacy Practice, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, MI
| | - Rachel M Kenney
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI
| | - Michael A Peters
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI
| | - Linoj P Samuel
- Division of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, MI
| | - Jennifer Swiderek
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Susan L Davis
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, and Department of Pharmacy Practice, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, MI
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Gentry EM, Kester S, Fischer K, Davidson LE, Passaretti CL. Bugs and Drugs: Collaboration Between Infection Prevention and Antibiotic Stewardship. Infect Dis Clin North Am 2019; 34:17-30. [PMID: 31836329 DOI: 10.1016/j.idc.2019.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Overall goals of antibiotic stewardship and infection prevention programs are to improve patient safety as it pertains to risk of infection or multidrug-resistant organism (MDRO) acquisition. Although the focus of day-to-day activities may differ, the themes of surveillance, education, clinician engagement, and multidisciplinary interactions are prevalent in both programs. Synergistic work between programs has yielded benefits in prevention of MDROs, surgical site infections, Clostridioides difficile infection, and reducing inappropriate testing and treatment for asymptomatic bacteriuria. Collaboration between programs can help maximize resources and minimize redundant work to keep issues related to bugs and drugs at bay.
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Affiliation(s)
- Erin M Gentry
- Antimicrobial Support Network, Carolinas Medical Center, Department of Pharmacy Services, Atrium Health, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Shelley Kester
- Infection Prevention, Division of Quality, Atrium Health, 1616 Scott Avenue, Charlotte, NC 28203, USA
| | - Kristin Fischer
- Department of Medicine, Division of Infectious Diseases, Atrium Health, 1540 Garden Terrace, Suite 209, Charlotte, NC 28203, USA
| | - Lisa E Davidson
- Antimicrobial Support Network, Internal Medicine, Division of Infectious Diseases, Atrium Health, 1540 Garden Terrace, Suite 211, Charlotte, NC 28203, USA
| | - Catherine L Passaretti
- Health System Infection Prevention, Internal Medicine, Division of Infectious Diseases, Atrium Health, 1616 Scott Avenue, Charlotte, NC 28203, USA
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Erickson RM, Tritle BJ, Spivak ES, Timbrook TT. Impact of an Antimicrobial Stewardship Bundle for Uncomplicated Gram-Negative Bacteremia. Open Forum Infect Dis 2019; 6:ofz490. [PMID: 32128333 PMCID: PMC7047945 DOI: 10.1093/ofid/ofz490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/12/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Recent studies in gram-negative bacteremia (GNB) suggest that intravenous (IV) to oral (PO) switch and short treatment durations yield similar clinical outcomes and fewer adverse events. Antimicrobial stewardship program (ASP) bundled initiatives have been associated with improved clinical outcomes for bloodstream infections. METHODS This single-center retrospective cohort evaluation included inpatient adults from 11/2014-10/2015 and 10/2017-9/2018 with GNB. The pre-ASP period was before the establishment of an ASP program. In the post period, the ASP promoted IV-to-PO switches, avoidance of repeat blood cultures, and short treatment durations for patients with uncomplicated GNB. The primary outcome was duration of antibiotic therapy. Secondary outcomes included process measures associated with the bundle and clinical outcomes. RESULTS One hundred thirty-seven patients met criteria for inclusion, with 51 patients in the pre group and 86 patients in the post group. Background characteristics were similar between groups. The median duration of therapy (interquartile range) was 14 (10-16) days in the pre group and 10 days (7-14) in the post group (P < .001). The median day of IV-to-PO switch was day 5 (4-6) in the pre group vs day 4 (3-5) in the post group (P = .046). The average total hospital cost per case decreased by 27% in the post group (P = .19). Mortality rates and bacteremia recurrence were not significantly different between groups. CONCLUSIONS An ASP bundle for uncomplicated GNB was associated with reduced durations of therapy and earlier PO switch. These findings highlight the synergistic role of ASPs in optimizing antibiotic use and promoting patient safety.
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Affiliation(s)
| | - Brandon J Tritle
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tristan T Timbrook
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
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Abstract
The role of biomarkers for detection of sepsis has come a long way. Molecular biomarkers are taking front stage at present, but machine learning and other computational measures using bigdata sets are promising. Clinical research in sepsis is hampered by lack of specificity of the diagnosis; sepsis is a syndrome with no uniformly agreed definition. This lack of diagnostic precision means there is no gold standard for this diagnosis. The final conclusion is expert opinion, which is not bad but not perfect. Perhaps machine learning will displace expert opinion as the final and most accurate definition for sepsis.
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Affiliation(s)
- Steven M Opal
- Infectious Disease Division, Alpert Medical School of Brown University, Ocean State Clinical Coordinating Center at Rhode Island Hospital, 1 Virginia Avenue Suite 105, Providence, RI 02905, USA.
| | - Xavier Wittebole
- Critical Care Department, (Pr Laterre), Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
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35
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Pettit NN, Han Z, Nguyen CT, Choksi A, Charnot-Katsikas A, Beavis KG, Tesic V, Pisano J. Antimicrobial Stewardship Review of Automated Candidemia Alerts Using the Epic Stewardship Module Improves Bundle-of-Care Adherence. Open Forum Infect Dis 2019; 6:ofz412. [PMID: 31660370 PMCID: PMC6788339 DOI: 10.1093/ofid/ofz412] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/30/2019] [Indexed: 11/14/2022] Open
Abstract
Background Antimicrobial stewardship interventions utilizing real-time alerting through the electronic medical record enable timely implementation of the bundle of care (BOC) for patients with severe infections, such as candidemia. Automated alerting for candidemia using the Epic stewardship module has been in place since July 2015 at our medical center. We sought to assess the impact of these alerts. Methods All adult inpatients with candidemia between April 1, 2011, and March 31, 2012 (pre-intervention), and June 30, 2016, and July 1, 2017 (post-intervention), were evaluated for BOC adherence. We also evaluated the impact on timeliness to initiate targeted therapy, length of stay (LOS), and 30-day mortality. Results Eighty-four patients were included, 42 in the pre- and 42 in the post-intervention group. Adherence to BOC was significantly improved, from 48% (pre-intervention) to 83% (post-intervention; P = .001). The median time to initiation of therapy was 4.8 hours vs 3.3 hours (P = .58), the median LOS was 24 and 18 days (P = .28), and 30-day mortality was 19% and 26% (P = .60) in the pre- and post-intervention groups, respectively. Conclusions Antimicrobial stewardship program review of automated alerts identifying patients with candidemia resulted in significantly improved BOC adherence and was associated with a 1.5-hour reduction in time to initiation of antifungal therapy. No significant change was observed with 30-day mortality or LOS.
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Affiliation(s)
- Natasha N Pettit
- Department of Pharmacy, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Zhe Han
- Department of Pharmacy, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Anish Choksi
- Department of Pharmacy, The University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Kathleen G Beavis
- Department of Pathology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Vera Tesic
- Department of Pathology, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Jennifer Pisano
- Infectious Diseases and Global Health, The University of Chicago Medicine, Chicago, Illinois, USA
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36
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Improved mortality in Staphylococcus aureus bacteremia with the involvement of antimicrobial stewardship team and infectious disease consultation. Infect Control Hosp Epidemiol 2019; 40:932-935. [PMID: 31196239 DOI: 10.1017/ice.2019.136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A retrospective study was conducted to evaluate the value of the antimicrobial stewardship team (AST) combined with infectious diseases consultation (IDC) on management and outcomes of Staphylococcus aureus bacteremia (SAB) in a tertiary-care academic center. Involvement of AST or IDC was associated with reduced mortality of SAB.
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37
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Wang F, Prier B, Bauer KA, Mellett J. Pharmacist-driven initiative for management of Staphylococcus aureus bacteremia using a clinical decision support system. Am J Health Syst Pharm 2019; 75:S35-S41. [PMID: 29802177 DOI: 10.2146/ajhp170087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The development and implementation of a clinical decision support system (CDSS) for pharmacists to use for identification of and intervention on patients with Staphylococcus aureus bacteremia (SAB) are described. SUMMARY A project team consisting of 3 informatics pharmacists and 2 infectious diseases (ID) pharmacists was formed to develop the CDSS. The primary CDSS component was a scoring system that generates a score in real time for a patient with a positive blood culture for S. aureus. In addition, 4 tools were configured in the CDSS to facilitate pharmacists' workflow and documentation tasks: a patient list, a patient list report, a handoff note, and a standardized progress note. Pharmacists are required to evaluate the patient list at least once per shift to identify newly listed patients with a blood culture positive for S. aureus and provide recommendations if necessary. The CDSS was implemented over a period of 2.5 months, with a pharmacy informatics resident dedicating approximately 200 hours in total. An audit showed that the standardized progress note was completed for 100% of the patients, with a mean time to completion of 8.5 hours. Importantly, this initiative can be implemented in hospitals without specialty-trained ID pharmacists. This study provides a framework for future antimicrobial stewardship program initiatives to incorporate pharmacists into the process of providing real-time recommendations. CONCLUSION A pharmacist-driven patient scoring system was successfully used to improve adherence to quality performance measures for management of SAB. A pharmacist-driven CDSS can be utilized to assist in the management of SAB.
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Affiliation(s)
- Fei Wang
- Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Beth Prier
- Ohio State University Wexner Medical Center, Columbus, OH
| | | | - John Mellett
- Ohio Sate University Wexner Medical Center, Columbus, OH
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38
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Chastain DB, Cluck DB, Stover KR, Lusardi KT, Marx A, Green S, Faulkner-Fennell C, Turner M, Chahine EB, Bookstaver PB, Bland CM. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2017. Open Forum Infect Dis 2019; 6:ofz133. [PMID: 31041343 PMCID: PMC6483124 DOI: 10.1093/ofid/ofz133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/21/2019] [Indexed: 12/01/2022] Open
Abstract
With an increasing number of antimicrobial stewardship-related articles published each year, attempting to stay current is challenging. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship-related peer-reviewed literature that detailed an "actionable" intervention for 2017. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the "actionable" intervention used by antimicrobial stewardship programs to provide key stewardship literature for training and teaching and identify potential intervention opportunities within their institutions.
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Affiliation(s)
| | - David B Cluck
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, Tennessee
| | - Kayla R Stover
- University of Mississippi School of Pharmacy, Jackson, Mississippi
| | | | - Ashley Marx
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Sarah Green
- Novant Health Forsyth Medical Center, Winston-Salem, North Carolina
| | | | | | - Elias B Chahine
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, Florida
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39
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Lam JC, Gregson DB, Robinson S, Somayaji R, Welikovitch L, Conly JM, Parkins MD. Infectious diseases consultation improves key performance metrics in the management of Staphylococcus aureus bacteremia: A multicentre cohort study. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2019; 4:24-32. [PMID: 36338780 PMCID: PMC9603189 DOI: 10.3138/jammi.2018-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 11/21/2018] [Indexed: 06/16/2023]
Abstract
BACKGROUND Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. We sought to identify factors associated with infectious diseases consultation (IDC) and understand how IDC associates with SAB patient management and outcomes. METHODS A multicentre retrospective study was performed between 2012 and 2014 in a large Canadian Health Zone in order to determine factors associated with IDC and performance of key quality of care determinants in SAB management and clinical outcomes. Factors subject to quality of care determinants were established a priori and studied for associations with IDC and 30-day all-cause mortality using multivariable analysis. RESULTS Of 961 SAB episodes experienced by 892 adult patients, 605 episodes received an IDC. Patients receiving IDC were more likely to have prosthetic valves and joints and to have community-acquired and known sources of SAB, but increasing age decreased IDC occurrence. IDC was the strongest independent predictor for quality of care performance metrics, including repeat blood cultures and echocardiography. Mortality at 30 days was 20% in the cohort, and protective factors included IDC, achievement of source control, targeted therapy within 48 hours, and follow-up blood cultures but not the performance of echocardiography. CONCLUSIONS There were significant gaps between the treatments and investigations that patients actually received for SAB and what is considered the optimal management of their condition. IDC is associated with improved attainment of targeted SAB quality of care determinants and reduced mortality rates. Based on our findings, we propose a policy of mandatory IDC for all cases of SAB to improve patient management and outcomes.
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Affiliation(s)
- John C Lam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel B Gregson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Calgary Laboratory Services, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
| | - Stephen Robinson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Welikovitch
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - John M Conly
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Parkins
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Disease, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
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40
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Remtulla S, Zurek K, Cervera C, Hernandez C, Lee MC, Hoang HL. Impact of an Unsolicited, Standardized Form-Based Antimicrobial Stewardship Intervention to Improve Guideline Adherence in the Management of Staphylococcus aureus Bacteremia. Open Forum Infect Dis 2019; 6:ofz098. [PMID: 30949538 PMCID: PMC6441557 DOI: 10.1093/ofid/ofz098] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/22/2019] [Indexed: 01/21/2023] Open
Abstract
Background Antimicrobial stewardship programs (ASPs) improve Staphylococcus aureus bacteremia (SAB) management. The objective of the current study was to evaluate the effect of unsolicited prospective audit and feedback (PAF) using a standardized SAB bundle form on the management of SAB. Methods Multicenter, pre-post quasi-experimental study of inpatients with SAB. The ASP developed an evidence-based SAB management bundle that included recommendations for infectious diseases consultation, blood culture clearance, appropriate empiric and definitive therapy, echocardiography, adequate treatment duration, and source control where applicable. ASP pharmacists performed PAF using a standardized form outlining bundle components. The primary outcome was bundle component adherence. Secondary outcomes were length of stay, 30-day readmission rate, and in-hospital and 30-day mortality rates. Results A total of 199 patients were included (preintervention group, 62; intervention group, 137). Bundle implementation with PAF resulted in significant improvements in infectious diseases consultation (56.5% in preintervention vs 93.4% in intervention group), appropriate definitive antibiotic therapy (83.9% vs 99.3%), ordering echocardiography (72.6% vs 95.6%), and adequate treatment duration (87.0% vs 100%) (all P < .001). Overall bundle adherence increased by 43.8% (P < .001). Readmission and 30-day mortality rates decreased, but this difference did not reach statistical significance. Conclusions Unsolicited PAF using a standardized SAB management bundle significantly improved adherence to evidence-based recommendations. This simple yet effective ASP-driven intervention can ensure consistent management of a highly morbid infection.
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Affiliation(s)
| | | | | | | | | | - Holly L Hoang
- Covenant Health, Edmonton, Canada.,University of Alberta, Edmonton, Canada
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41
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Beganovic M, McCreary EK, Mahoney MV, Dionne B, Green DA, Timbrook TT. Interplay between Rapid Diagnostic Tests and Antimicrobial Stewardship Programs among Patients with Bloodstream and Other Severe Infections. J Appl Lab Med 2018; 3:601-616. [PMID: 31639729 DOI: 10.1373/jalm.2018.026450] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) aim to provide optimal antimicrobial therapy to patients quickly to improve the likelihood of overcoming infection while reducing the risk of adverse effects. Rapid diagnostic tests (RDTs) for infectious diseases have become an integral tool for ASPs to achieve these aims. CONTENT This review explored the demonstrated clinical value of longer-standing technologies and implications of newer RDTs from an antimicrobial stewardship perspective. Based on available literature, the focus was on the use of RDTs in bloodstream infections (BSIs), particularly those that perform organism identification and genotypic resistance detection, phenotypic susceptibility testing, and direct specimen testing. Clinical implications of rapid testing among respiratory, central nervous system, and gastrointestinal infections are also reviewed. SUMMARY Coupling RDTs with ASPs facilitates the appropriate and timely use of test results, translating into improved patient outcomes through optimization of antimicrobial use. These benefits are best demonstrated in the use of RDT in BSIs. Rapid phenotypic susceptibility testing offers the potential for early pharmacokinetic/pharmacodynamic optimization, and direct specimen testing on blood may allow ASPs to initiate appropriate therapy and/or tailor empiric therapy even sooner than other RDTs. RDTs for respiratory, central nervous system, and gastrointestinal illnesses have also shown significant promise, although more outcome studies are needed to evaluate their full impact.
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Affiliation(s)
- Maya Beganovic
- Advocate Lutheran General Hospital, Department of Pharmacy, Park Ridge, IL
| | - Erin K McCreary
- University of Pittsburgh Medical Center, Department of Pharmacy, Pittsburgh, PA
| | - Monica V Mahoney
- Beth Israel Deaconess Medical Center, Department of Pharmacy, Boston, MA
| | - Brandon Dionne
- Northeastern University, School of Pharmacy, Bouvé College of Health Sciences, Boston, MA.,Brigham and Women's Hospital, Department of Pharmacy, Boston, MA
| | - Daniel A Green
- Columbia University College of Physicians and Surgeons, New York, NY
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Tang SJ, Gupta R, Lee JI, Majid AM, Patel P, Efird L, Loo A, Mazur S, Calfee DP, Archambault A, Jannat-Khah D, Dargar SK, Simon MS. Impact of Hospitalist-Led Interdisciplinary Antimicrobial Stewardship Interventions at an Academic Medical Center. Jt Comm J Qual Patient Saf 2018; 45:207-216. [PMID: 30482662 DOI: 10.1016/j.jcjq.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/17/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes. METHODS A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5). RESULTS Total antibiotic use decreased by 16.8% (p < 0.001), 6.8% (p = 0.08), and 33.0% (p < 0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p < 0.001), 7.8% (p = 0.09), and 32.4% (p < 0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p < 0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p < 0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team. CONCLUSION Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.
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43
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Garau J, Bassetti M. Role of pharmacists in antimicrobial stewardship programmes. Int J Clin Pharm 2018; 40:948-952. [PMID: 30242589 DOI: 10.1007/s11096-018-0675-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
Antimicrobial resistance is a growing public health problem of global concern and, unless action is taken, the burden of death could reach 10 million per year by 2050. Resistance has been associated with increasing mortality, treatment failure and healthcare costs. In order to help combat this, antimicrobial stewardship programmes, have been implemented in many countries. These stewardship programmes can help, reduce inappropriate prescription and broad-spectrum use of antimicrobials, improve, clinical outcomes for the population as a whole, slow down the emergence of antimicrobial resistance and conserve healthcare resources. Pharmacists are an integral part of the stewardship team and have an important role in tackling antimicrobial resistance. This article aims to review the role of pharmacists within antimicrobial stewardship programmes and the opportunities for pharmacist-driven antimicrobial stewardship strategies in hospital and community settings.
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Affiliation(s)
- Javier Garau
- Department of Medicine, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital, University of Udine, Udine, Italy
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44
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Abstract
Because of the increasing plague of antimicrobial resistance and antibiotic misuse, antimicrobial stewardship programs (ASPs) are now a mandatory entity in all US hospitals. ASPs can use technological advances, such as the electronic medical record and clinical decision support systems, to impact a larger patient population with more efficiency. Additionally, through the use of mobile applications and social media, ASPs can highlight and propagate educational information regarding antimicrobial utilization to patients and providers in a widespread and timely manner. In this article, the authors describe how technology can play an important role in antimicrobial stewardship.
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Affiliation(s)
- Derek N Bremmer
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA 15212, USA.
| | - Tamara L Trienski
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Thomas L Walsh
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, 4th Floor East Wing, Suite 406, Pittsburgh, PA 15212, USA
| | - Matthew A Moffa
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, 4th Floor East Wing, Suite 406, Pittsburgh, PA 15212, USA
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45
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Improved rates of antimicrobial stewardship interventions following implementation of the Epic antimicrobial stewardship module. Infect Control Hosp Epidemiol 2018; 39:980-982. [PMID: 29950188 DOI: 10.1017/ice.2018.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We evaluated the impact of the Epic antimicrobial stewardship module (EAM) on the number of interventions, antimicrobial usage, and clinical outcomes. Use of the EAM allowed us to significantly increase the number of ASP antimicrobial reviews and interventions while maintaining a sustained impact on antimicrobial utilization.
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46
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Mercuro NJ, Stogsdill P, Wungwattana M. Retrospective analysis comparing oral stepdown therapy for enterobacteriaceae bloodstream infections: fluoroquinolones versus β-lactams. Int J Antimicrob Agents 2018; 51:687-692. [DOI: 10.1016/j.ijantimicag.2017.12.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/16/2017] [Accepted: 12/16/2017] [Indexed: 01/10/2023]
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Affiliation(s)
- Debra A Goff
- The Ohio State University Wexner Medical Center, Columbus, USA
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48
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Djelic L, Andany N, Craig J, Daneman N, Simor A, Leis JA. Automatic notification and infectious diseases consultation for patients with Staphylococcus aureus bacteremia. Diagn Microbiol Infect Dis 2018; 91:282-283. [PMID: 29699836 DOI: 10.1016/j.diagmicrobio.2018.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/24/2018] [Accepted: 03/02/2018] [Indexed: 11/24/2022]
Abstract
Observational studies suggest that Infectious Diseases (ID) consultation is associated with improved outcomes for patients with Staphylococcus aureus bacteremia (SAB), but few studies have sought to standardize timely ID consultation through automatic notification by the Microbiology laboratory. In this 3-year quasi-experimental evaluation, introduction of this change resulted in increased ID consultation for SAB (70% versus 100%, P < 0.001) and decreased time to consultation (14.5 versus 4 h, P < 0.0001). Adherence to Quality of Care Indicators (QCIs) increased (45% versus 87%, P < 0.0002), transfer to intensive care unit decreased (38% versus 16%, P = 0.03), while decrease in 30-day readmission or death did not reach statistical significance (33% versus 27%, P = 0.5). Automatic notification and ID consultation for patients with SAB are a feasible system for ensuring improved adherence to established QCIs.
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Affiliation(s)
| | - Nisha Andany
- Department of Medicine, University of Toronto; Division of Infectious Diseases, Sunnybrook Health Sciences Centre
| | | | - Nick Daneman
- Department of Medicine, University of Toronto; Division of Infectious Diseases, Sunnybrook Health Sciences Centre
| | - Andrew Simor
- Department of Medicine, University of Toronto; Division of Infectious Diseases, Sunnybrook Health Sciences Centre; Department of Microbiology, Sunnybrook Health Sciences Centre
| | - Jerome A Leis
- Department of Medicine, University of Toronto; Division of Infectious Diseases, Sunnybrook Health Sciences Centre; Centre for Quality Improvement and Patient Safety, University of Toronto.
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49
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Abstract
PURPOSE OF REVIEW Diabetes affects about a third of all hospitalized patients and up to 50% of inpatients go on to experience hyperglycemia. Despite strong evidence supporting the importance of adequate glycemic control, as well detailed guidelines from major national organizations, many patients continue to have hypo- and hyperglycemia during their hospital stay. While this may be partially related to provider and patient-specific factors, system-based barriers continue to pose a major obstacle. Therefore, there is a need to go beyond merely discussing specific insulin protocols and provide guidance for effective models of care in the acute glycemic management of hospitalized patients. RECENT FINDINGS To date, there is limited data evaluating the various models of care for inpatient diabetes management in terms of efficacy or cost, and there is no summary on this topic guiding physicians and hospital administrators. In this paper, four common models of inpatient diabetes care will be presented including those models led by the following: an endocrinologist(s), mid-level provider(s), pharmacist(s), and a virtual glucose management team. The authors will outline the intrinsic benefits as well as limitations of each model of care as well as cite supporting evidence, when available. Discussion pertaining to how a given model of care shapes and formulates a particular organization's structured glucose management program (GMP) will be examined. Furthermore, the authors describe how the model of care chosen by an institution serves as the foundation for the creation of a GMP. Finally, the authors examine the critical factors needed for GMP success within an institution and outline the nature of hospital administrative support and accompanying reporting structure, the function of a multidisciplinary diabetes steering committee, and the role of the medical director.
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Affiliation(s)
- Andjela T Drincic
- Department of Internal Medicine: Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA.
| | - Padmaja Akkireddy
- Department of Internal Medicine: Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA
| | - Jon T Knezevich
- Department of Pharmaceutical and Nutrition Care, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA
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50
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Antimicrobial Stewardship Program Implementation of a Quality Improvement Intervention Using Real-Time Feedback and an Electronic Order Set for the Management of Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2018; 39:346-349. [DOI: 10.1017/ice.2017.325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Antimicrobial stewardship programs can optimize the management of Staphylococcus aureus bacteremia by integrating information technology and microbiology laboratory resources. This study describes our experience implementing an intervention consisting of real-time feedback and the use of an electronic order set for the management of S. aureus bacteremia.Infect Control Hosp Epidemiol 2018;39:346–349
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