Evaluating a pilot, structured, face-to-face, antimicrobial stewardship, prospective audit-and-feedback program in emergency general surgery service in a community hospital

Background

Prospective audit and feedback (PAF) is an established practice in critical care settings but not in surgical populations. We pilot-tested a structured face-to-face PAF program for our acute-care surgery (ACS) service.

Methods

This was a mixed-methods study. For the quantitative analysis, the structured PAF period was from August 1, 2017, to April 30, 2019. The ad hoc PAF period was from May 1, 2019, to January 31, 2021. Interrupted time-series segmented negative binomial regression analysis was used to evaluate change in antimicrobial usage measured in days of therapy per 1,000 patient days for all systemic and targeted antimicrobials. Secondary outcomes included C. difficile infections, length of stay and readmission within 30 days. Each secondary outcome was analyzed using a logistic regression or negative binomial regression model. For the qualitative analyses, all ACS surgeons and trainees from November 23, 2015, to April 30, 2019, were invited to participate in an email-based anonymous survey developed using implementation science principles. Responses were measured using counts.

Results

In total, 776 ACS patients were included in the structured PAF period and 783 patients were included in the in ad hoc PAF period. No significant changes in level or trend for antimicrobial usage were detected for all and targeted antimicrobials. Similarly, no significant differences were detected for secondary outcomes. The survey response rate was 25% (n = 10). Moreover, 50% agreed that PAF provided them with skills to use antimicrobials more judiciously, and 80% agreed that PAF improved the quality of antimicrobial treatment for their patients.

Conclusion

Structured PAF showed clinical outcomes similar to ad hoc PAF. Structured PAF was well received and was perceived as beneficial by surgical staff.

Impact of extended-infusion piperacillin-tazobactam in a Canadian community hospital

BACKGROUND

Studies have demonstrated improved clinical outcomes with extended infusion (EI) piperacillin/tazobactam (TZP) compared to standard infusion (SI). However, there is less evidence on its benefits in noncritically-ill patients. Hospital-wide EI TZP was implemented at our site on February 21, 2012. Our objectives were to compare clinical, safety and economic outcomes between EI and SI TZP.

METHODS

A retrospective cohort study of all adult patients who received EI TZP (3.375 g IV q8h infused over 4 hours and SI TZP for ≥ 48 hours during 3 years pre-and postimplementation was conducted. The primary study outcome was 14-day mortality while secondary outcomes included length of hospital stay (LOS), nursing plus pharmacy cost, occurrence of Clostridioides difficile infection, readmission within 30 days and change in Pseudomonas aeruginosa minimum inhibitory concentration (MIC) distribution for TZP. The primary outcome and binary secondary outcomes were analyzed using a logistic regression model. LOS was examined using time to event analysis. Cost was examined using linear regression modelling.

RESULTS

Overall, 2034 patients received EI TZP and 1364 patients received SI TZP. EI TZP was associated with lower odds of mortality (OR 0.76, 95% CI 0.63-0.91), lower odds of C. difficile infection (OR 0.59, 95% CI 0.41-0.84) and 8% lower cost (estimate 0.92, 95% CI 0.87-0.98) compared to SI TZP.

CONCLUSIONS

Hospital-wide implementation of EI TZP was associated with lower odds of 14-day mortality and incidence of C. difficile infection with cost savings at our institution.

1772. Evaluating the Impact of a Pilot Structured Antimicrobial Stewardship Prospective Audit and Feedback Program in Emergency General Surgery in a Community Hospital

Background

The benefits of prospective audit and feedback (PAF) are established in critical care settings but not in the surgical population. We piloted once-weekly structured face-to-face PAF with the Acute Care Surgery (ACS) Service surgeon(s) and compared outcomes to usual care which comprised of ad-hoc PAF on targeted antimicrobials once or twice weekly with recommendations made to ACS surgeon(s) using written or verbal methods.

Methods

Interrupted time series segmented negative binomial regression analysis was used to evaluate the change in the primary outcome of antimicrobial usage measured in Days of Therapy/1000 patient days (DOT/1000-PD) for all systemic and targeted antimicrobials ordered by the ACS team. The structured PAF period was from August 1, 2017- April 30, 2019 while the ad-hoc PAF period was from May 1, 2019-January 31, 2021. Targeted antimicrobials included 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems and clindamycin. Secondary outcomes included C. difficile infections, length of stay and readmission within 30 days. The first two secondary outcomes were analyzed using a logistic regression model while a negative binomial regression model was used to evaluate readmission within 30 days.

Results

There were 776 ACS patients in the structured PAF period with 783 patients in the ad-hoc PAF period. = No significant changes in level or trend of the primary outcome of DOT/1000-PD in both periods was found for all and targeted antimicrobials. However, there was a trend to small reduction in DOT/1000-PD of 0.9% per month (rate ratio 1.0, CI 0.99-1.02) for all antimicrobials and 0.3% per month (rate ratio 1.0, CI 0.98-1.03) for targeted antimicrobials in the ad-hoc PAF period. Similarly, there were no significant differences with respect to any of the secondary outcomes. There was a trend of 10% increase in length of stay (rate ratio 1.07, CI 0.98-1.17) and 13% reduction in 30-day readmission (OR 0.87, CI 0.56-1.35) in the ad-hoc PAF period.

Conclusion

Structured PAF showed similar clinical outcomes to ad-hoc PAF for the Acute Care Surgery Service at our institution. Other antimicrobial stewardship interventions can be explored to better support judicious antimicrobial use in General Surgery.

Disclosures

All Authors: No reported disclosures.

Trends in hospital antibiotic utilization during the coronavirus disease 2019 (COVID-19) pandemic: A multicenter interrupted time-series analysis

OBJECTIVE

To describe the evolution of respiratory antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic across 3 large hospitals that maintained antimicrobial stewardship services throughout the pandemic.

DESIGN

Retrospective interrupted time-series analysis.

SETTING

A multicenter study was conducted including medical and intensive care units (ICUs) from 3 hospitals within a Canadian epicenter for COVID-19.

METHODS

Interrupted time-series analysis was used to analyze rates of respiratory antibiotic utilization measured in days of therapy per 1,000 patient days (DOT/1,000 PD) in medical units and ICUs. Each of the first 3 waves of the pandemic were compared to the baseline.

RESULTS

Within the medical units, use of respiratory antibiotics increased during the first wave of the pandemic (rate ratio [RR], 1.76; 95% CI, 1.38-2.25) but returned to the baseline in waves 2 and 3 despite more COVID-19 admissions. In ICU, the use of respiratory antibiotics increased in wave 1 (RR, 1.30; 95% CI, 1.16-1.46) and wave 2 of the pandemic (RR, 1.21; 95% CI, 1.11-1.33) and returned to the baseline in the third wave, which had the most COVID-19 admissions.

CONCLUSIONS

After an initial surge in respiratory antibiotic prescribing, we observed the normalization of prescribing trends at 3 large hospitals throughout the COVID-19 pandemic. This trend may have been due to the timely generation of new research and guidelines developed with frontline clinicians, allowing for the active application of new research to clinical practice.

Evaluating the impact of mandatory indications on antibiotic utilization in a community hospital

OBJECTIVE

We evaluated the impact of introducing a mandatory indication field into electronic order entry for targeted antibiotics in adult inpatients.

DESIGN

Retrospective, before-and-after trial.

SETTING

A 400-bed community hospital.

INTERVENTIONS

All adult electronic intravenous (IV) and enteral orders for targeted antibiotics (moxifloxacin, ciprofloxacin, clindamycin, vancomycin, and metronidazole) had a mandatory indication field added. Control antibiotics (amoxicillin-clavulanate, ceftriaxone and piperacillin-tazobactam) were chosen to track shifts in antibiotic prescribing due to the introduction of mandatory indication field.

METHODS

Descriptive statistics were used to summarize the primary outcome, measured in Defined Daily Doses (DDD) per 1000 patient days (PD). Interrupted time-series (ITS) analysis was performed to compare levels and trends in antibiotic usage of targeted and control antibiotics during 24 months before and after the intervention. Additionally, a descriptive analysis of mandatory indication fields for targeted antibiotics in the postintervention period was conducted.

RESULTS

In total, 4,572 study antibiotic orders were evaluated after the intervention. Preset mandatory indications were selected for 30%-55% of orders. There was decreased usage of targeted antibiotics (mean, 92.02 vs 72.07 DDD/1000-PD) with increased usage of control antibiotics (mean, 102.73 vs 119.91 DDD/1000-PD). ITS analysis showed no statistically significant difference in overall antibiotic usage before and after the intervention for all targeted antibiotics.

CONCLUSION

This study showed moderate use of preset mandatory indications, suggesting that the preset list of indications can be optimized. There was no impact on overall antibiotic usage with the use of mandatory indications. More prospective research is needed to study the utility of this intervention in different contexts.

Barriers and facilitators of implementing an antimicrobial stewardship intervention for urinary tract infection in a long-term care facility

Background

Fifty percent of antibiotic courses in long-term care facilities (LTCFs) are unnecessary, leading to increased risk of harm. Most studies to improve antibiotic prescribing in LTCFs showed modest and unsustained results. We aimed to identify facilitators, barriers and strategies in implementing a urinary tract infection (UTI)-focused antimicrobial stewardship (AS) intervention at a LTCF, with the secondary objective of exploring the pharmacist's potential roles.

Methods

The study used a qualitative descriptive design. Participants attended either a focus group or one-on-one interview. Data were analyzed inductively using a codebook modified in an iterative analytic process. Barrier and facilitator themes were mapped using the capability, opportunity, motivation and behaviour (COM-B) model. Similarly, themes were identified from the transcripts regarding the pharmacist's roles.

Results

Sixteen participants were interviewed. Most barriers and facilitators mapped to the opportunities domain of the COM-B model. The main barrier themes were lack of access, lack of knowledge, ineffective communication, lack of resources and external factors, while the main facilitator themes were education, effective collaboration, good communication, sufficient resources and access. For the pharmacist's role, the barrier themes were ineffective collaboration and communication.

Conclusion

This study supports the importance of tailoring interventions to target factors underlying barriers to behaviour change. At this LTCF, an effective antimicrobial stewardship intervention should incorporate strategies to improve access, knowledge, communication and collaboration in its design, having sufficient resources and addressing external factors to optimize its success and long-term sustainability. Can Pharm J (Ott) 2021;154:xx-xx.

Site and mechanism of the colokinetic action of the ghrelin receptor agonist, HM01

BACKGROUND

It has been recently demonstrated that the ghrelin receptor agonist, HM01, caused defecation in rats that were treated to provide a model for the constipation of Parkinson's disease. HM01 significantly increased fecal output and increased Fos activity in neurons of the hypothalamus and hindbrain, but not in the spinal defecation center. Other ghrelin agonists act on the defecation center.

METHODS

Receptor pharmacology was examined in ghrelin receptor (GHSR1a) transfected cells. Anesthetized rats were used to investigate sites and mechanisms of action.

KEY RESULTS

HM01 activated rat GHSR1a at nanomolar concentrations and was antagonized by the GHSR1a antagonist, YIL781. HM01, intravenous, was potent to activate propulsive colorectal contractions. This was prevented by pelvic nerve section and by intravenous YIL781, but not by spinal cord section rostral to the defecation centers. Direct intrathecal application of HM01 to the defecation center at spinal level L6-S1 initiated propulsive contractions of the colorectum.

CONCLUSIONS & INFERENCES

HM01 stimulates GHSR1a receptors on neurons in the lumbosacral defecation centers to cause propulsive contractions and emptying of the colorectum. It has greater potency when given systemically, compared with other GHSR1a agonists.

High-dose methotrexate in adult oncology patients: A case-control study assessing the risk association between drug interactions and methotrexate toxicity

Introduction

High-dose methotrexate, defined as dose ≥1 g/m2, is commonly used in chemotherapy protocols. Certain drugs such as acyclovir, allopurinol, proton pump inhibitors and some antibiotics have been associated with delayed renal clearance of methotrexate and may predispose patients to toxicities. Currently, no specific recommendations exist on adjusting the high-dose methotrexate regimen in the presence of potential interacting drugs. This study aims to determine whether presence of interacting drugs is associated with delayed methotrexate clearance.

Methods

This was a case-control study of adult oncology patients who received their first cycle of high-dose methotrexate. Cases were defined as patients who experienced delayed methotrexate clearance, as indicated by serum methotrexate level ≥ 0.1 umol/L at 72 h. The primary endpoint was the frequency of presence of interacting drugs between cases and controls. These were compared using Fisher's exact test. Where possible, adjustment for significant baseline differences that can affect methotrexate clearance was made using logistic regression. The secondary endpoint was frequency of methotrexate-related clinical toxicities between groups and included myelosuppression, nephrotoxicity, hepatotoxicity and mucositis.

Results

From January 2004 to March 2011, 73 patients met study criteria, of which 23 were defined as cases. Significant baseline differences were methotrexate dose received (9116 mg ± 4339 versus 6054 mg ± 2874, p=0.012) and renal impairment (5 versus 0, p = 0.002). The presence of interacting drugs was not associated with delayed methotrexate clearance (OR 0.91, 95% CI 0.24–3.38, p > 0.999). After adjusting for methotrexate dose, drugs observed more frequently (allopurinol, proton pump inhibitors and sulfamethoxazole/trimethoprim) were not associated with delayed methotrexate clearance ( p = 0.95, 0.59 and 0.20, respectively). Cases experienced more severe anemia (grade 2.52 versus 1.68, p = 0.007) and higher rates of mucositis (65.2% versus 20.0%, p < 0.001).

Conclusion

This study showed no significant association between presence of interacting drugs and delayed methotrexate clearance. Patients who experienced delayed methotrexate clearance had higher incidence of severe anemia and mucositis.

Total knee arthroplasty using the S-ROM mobile-bearing hinge prosthesis

A retrospective study was performed on 15 patients receiving 16 S-ROM mobile-bearing hinge total knee prostheses that were evaluated with at least a 2-year follow-up (range, 27-71 months). Indications for its use included severe instability and bone loss. The average patient age was 63 years (range, 33-83 years). There were 15 revision arthroplasties and 1 primary arthroplasty. Knee Society scores showed notable improvement in pain, motion, and stability (33.6 preoperatively vs 76.5 postoperatively; P <.0001) and approached significant improvement in function (29.2 preoperatively vs 43.5 postoperatively; P =.11). After excluding a patient with a traumatically ruptured patellar tendon, the probability of the latter comparison improved (P <.01). There was no evidence of loosening, and complete bone apposition was seen in nearly all cases. A high percentage of satisfactory results can be achieved when using this mobile-bearing hinge knee prosthesis for these indications.

Magnetic resonance imaging in endourology

Historically, the utilization of magnetic resonance imaging (MRI) in endourology has been limited. The availability of faster and stronger gradient systems has given rise to a number of data acquisition strategies that have significantly broadened the scope of MRI applications. These methods have led to the evaluation of anatomy and function using a single modality, and we describe our experience with MRI for comprehensive evaluation of the obstructed ureteropelvic junction. We also utilize these new imaging sequences in the investigation of alterated renal hemodynamics after extracorporeal shockwave lithotripsy and present our preliminary data on the application of MR perfusion imaging as a noninvasive technique for the evaluation of renal blood flow.

Role of brachytherapy in patients with stage T1c, T2a adenocarcinoma of the prostate

The precise role of brachytherapy in treating patients with adenocarcinoma of the prostate remains unclear. Recent literature suggests that the long-term disease-free survival of patients with well-differentiated and localized tumors who receive brachytherapy is comparable to that of patients with similar tumors who are treated with radical prostatectomy or external-beam radiation. Advances in imaging technology, treatment planning software, and delivery apparatus have resulted in a technique that is accurate and reproducible. We explore the development of contemporary brachytherapy and examine the current published data relating to its emergence as a medically successful, cost-effective, and low-morbidity therapeutic modality for patients with stage T(1c), T(2a) prostate cancer.

Protective effect of aminophylline on renal perfusion changes induced by high-energy shockwaves identified by Gd-DTPA-enhanced first-pass perfusion MRI

PURPOSE

The purpose of this study was to evaluate regional renal hemodynamics in a noninvasive manner using gadolinium-DPTA magnetic resonance imaging (MRI) before and after extracorporeal shockwave lithotripsy (SWL). In addition, the renoprotective effect of intravenous aminophylline was evaluated on the perfusion on kidneys undergoing SWL.

PATIENTS AND METHODS

Ten randomly selected patients were evaluated for regional renal blood flow in the cortex and medulla with Gd-DTPA MRI studies within 2 weeks before and 4 hours after SWL. Five of these patients were treated with 500 mg of intravenous aminophylline 45 minutes prior to SWL. Renal hemodynamics were assessed utilizing relative perfusion indices (PI) calculated from signal intensity-v-time curves obtained from regions of interest (ROI). The ROI choice was based on the contrast-enhanced MRI images. Relative PIs of pre-SWL and post-SWL studies were compared in the first group of patients. Relative PIs of the treated kidney were compared with those of the contralateral kidney in the second group of patients, who received aminophylline.

RESULTS

In the group not treated with aminophylline, there was no significant difference in cortical perfusion before SWL (average PI -7+/-3%). However, after lithotripsy, there was a reduction of cortical flow (average PI 31+/-12%) in the treated kidney. In the group treated with aminophylline, renal hemodynamics study after SWL revealed no significant difference in relative perfusion (average PI -8+/-6%). Relative PIs of the medulla were small for all patients, but standard errors were large, indicating a wide range of values.

CONCLUSIONS

This study helps to establish reduced cortical flow after SWL and demonstrates that aminophylline attenuated this response in the kidneys subjected to lithotripsy. It appears that aminophylline administration causes no alteration in medullary blood flow.

A human modifier of methylation for class I HLA genes (MEMO-1) maps to chromosomal bands 1p35-36.1

Class I HLA genes are expressed in almost all tissues, but expression is low or undetectable in many neuroblastomas. We analysed class I HLA methylation in normal tissues and in 28 neuroectodermal tumour cell lines. HLA-C is hypermethylated in normal adult tissues and 13 cell lines, while 15 cell lines show the hypomethylated phenotype. Hypomethylation of HLA-C strongly correlates with hemizygous deletion of a 9 cM interval on 1p35-36.1, suggesting that this region encodes a modifier of methylation for HLA-C. To test whether hypomethylation of class I HLA genes results from loss of a modifier gene, we fused a hypomethylating neuroblastoma cell line with a hypermethylating cell line. Methylation of class I HLA genes was induced in the hybrids. Furthermore, methylation of HLA-C, -E and -A genes, which are encoded in a 1.4 Mb region on 6p21, is correlated in most cell lines. Our results suggest that 1p35-36.1 encodes a modifier of methylation for class I HLA genes, that is deleted in many neuroblastomas.

Effect of thiazides on colonic NaCl absorption: role of carbonic anhydrase

The mechanisms by which the benzothiadiazide class of diuretics inhibit electroneutral NaCl absorption are not fully understood. We studied the mechanisms of thiazide action in perfused loops of distal colon in anesthetized male Sprague-Dawley rats. Hydroflumethiazide (1 mM) reversibly inhibited greater than 40% of Na, Cl, and water absorption. Prior exposure of the colon to the carbonic anhydrase inhibitor methazolamide (0.1 mM) prevented the effects of hydroflumethiazide and metolazone, a thiazide-like drug, on colonic absorption. In Ussing flux chambers, addition of hydroflumethiazide to both the mucosal and serosal bathing solutions (but not to the mucosal solution alone) caused marked decreases in Na and Cl absorption. Such inhibition only occurred at concentrations of hydroflumethiazide (0.1 and 1.0 mM) that inhibited greater than 90% of carbonic anhydrase activity in homogenized colonic mucosa. We conclude that an important mechanism by which thiazides inhibit NaCl absorption in the rat distal colon is by inhibition of mucosal carbonic anhydrase. In tissues containing this enzyme, this mechanism of thiazide effect on ion flux must be considered.