Reducing Broad-Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study

Background

The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across 3 time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol.

Methods

In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and National Healthcare Safety Network–reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we reevaluated the same metrics.

Results

Our study population included 338 intensive care unit patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol, we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad-spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates.

Conclusions

Our final protocol significantly reduces broad-spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience.

Summary: There are no guidelines for antimicrobial prophylaxis in patients on extracorporeal membrane oxygenation (ECMO). A rational approach employing concepts of antimicrobial stewardship can drive logical antimicrobial selection for prophylaxis in patients on ECMO without adversely impacting outcomes.

Machine learning in data abstraction: A computable phenotype for sepsis and septic shock diagnosis in the intensive care unit

BACKGROUND

With the recent change in the definition (Sepsis-3 Definition) of sepsis and septic shock, an electronic search algorithm was required to identify the cases for data automation. This supervised machine learning method would help screen a large amount of electronic medical records (EMR) for efficient research purposes.

AIM

To develop and validate a computable phenotype via supervised machine learning method for retrospectively identifying sepsis and septic shock in critical care patients.

METHODS

A supervised machine learning method was developed based on culture orders, Sequential Organ Failure Assessment (SOFA) scores, serum lactate levels and vasopressor use in the intensive care units (ICUs). The computable phenotype was derived from a retrospective analysis of a random cohort of 100 patients admitted to the medical ICU. This was then validated in an independent cohort of 100 patients. We compared the results from computable phenotype to a gold standard by manual review of EMR by 2 blinded reviewers. Disagreement was resolved by a critical care clinician. A SOFA score ≥ 2 during the ICU stay with a culture 72 h before or after the time of admission was identified. Sepsis versions as V1 was defined as blood cultures with SOFA ≥ 2 and Sepsis V2 was defined as any culture with SOFA score ≥ 2. A serum lactate level ≥ 2 mmol/L from 24 h before admission till their stay in the ICU and vasopressor use with Sepsis-1 and-2 were identified as Septic Shock-V1 and-V2 respectively.

RESULTS

In the derivation subset of 100 random patients, the final machine learning strategy achieved a sensitivity-specificity of 100% and 84% for Sepsis-1, 100% and 95% for Sepsis-2, 78% and 80% for Septic Shock-1, and 80% and 90% for Septic Shock-2. An overall percent of agreement between two blinded reviewers had a k = 0.86 and 0.90 for Sepsis 2 and Septic shock 2 respectively. In validation of the algorithm through a separate 100 random patient subset, the reported sensitivity and specificity for all 4 diagnoses were 100%-100% each.

CONCLUSION

Supervised machine learning for identification of sepsis and septic shock is reliable and an efficient alternative to manual chart review.

1077. Reduce Anti-Microbial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study

Background

The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. Patients on ECMO are at high risk for infections, with 20.5% of adults acquiring infections while on ECMO. An Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force statement concluded that no antibiotic prophylaxis is needed for patients on ECMO though it also noted that this was based on limited data. We implemented an antimicrobial prophylaxis protocol for patients on ECMO at our institution and analyzed antimicrobial use and outcomes in these patients with a pre- and post-analysis.

Methods

We conducted a retrospective review of 294 patients on ECMO between July 1, 2011 and July 1, 2017. An ECMO antimicrobial prophylaxis guideline was initially implemented on July 1, 2014; there was poor adherence to the guideline and antimicrobial use actually increased. A more restrictive protocol was implemented in November 2018 with input from stakeholders including cardiac surgeons, critical care and infectious disease (ID) providers. We had a cohort of 161 patients before (July 2014–November 2018) and 37 patients after (November 2018–April 2018) the implementation of the updated protocol. We evaluated primary outcomes of gross days of antimicrobial use, percent of antibiotic-free days and days of individual antimicrobial use, adjusted for APACHE scores and ECMO duration.

Results

When adjusted for days on ECMO, mean antibiotic days decreased after implementation of the protocol; for vancomycin (0.27 vs. 0.02, P < 0.0003), cefepime (0.15 vs. 0.02, P < 0.02), meropenem (0.09 vs. 0, P < 0.02), zosyn (0.16 vs. 0, P < 0.002), caspofungin (0.346, 0.138 P < 0.003). This was accompanied by a nonsignificant increase in mean fluconazole use (0.29 vs. 0.37, P < 0.3). There was no impact on patient mortality or nosocomial infection rate. Additional results can be found in table.

Conclusion

The use of an antimicrobial prophylaxis protocol in ECMO patients led to improvement in antimicrobial usage without increasing nosocomial infections in a population at a high risk of infection.

Disclosures

All authors: No reported disclosures.

250. Antimicrobial Management in Extracorporeal Membrane Oxygenation: The AMMO study

Background

Methods

Results

Conclusion

Disclosures

Pattern of Self-medication in Undergraduate Students at BP Koirala Institute of Health Sciences

Background Self-medication is a growing health problem. It may lead to wastage of resources, emergence of antimicrobial resistance, adverse drug reactions and prolonged suffering. Little has been reported on the extent of self-medication practiced in medical students in Nepal. Objective To study the pattern, reason and perception of self-medication among undergraduate students. Method A cross-sectional study was conducted among all undergraduate students at BP Koirala Institute of Health Sciences, Dharan, Nepal between April and May, 2015. After obtaining ethical clearance, pre-validated questionnaire was used to collect data. The date were analyzed and presented as frequency and percentage using SPSS version 11.5. Result Total of 520 students participated in the study with a mean age of 21.2±1.7 years. Prevalence of self-medication was found to be 48.3%. Most common cause for self-medication was common cold (53.3%). Nonsteroidal anti-inflammatory drugs (78.9%) were the most commonly used medicine for self-medication. The students commonly approached their seniors (50.2%) for the drug information. The most common adverse drug reaction experienced by the students was drowsiness (50.9%). Approximately one third of the students (33.2%) used to prescribe medicines to others. More than half of the students (53.8%) opined that self-medication is a part of self-care. Around one-fifth of the students (21.5%) students opined that self-medication is recommended by WHO. Conclusion Self-medication is commonly practiced by undergraduate students. Nearly one third of the students also prescribe medicines to others. Nonsteroidal anti-inflammatory drugs are the most commonly used medicine as self-medication. The students need to be educated regarding appropriate safe-medication.

Ocular Morbidity among Orphanages

INTRODUCTION: The study assesses the spectrum of ocular morbidity and predictors of morbidity in children living in orphanages in the Kathmandu Valley. METHODS: A descriptive, cross-sectional survey was performed at 12 orphanages over a period of three months. The survey included a questionnaire and a complete eye examination, which included measurement of refraction, ocular deviation, and a fundus exam. Prevalence of ocular morbidity was calculated. Factors associated with ocular morbidity were examined using logistic regression. RESULTS: A total of 660 children were included in the study (median age nine years [range 0.25-15]; 53% male). The prevalence of ocular morbiditywas 17.9% (118). Of those with ocular morbidity, 88.1% (104) had similar ocular problems bilaterally. The most common type of morbidity was refractive error, found in 70.3% (83) of those with ocular morbidity (12.6% overall). CONCLUSIONS: Refractive errors, which are largely correctable, are the greatest source of morbidity. In order to reduce childhood blindness, children living in orphanages are an appropriate group to target for future ocular screening in Nepal. Keywords: children, Nepal, ocular morbidity, ocular screening, orphanage

Ocular morbidity among orphanages

INTRODUCTION

The study assesses the spectrum of ocular morbidity and predictors of morbidity in children living in orphanages in the Kathmandu Valley.

METHODS

A descriptive, cross-sectional survey was performed at 12 orphanages over a period of three months. The survey included a questionnaire and a complete eye examination, which included measurement of refraction, ocular deviation, and a fundus exam. Prevalence of ocular morbidity was calculated. Factors associated with ocular morbidity were examined using logistic regression.

RESULTS

A total of 660 children were included in the study (median age nine years [range 0.25-15]; 53% male). The prevalence of ocular morbidity was 17.9% (118). Of those with ocular morbidity, 88.1% (104) had similar ocular problems bilaterally. The most common type of morbidity was refractive error, found in 70.3% (83) of those with ocular morbidity (12.6% overall).

CONCLUSIONS

Refractive errors, which are largely correctable, are the greatest source of morbidity. In order to reduce childhood blindness, children living in orphanages are an appropriate group to target for future ocular screening in Nepal.