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Elligsen M, Pinto R, Leis JA, Walker SAN, Daneman N, MacFadden DR. Improving Decision Making in Empiric Antibiotic Selection (IDEAS) for Gram-negative Bacteremia: A Prospective Clinical Implementation Study. Clin Infect Dis 2021; 73:e417-e425. [PMID: 32640028 DOI: 10.1093/cid/ciaa921] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/07/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Timely selection of adequate empiric antibiotics has become increasingly difficult due to rising resistance rates and the competing desire to apply antimicrobial stewardship (AMS) principles. Individualized clinical prediction models offer the promise of reducing broad-spectrum antibiotic use and preserving/improving adequacy of treatment, but few have been validated in the clinical setting. METHODS Multivariable models were used to predict the probability of susceptibility for gram-negative (GN) bacteria in bloodstream infections (bacteremia) to ceftriaxone, ciprofloxacin, ceftazidime, piperacillin-tazobactam, and meropenem. The models were combined with existing resistance-prediction methods to generate optimized and individualized suggestions for empiric therapy that were provided to prescribers by an AMS pharmacist. De-escalation of empiric antibiotics and adequacy of therapy were analyzed using a quasi-experimental design comparing two 9-month periods (pre- and postintervention) at a large academic tertiary care institution. RESULTS Episodes of bacteremia (n = 182) were identified in the preintervention and postintervention (n = 201) periods. Patients who received the intervention were more likely to have their therapy de-escalated (29 vs 21%; aOR = 1.77; 95% CI, 1.09-2.87; P = .02). The intervention also increased the proportion of patients who were on the narrowest adequate therapy at the time of culture finalization (44% in the control and 55% in the intervention group; aOR = 2.04; 95% CI, 1.27-3.27; P = .003). Time to adequate therapy was similar in the intervention and control groups (5 vs 4 hours; P = .95). CONCLUSIONS An AMS intervention, based on individualized predictive models for resistance, can influence empiric antibiotic selections for GN bacteremia to facilitate early de-escalation of therapy without compromising adequacy of antibiotic coverage.
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Affiliation(s)
- Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Ruxandra Pinto
- Department of Critical Care and Population Health, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jerome A Leis
- Division of Infectious Diseases, University of Toronto, Toronto, Canada.,Centre of Quality Improvement and Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Nick Daneman
- Division of Infectious Diseases, University of Toronto, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Derek R MacFadden
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Elligsen M, Pinto R, Leis JA, Walker SAN, MacFadden DR, Daneman N. Using Prior Culture Results to Improve Initial Empiric Antibiotic Prescribing: An Evaluation of a Simple Clinical Heuristic. Clin Infect Dis 2021; 72:e630-e638. [PMID: 32930719 DOI: 10.1093/cid/ciaa1397] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND A patient's prior cultures can inform the subsequent risk of infection from resistant organisms, yet prescribers often fail to incorporate these results into their empiric antibiotic selection. Given that timely initiation of adequate antibiotics has been associated with improved outcomes, there is an urgent need to address this gap. METHODS In order to better incorporate prior culture results in the selection of empiric antibiotics, we performed a pragmatic, prospective, hospital-wide intervention: (1) empiric antibiotic prescriptions were assessed for clinically significant discordance with the most recent methicillin-resistant Staphylococcus aureus (MRSA) surveillance swab, previous cultures for extended-spectrum beta-lactamases (ESBLs), and the most recent culture for a Gram-negative (GN) organism; and (2) if discordant, an antimicrobial stewardship pharmacist provided recommendations for alternative therapy. The impact was analyzed using a quasi-experimental design comparing two 9-month periods (pre- and postintervention) at a large academic, tertiary care institution. RESULTS Clinically significant discordance was identified 99 times in the preintervention period and 86 times in the intervention period. The proportion of patients that received concordant therapy increased from 73% (72/99) in the control group to 88% (76/86) in the intervention group (P = .01). The median time to concordant therapy was shorter in the intervention group than the control group (25 vs 55 hrs, respectively; P < .001; adjusted hazard ratio = 1.95 [95% confidence interval {CI}, 1.37-2.77; P < .001]). The median duration of unnecessary vancomycin therapy was reduced by 1.1 days (95% CI, .5-1.6 days; P < .001). CONCLUSIONS This intervention improved prescribing, with a shorter time to concordant therapy and an increased proportion of patients receiving empiric therapy concordant with prior culture results. The use of unnecessary vancomycin was also reduced.
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Affiliation(s)
- Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Ruxandra Pinto
- Department of Critical Care and Population Health, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jerome A Leis
- Division of Infectious Diseases, University of Toronto, Toronto, Canada.,Centre of Quality Improvement and Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Derek R MacFadden
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Nick Daneman
- Division of Infectious Diseases, University of Toronto, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Ma NH, Walker SAN, Elligsen M, Kiss A, Palmay L, Ho G, Powis J, Bansal V, Leis JA. Retrospective multicentre matched cohort study comparing safety and efficacy outcomes of intermittent-infusion versus continuous-infusion vancomycin. J Antimicrob Chemother 2021; 75:1038-1046. [PMID: 31919504 DOI: 10.1093/jac/dkz531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/11/2019] [Accepted: 11/30/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Patients with good renal function receiving intermittent-infusion vancomycin (IIV) may require total daily doses ≥4 g to achieve trough concentrations of 15-20 mg/L, increasing the risk of vancomycin-associated nephrotoxicity. Continuous-infusion vancomycin (CIV) may be associated with a lower risk of vancomycin-associated nephrotoxicity compared with IIV, but studies comparing safety of both dosing strategies are lacking. OBJECTIVES To compare the risk of nephrotoxicity with CIV versus IIV when target concentration ranges were the same with both dosing modalities. METHODS A retrospective multicentre matched cohort study of admitted patients between 1 January 2010 and 31 December 2016 was completed. Adult patients who received ≥48 h of vancomycin with at least one steady-state vancomycin concentration were eligible. The primary outcome was to compare the rates of nephrotoxic risk and renal injury, defined by the RIFLE criteria, between CIV and IIV. RESULTS Of 2136 patients who received vancomycin during the study period, 146 CIV patients were eligible and matched to 146 IIV patients. After adjustment of potential confounders, CIV was found to have a lower odds of developing nephrotoxic risk (OR 0.42, 95% CI 0.21-0.98, P = 0.025) and renal injury (OR 0.19, 95% CI 0.05-0.59, P = 0.004). CONCLUSIONS CIV is associated with a lower odds of nephrotoxicity compared with IIV when targeting the same concentration range and should be an alternative dosing strategy for patients who will receive prolonged therapy or require >4 g/day to achieve therapeutic levels.
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Affiliation(s)
- Nathan H Ma
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Grace Ho
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Jeff Powis
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Vikas Bansal
- Holland Orthopaedic and Arthritic Centre, Toronto, Ontario, Canada
| | - Jerome A Leis
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Peragine C, Walker SAN, Simor A, Walker SE, Kiss A, Leis JA. Impact of a Comprehensive Antimicrobial Stewardship Program on Institutional Burden of Antimicrobial Resistance: A 14-Year Controlled Interrupted Time-series Study. Clin Infect Dis 2021; 71:2897-2904. [PMID: 31813967 DOI: 10.1093/cid/ciz1183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/06/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) constitutes an international public health threat widely believed to result from excessive antimicrobial use (AMU). Numerous authorities have recommended antimicrobial stewardship programs (ASPs) to curb the selection of AMR, but there is a lack of data confirming this benefit. METHODS A controlled interrupted time-series study spanning 14 years was performed to assess impact of a comprehensive hospital-based ASP that included pharmacist-led audit and feedback on institutional AMR. Patient-level microbiologic and AMU data were obtained from October 2002 to September 2016. Poisson regression models were used to identify changes in the incidence and trend of hospital-acquired (HA) antibiotic-resistant organisms (AROs) and multidrug-resistant organisms (MDROs). Changes in community-acquired (CA)-ARO, CA-MDRO, and inpatient AMU were assessed as controls and process outcomes. RESULTS Statistically significant shifts in AMU, HA-ARO, and HA-MDRO trends coinciding with ASP implementation were observed, corresponding with a 9% reduction in HA-ARO burden (incidence rate ratio [IRR], 0.91 [95% confidence interval {CI}, .83-.99]; P = .03) and a 13% reduction in HA-MDRO burden (IRR, 0.87 [95% CI, .73-1.04]; P = .13) in the intervention period. In contrast, CA-ARO and CA-MDRO incidence continued to rise, with 40% (IRR, 1.40 [95% CI, 1.28-1.54]; P < .0001) and 68% (IRR, 1.68 [95% CI, 1.57-1.82]; P < .0001) increases in burden found, respectively. CONCLUSIONS Implementation of a comprehensive ASP resulting in reduced AMU was associated with a significant reduction in institutional AMR, even though community AMR increased during the same period. These results confirm that ASPs play an important role in the fight against AMR.
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Affiliation(s)
- Christine Peragine
- Department of Pharmacy, Sunnybrook Health Sciences Centre Bayview Campus, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre Bayview Campus, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Simor
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Scott E Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre Bayview Campus, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Kiss
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jerome A Leis
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Kispal B, Walker SAN. Monte Carlo simulation evaluation of tigecycline dosing for bacteria with raised minimum inhibitory concentrations in non-critically ill adults. Eur J Clin Pharmacol 2020; 77:197-205. [PMID: 32975650 DOI: 10.1007/s00228-020-02998-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Tigecycline is one of few antibiotics active against multidrug-resistant bacteria; however, the assessment of dosing strategies to optimize its activity is needed. The purpose was to use Monte Carlo Simulation (MCS) to determine if safe tigecycline dosing options attaining breakpoints for pharmacokinetic/pharmacodynamic (PK-PD) targets in non-critically ill adults could be identified. METHODS Publications that evaluated tigecycline dosing regimens and provided mean PK variables of interest (minimum 2 of: elimination rate constant or half-life and volume of distribution or clearance), with SDs, were included. Weighted mean (±SDs) for each PK parameter were determined. Food and Drug Administration minimum inhibitory concentration (MIC) tigecycline breakpoints for susceptible (MIC ≤ 2 μg/mL), intermediate (MIC 4 μg/mL), and resistant (MIC ≥ 8 μg/mL) Enterobacteriaceae were used. MCS probability distributions for PK-PD target attainment of AUC for total tigecycline plasma concentration from 0 to 24 h following an intravenous dose (AUCtotal, 0-24h) to MIC ratios of ≥ 18, 7, and 4.5 were generated, with success defined as ≥ 80% probability of target attainment at a given MIC. RESULTS Ten studies (n = 442) were eligible. Tigecycline 150 mg IV q12h for ward patients with resistant bacteria up to a MIC of 0.48, 1, and 2 μg/mL for an AUCtotal, 0-24h/MIC target attainment of 18, 7, and 4.5, respectively, may be appropriate. CONCLUSION Bacterial infections with tigecycline MICs ≥ 0.48-2 μg/mL, depending on AUCtotal, 0-24h/MIC target, may require treatment with alternate antibiotics due to target attainment failure.
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Affiliation(s)
- Brianna Kispal
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario, M5S 3M2, Canada
- Department of Pharmacy, Kingston General Hospital, 76 Stuart St, Kingston, Ontario, K7L 2V7, Canada
| | - Sandra A N Walker
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario, M5S 3M2, Canada.
- Department of Pharmacy Bayview Campus, Sunnybrook Health Sciences Center (SHSC), 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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Walker SAN, Bannerman H, Ma N, Peragine C, Elligsen M, Palmay L, Williams E, Liu B. Development and validation of a screening tool for early identification of bloodstream infection in older patients - a retrospective case-control study. BMC Geriatr 2020; 20:6. [PMID: 31900110 PMCID: PMC6942330 DOI: 10.1186/s12877-019-1402-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 12/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed diagnosis of bloodstream infection (BSI) occurs in > 20% of older patients, with misdiagnosis in 35%. Our objective was to develop and validate a clinically useful screening tool to identify older patients with a high probability of having a BSI. METHODS Hospitalized patients > 80 years old with BSI (n = 105/group) were evaluated for the tool development in this retrospective matched case-controlled study (learn cohort). The tool was validated in different retrospectively matched case and control patients > 80 years old (n = 120/group) and 65 to 79 years old (n = 250/group) (test cohort). Binary logistic regression was used to develop a screening tool using laboratory and clinical parameters that were significantly associated with BSI (P < 0.05; adjusted odds ratio (OR) > 1); and Classification and Regression Tree (CART) analysis was used to identify parameter breakpoints. Performance metrics were used to evaluate and validate the tool. RESULTS The significant parameters associated with BSI were maximum temperature (Tmax)(> 37.55C)(OR = 42.575), neutrophils (> 7.95)(OR = 1.923), a change in level of consciousness (LOC) (Yes = 1, No = 0)(OR = 1.571), blood urea nitrogen (BUN)(> 10.05)(OR = 1.359), glucose (> 7.35)(OR = 1.167), albumin (< 33.5)(OR = 1.038) and alanine aminotransferase (ALT) (> 19.5)(OR = 1.005). The optimal screening tool [Ln (odds of BSI) = - 150.299 + 3.751(Tmax) + 0.654(neutrophils) + 0.452(change in LOC) + 0.307(BUN) + 0.154(glucose) + 0.038(albumin) + 0.005(ALT)] had favorable performance metrics in the learn and test cohorts (sensitivity, specificity and accuracy of 95% in the learn cohort and 77, 89, and 81% in the total test cohort); and performed better than using only temperature and neutrophil count. CONCLUSIONS The validated tool had high predictive value which may improve early identification and management of BSI in older patients.
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Affiliation(s)
- Sandra A. N. Walker
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ,0000 0001 2157 2938grid.17063.33Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Heather Bannerman
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Nathan Ma
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ,0000 0001 2157 2938grid.17063.33Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Christine Peragine
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ,0000 0001 2157 2938grid.17063.33Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Marion Elligsen
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Lesley Palmay
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Evelyn Williams
- 0000 0000 9743 1587grid.413104.3Division Long-Term Care, Sunnybrook Health Sciences Centre, Toronto, Canada ,0000 0001 2157 2938grid.17063.33Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Barbara Liu
- 0000 0000 9743 1587grid.413104.3Division Long-Term Care, Sunnybrook Health Sciences Centre, Toronto, Canada ,0000 0001 2157 2938grid.17063.33Faculty of Medicine, University of Toronto, Toronto, Canada
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Dragan V, Wei Y, Elligsen M, Kiss A, Walker SAN, Leis JA. Prophylactic Antimicrobial Therapy for Acute Aspiration Pneumonitis. Clin Infect Dis 2019; 67:513-518. [PMID: 29438467 DOI: 10.1093/cid/ciy120] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/07/2018] [Indexed: 11/12/2022] Open
Abstract
Background Prophylactic antimicrobial therapy is frequently prescribed for acute aspiration pneumonitis, with the intent of preventing the development of aspiration pneumonia. However, few clinical studies have examined the benefits and harms of this practice. Methods A retrospective cohort study design was used to compare outcomes of patients with aspiration pneumonitis who received prophylactic antimicrobial therapy with those managed with supportive care only during the initial 2 days following macroaspiration. The primary outcome was in-hospital mortality within 30 days. Secondary outcomes included transfer to critical care and antimicrobial therapy received between days 3 and 14 following macroaspiration including escalation of therapy and antibiotic-free days. Results Among 1483 patients reviewed, 200 met the case definition for acute aspiration pneumonitis, including 76 (38%) who received prophylactic antimicrobial therapy and 124 (62%) who received supportive management only. After adjusting for patient-level predictors, antimicrobial prophylaxis was not associated with any improvement in mortality (odds ratio, 0.9; 95% confidence interval [CI], 0.4-1.7; P = .7). Patients receiving prophylactic antimicrobial therapy were no less likely to require transfer to critical care (5% vs 6%; P = .7) and subsequently received more frequent escalation of antibiotic therapy (8% vs 1%; P = .002) and fewer antibiotic-free days (7.5 vs 10.9; P < .0001). Conclusions Prophylactic antimicrobial therapy for patients with acute aspiration pneumonitis does not offer clinical benefit and may generate antibiotic selective pressures that results in the need for escalation of antibiotic therapy among those who develop aspiration pneumonia.
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Affiliation(s)
- Vlad Dragan
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Yanliang Wei
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Alex Kiss
- Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation, Ontario, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Jerome A Leis
- Department of Medicine, University of Toronto, Ontario, Canada.,Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation, Ontario, Canada.,Division of Infectious Diseases and General Internal Medicine, Sunnybrook Health Sciences Centre, Ontario, Canada.,Centre for Quality Improvement and Patient Safety, University of Toronto, Ontario, Canada
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Bergenwall M, Walker SAN, Elligsen M, Iaboni DC, Findlater C, Seto W, Ng E. Optimizing gentamicin conventional and extended interval dosing in neonates using Monte Carlo simulation - a retrospective study. BMC Pediatr 2019; 19:318. [PMID: 31492162 PMCID: PMC6729057 DOI: 10.1186/s12887-019-1676-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although aminoglycosides are routinely used in neonates, controversy exists regarding empiric dosing regimens. The objectives were to determine gentamicin pharmacokinetics in neonates, and develop initial mg/kg dosing recommendations that optimized target peak and trough concentration attainment for conventional and extended-interval dosing (EID) regimens. METHODS Patient demographics and steady-state gentamicin concentration data were retrospectively collected for 60 neonates with no renal impairment admitted to a level III neonatal intensive care unit. Mean pharmacokinetics were calculated and multiple linear regression was performed to determine significant covariates of clearance (L/h) and volume of distribution (L). Classification and regression tree (CART) analysis identified breakpoints for significant covariates. Monte Carlo Simulation (MCS) was used to determine optimal dosing recommendations for each CART-identified sub-group. RESULTS Gentamicin clearance and volume of distribution were significantly associated with weight at gentamicin initiation. CART-identified breakpoints for weight at gentamicin initiation were: ≤ 850 g, 851-1200 g, and > 1200 g. MCS identified that a conventional dose of gentamicin 3.5 mg/kg given every 48 h or an EID of 8-9 mg/kg administered every 72 h in neonates weighing ≤ 850 g, and every 24 and 48 h, respectively, in neonates weighing 851-1200 g, provided the best probability of attaining conventional (peak: 5-10 mg/L and trough: ≤ 2 mg/L) and EID targets (peak:12-20 mg/L, trough:≤ 0.5 mg/L). Insufficient sample size in the > 1200 g neonatal group precluded further investigation of this weight category. CONCLUSIONS This study provides initial gentamicin dosing recommendations that optimize target attainment for conventional and EID regimens in neonates weighing ≤ 1200 g. Prospective validation and empiric dose optimization for neonates > 1200 g is needed.
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Affiliation(s)
- Monique Bergenwall
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Present Address: Grandview Medical Centre Family Health Team, 167 Hespeler Rd, Cambridge, ON N1R 3H7 Canada
| | - Sandra A. N. Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Sunnybrook Health Sciences Centre Research Institute, Toronto, ON Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
| | - Dolores C. Iaboni
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Carla Findlater
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Winnie Seto
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Department of Pharmacy, Hospital for Sick Children, Toronto, ON Canada
| | - Eugene Ng
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Department of Paediatrics, University of Toronto, Toronto, ON Canada
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9
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Walker SAN, Cormier M, Elligsen M, Choudhury J, Rolnitsky A, Findlater C, Iaboni D. Development, evaluation and validation of a screening tool for late onset bacteremia in neonates - a pilot study. BMC Pediatr 2019; 19:253. [PMID: 31340780 PMCID: PMC6651932 DOI: 10.1186/s12887-019-1633-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/16/2019] [Indexed: 11/29/2022] Open
Abstract
Background Clinical and laboratory parameters can aid in the early identification of neonates at risk for bacteremia before clinical deterioration occurs. However, current prediction models have poor diagnostic capabilities. The objective of this study was to develop, evaluate and validate a screening tool for late onset (> 72 h post admission) neonatal bacteremia using common laboratory and clinical parameters; and determine its predictive value in the identification of bacteremia. Methods A retrospective chart review of neonates admitted to a neonatal intensive care unit (NICU) between March 1, 2012 and January 14, 2015 and a prospective evaluation of all neonates admitted between January 15, 2015 and March 30, 2015 were completed. Neonates with late-onset bacteremia (> 72 h after NICU admission) were eligible for inclusion in the bacteremic cohort. Bacteremic patients were matched to non-infected controls on several demographic parameters. A Pearson’s Correlation matrix was completed to identify independent variables significantly associated with infection (p < 0.05, univariate analysis). Significant parameters were analyzed using iterative binary logistic regression to identify the simplest significant model (p < 0.05). The predictive value of the model was assessed and the optimal probability cut-off for bacteremia was determined using a Receiver Operating Characteristic curve. Results Maximum blood glucose, heart rate, neutrophils and bands were identified as the best predictors of bacteremia in a significant binary logistic regression model. The model’s sensitivity, specificity and accuracy were 90, 80 and 85%, respectively, with a false positive rate of 20% and a false negative rate of 9.7%. At the study bacteremia prevalence rate of 51%, the positive predictive value, negative predictive value and negative post-test probability were 82, 89 and 11%, respectively. Conclusion The model developed in the current study is superior to currently published neonatal bacteremia screening tools. Validation of the tool in a historic data set of neonates from our institution will be completed. Electronic supplementary material The online version of this article (10.1186/s12887-019-1633-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandra A N Walker
- Department of Pharmacy E-302, Sunnybrook Health Sciences Centre (SHSC), 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
| | - Melanie Cormier
- Department of Pharmacy E-302, Sunnybrook Health Sciences Centre (SHSC), 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Marion Elligsen
- Department of Pharmacy E-302, Sunnybrook Health Sciences Centre (SHSC), 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | | | | | | | - Dolores Iaboni
- SHSC, Women and Babies Program, Toronto, Ontario, Canada
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10
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Leis JA, Palmay L, Ho G, Raybardhan S, Gill S, Kan T, Campbell J, Kiss A, McCready JB, Das P, Minnema B, Powis JE, Walker SAN, Ferguson H, Wong B, Weber E. Point-of-Care β-Lactam Allergy Skin Testing by Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation. Clin Infect Dis 2019; 65:1059-1065. [PMID: 28575226 DOI: 10.1093/cid/cix512] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023] Open
Abstract
Background β-lactam allergy skin testing (BLAST) is recommended by antimicrobial stewardship program (ASP) guidelines, yet few studies have systematically evaluated its impact when delivered at point of care. Methods We conducted a pragmatic multicenter prospective evaluation of the use of point-of-care BLAST by ASPs. In staggered 3-month intervals, ASP teams at 3 hospitals received training by allergists to offer BLAST for eligible patients with infectious diseases receiving nonpreferred therapy due to severity of their reported allergy. The primary outcome was the proportion of patients receiving the preferred β-lactam therapy. Results Of 827 patients with reported β-lactam allergy over 15 months, β-lactam therapy was preferred among 632 (76%). During baseline periods, 50% (124/246) received preferred β-lactam therapy based on history, compared with 60% (232/386) during the intervention periods (P = .02), which improved further to 81% (313/386) upon provision of BLAST (P < .001) without any increase in incidence of adverse drug reactions (4% vs 3%; P = .4). After adjusting for patient variables and the correlation between hospitals, the intervention period was associated with a 4.5-fold greater odds of receiving preferred β-lactam therapy (95% confidence interval, 2.4-8.2; P < .0001). Conclusions The use of BLAST at the point of care across 3 hospital ASPs resulted in greater use of preferred β-lactam therapy without increasing the risk of adverse drug reactions. Longer-term studies are needed to better assess the safety and clinical impact of this ASP intervention.
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Affiliation(s)
- Jerome A Leis
- Division of Infectious Diseases, Department of Medicine.,Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation.,Centre for Quality Improvement and Patient Safety, and
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, and Lesley Dan Faculty of Pharmacy, University of Toronto
| | | | | | | | | | - Jackie Campbell
- Department of Pharmacy, Sunnybrook Health Sciences Centre, and Lesley Dan Faculty of Pharmacy, University of Toronto.,Drug Safety Clinic, Sunnybrook Health Sciences Centre ; and
| | - Alex Kiss
- Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation
| | - Janine B McCready
- Division of Infectious Diseases, Department of Medicine.,Michael Garron Hospital
| | - Pavani Das
- Division of Infectious Diseases, Department of Medicine.,North York General Hospital
| | - Brian Minnema
- Division of Infectious Diseases, Department of Medicine.,North York General Hospital
| | - Jeff E Powis
- Division of Infectious Diseases, Department of Medicine.,Centre for Quality Improvement and Patient Safety, and.,Michael Garron Hospital
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, and Lesley Dan Faculty of Pharmacy, University of Toronto
| | | | - Benny Wong
- North York General Hospital.,Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Ontario, Canada
| | - Elizabeth Weber
- Drug Safety Clinic, Sunnybrook Health Sciences Centre ; and.,Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Ontario, Canada
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11
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Lee C, Walker SAN, Palmay L, Walker SE, Tobe S, Simor A. Steady-State Pharmacokinetics of Oral Ciprofloxacin in Continuous Cycling Peritoneal Dialysis Patients: Brief Report. Perit Dial Int 2018; 38:73-76. [PMID: 29311199 DOI: 10.3747/pdi.2017.00052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Steady-state pharmacokinetics of oral ciprofloxacin in 3 continuous cycling peritoneal dialysis (CCPD) outpatients given ciprofloxacin 750 mg b.i.d. for 5 doses was determined. Mean steady-state maximum serum concentration and half-life were 4.4 ± 1.5 mg/L and 10.3 ± 2.6 hours, respectively. Mean maximum dialysate concentration in the daytime long dwell and overnight continuous cycling dwell were 7.4 ± 1.2 mg/L and 3.3 ± 1.2 mg/L, respectively. Oral ciprofloxacin 750 mg b.i.d. may be reasonable for bloodstream and peritoneal infections caused by susceptible bacteria in CCPD patients.
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Affiliation(s)
- Colin Lee
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada.,University of Toronto, Leslie L. Dan Faculty of Pharmacy, Toronto, ON, Canada
| | - Sandra A N Walker
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada .,University of Toronto, Leslie L. Dan Faculty of Pharmacy, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Division of Infectious Diseases, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre Research Institute, Toronto, ON, Canada
| | - Lesley Palmay
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada
| | - Scott E Walker
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada.,University of Toronto, Leslie L. Dan Faculty of Pharmacy, Toronto, ON, Canada
| | - Sheldon Tobe
- Sunnybrook Health Sciences Centre Research Institute, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Department of Nephrology, Toronto, ON, Canada.,University of Toronto, Faculty of Medicine, Toronto, ON, Canada
| | - Andrew Simor
- Sunnybrook Health Sciences Centre, Division of Infectious Diseases, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre Research Institute, Toronto, ON, Canada.,University of Toronto, Faculty of Medicine, Toronto, ON, Canada
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12
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Wan M, Walker SAN, Martin E, Elligsen M, Palmay L, Leis JA. The impact of vancomycin trough concentrations on outcomes in non-deep seated infections: a retrospective cohort study. BMC Pharmacol Toxicol 2018; 19:47. [PMID: 30064515 PMCID: PMC6069851 DOI: 10.1186/s40360-018-0236-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/11/2018] [Indexed: 11/20/2022] Open
Abstract
Background Guidelines recommending vancomycin trough concentrations > 10 mg/L in non-deep seated infections are based on expert opinion. The objective of this study was to evaluate patients with non-deep seated infections treated with short-course vancomycin to determine whether there were differences in outcomes with trough concentrations of ≤10 mg/L (low) versus > 10 mg/L (high). Methods A retrospective cohort study of patients hospitalized between March 10, 2010 and December 31, 2015 who received ≤14 days of vancomycin to treat a non-deep seated infection and had at least one steady state trough concentration was completed. Patient data for the low versus high trough cohorts were compared using appropriate statistical tests and binary logistic regression was used to identify factors associated with clinical outcome. Results Of 2098 patients screened, 103 (5%) met inclusion criteria. Baseline characteristics between cohorts were not different. Clinical cure was not different between the low (42/48 [88%]) and high trough (48/55 [87%]) cohorts (p > 0.99) and vancomycin trough concentration was not associated with clinical outcome (p = 0.973). More patients in the high trough group had dosing changes (7/48 [15%] vs. 22/55 [40%], p = 0.0046), with approximately three times more dose adjustments per patient (0.17 vs. 0.55, p = 0.0193). No signal for increased vancomycin resistance associated with vancomycin troughs was identified. Conclusions: No difference in clinical or microbiological outcomes based on vancomycin trough concentrations were observed in patients with non-deep seated infections treated with vancomycin for ≤14 days. Targeting higher vancomycin trough concentrations of > 10 mg/L may be associated with increased workload with no corresponding benefit in clinical or microbiological outcomes in these patients.
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Affiliation(s)
- Michael Wan
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada. .,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Elaine Martin
- Present address: Elaine Martin, Trillium Health Partners, 100 Queensway W, Mississauga, ON, L5B 1B8, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Jerome A Leis
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
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13
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Lamb MJ, Baillie L, Pajak D, Flynn J, Bansal V, Simor A, Vearncombe M, Walker SAN, Clark S, Gollish J, Leis JA. Elimination of Screening Urine Cultures Prior to Elective Joint Arthroplasty. Clin Infect Dis 2017; 64:806-809. [PMID: 28011604 DOI: 10.1093/cid/ciw848] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/10/2016] [Indexed: 11/14/2022] Open
Abstract
Discontinuing routine processing of screening urine cultures prior to elective joint arthroplasty resulted in substantial reduction in urine cultures ordered and antimicrobial prescriptions for asymptomatic bacteriuria, without any significant impact on incidence of prosthetic joint infection. This simple change would be scalable across institutions with potential for significant healthcare savings.
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Affiliation(s)
- Michael J Lamb
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laura Baillie
- Department of Microbiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Dariusz Pajak
- Department of Microbiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jan Flynn
- Division of Orthopedics, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Vikas Bansal
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrew Simor
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Microbiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mary Vearncombe
- Department of Microbiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sandra A N Walker
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Pharmacy, Sunnybrook Health Sciences Centre, and Lesley Dan Faculty of Pharmacy, Canada
| | - Susan Clark
- Division of Orthopedics, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeffrey Gollish
- Division of Orthopedics, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jerome A Leis
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada.,Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
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14
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Abstract
BACKGROUND Once-daily aminoglycoside dosing (ODA) is used in most patient populations to optimize antibacterial activity and reduce toxicity. Unfortunately, burn patients are excluded from ODA due to concerns over altered pharmacokinetics resulting in a shortened half-life and low peak aminoglycoside concentrations. Retrospective studies suggest that ODA may be appropriate if higher milligram/kilogram doses are used. However, no prospective clinical trials in burn patients exist to confirm these findings. OBJECTIVE To determine the adequacy of once daily tobramycin dosed at 10mg/kg in adult burn patients. METHODS This prospective single dose pharmacokinetic clinical trial was conducted at the Ross Tilley Burn Centre. Patients with a total burn surface area (TBSA) of <20% and creatinine clearance ≥50mL/min were eligible. A first-order one compartment model was used to determine the pharmacokinetic profile from 3 or 5 tobramycin levels over a 24h period per patient. Monte Carlo simulation (MCS) was performed to determine the probability of target level attainment. RESULTS The mean percent TBSA, partial, and full thickness burn were 10%, 6%, and 4%, respectively. Nine of the ten patients recruited achieved peak concentrations of ≥20mg/L (mean of 29.4±5.7mg/L) and all patients had a trough level ≤0.5mg/L. The mean half-life, volume of distribution, and clearance were 2.58h, 0.33L/kg, and 7.40L/h, respectively. The MCS determined probability of attaining target peak concentrations with the 10mg/kg dose was 97%, which almost doubled that predicted with the usual 7mg/kg dose. CONCLUSION Burn patients with adequate renal function and <20% TBSA are candidates for ODA. Tobramycin half-life was similar to healthy, non-burn patients. The larger than normal volume of distribution supports the use of the higher empiric dose of 10mg/kg total body or adjusted weight in non-obese and obese patients, respectively, with further dose adjustment based on therapeutic drug monitoring.
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Affiliation(s)
- Colin Lee
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Sandra A N Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada.
| | - Scott E Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Winnie Seto
- University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; Hospital for Sick Children (HSC), Department of Pharmacy, Canada
| | - Andrew Simor
- SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada; University of Toronto, Faculty of Medicine, Canada
| | - Marc Jeschke
- University of Toronto, Faculty of Medicine, Canada; SHSC, Ross Tilley Burn Centre, Canada
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15
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Abstract
BACKGROUND Antimicrobial stewardship may be important in long-term care facilities because of unnecessary or inappropriate antibiotic use observed in these residents, coupled with their increased vulnerability to health care-associated infections. OBJECTIVES To assess antibiotic use in a long-term care facility in order to identify potential antimicrobial stewardship needs. METHODS A retrospective descriptive study was conducted at the Veterans Centre, a long-term care facility at Sunnybrook Health Sciences Centre, Toronto, Ontario. All residents taking one or more antibiotics (n = 326) were included as participants. Antibiotic-use data for patients residing in the facility between April 1, 2011, and March 31, 2012, were collected and analyzed. RESULTS Totals of 358 patient encounters, 835 antibiotic prescriptions, and 193 positive culture results were documented during the study period. For 36% (302/835) of antibiotic prescriptions, the duration was more than 7 days. Cephalosporins (30%; 251/835) and fluoroquinolones (28%; 235/835) were the most frequently prescribed antibiotic classes. Urine was the most common source of samples for culture (60%; 116/193). CONCLUSIONS Characteristics of antimicrobial use at this long-term care facility that might benefit from further evaluation included potentially excessive use of fluoroquinolones and cephalosporins and potentially excessive duration of antibiotic use for individual patients.
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Affiliation(s)
- Lisa Dong-Ying Wu
- BScPhm, was, at the time of this study, a pharmacy research student in the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario. She is now with the Department of Pharmacy at West Park Healthcare Centre, Toronto, Ontario
| | - Sandra A N Walker
- BSc, BScPhm, PharmD, FCSHP, is with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario. She has affiliate status with the Department of Medicine, Division of Infectious Diseases, and Division of Clinical Pharmacology, Sunnybrook Health Sciences Centre; the Sunnybrook Research Institute; and the Leslie L Dan Faculty of Pharmacy, University of Toronto
| | - Marion Elligsen
- BScPhm, is with the Department of Pharmacy, Sunny-brook Health Sciences Centre, Toronto, Ontario
| | - Lesley Palmay
- BSc, BScPhm, MSc, is with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Andrew Simor
- MD, is with the Department of Microbiology and the Division of Infectious Diseases, Sunnybrook Health Sciences Centre; the Sunnybrook Research Institute; and the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Nick Daneman
- MD, MSc, is with the Division of Infectious Diseases, Sunnybrook Health Sciences Centre; the Sunnybrook Research Institute; the Faculty of Medicine, University of Toronto; and the Institute for Clinical Evaluative Sciences, Toronto, Ontario
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16
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Wanis M, Walker SAN, Daneman N, Elligsen M, Palmay L, Simor A, Cartotto R. Impact of hospital length of stay on the distribution of Gram negative bacteria and likelihood of isolating a resistant organism in a Canadian burn center. Burns 2015; 42:104-111. [PMID: 26547832 DOI: 10.1016/j.burns.2015.07.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/27/2015] [Accepted: 07/01/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE The impact of hospital length of stay (LOS) on the distribution and susceptibility of Gram negative bacteria (GNB) causing infection in burn patients remains unexplored. Knowledge of causative pathogens is important in guiding empiric antibiotic therapy. OBJECTIVES To characterize the distribution of GNB causing infection and to identify changes in susceptibility with LOS in a tertiary care burn center. METHODS A retrospective review of all admissions to the Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre with clinical cultures yielding GNB (duplicates excluded) between March 12, 2010 to July 17, 2013 was completed. Positive cultures were categorized into 5 clinically relevant time periods (in days) based on specimen collection date relative to the patient's date of admission: 0-7, 7-14, 14-21, 21-28, >28. Chi-square for proportions was used to compare the time periods. RESULTS The proportion of patients with clinical cultures for P. aeruginosa increased with hospital LOS (0-7 days: 8% vs. >28 days: 55%; p<0.05). Conversely, clinical cultures for H. influenzae occurred primarily within the first 7 days of hospitalization (0-7 days: 36% vs. >28 days: 0.7%; p<0.05). Enterobacteriaceae isolation was highest between 7 and 14 days of hospitalization (7-14 days: 62% vs. >28 days: 38%; p<0.05). Antibiotic resistance was directly proportional to hospital LOS (% patients with multidrug resistant GNB increased from 6% [LOS 0-7 days] to 44% [LOS>28 days]; p<0.05). CONCLUSIONS This study provides objective data documenting changes in species and resistance patterns of GNB causing infection in patients admitted to a burn center as a function of hospital LOS; which may support delaying the use of broad spectrum antibiotics (e.g. carbapenems and beta-lactam/beta-lactamase inhibitors) in clinically stable patients.
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Affiliation(s)
- Marsail Wanis
- University of Toronto, Leslie L. Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Sandra A N Walker
- University of Toronto, Leslie L. Dan Faculty of Pharmacy, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Department of Microbiology and Division of Infectious Diseases, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada.
| | - Nick Daneman
- Sunnybrook Health Sciences Centre, Department of Microbiology and Division of Infectious Diseases, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - Marion Elligsen
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, Ontario, Canada
| | - Lesley Palmay
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, Ontario, Canada
| | - Andrew Simor
- Sunnybrook Health Sciences Centre, Department of Microbiology and Division of Infectious Diseases, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - Robert Cartotto
- Sunnybrook Health Sciences Centre, Ross Tilley Burn Centre, Toronto, Ontario, Canada
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17
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Maslikowska JA, Walker SAN, Elligsen M, Mittmann N, Palmay L, Daneman N, Simor A. Impact of infection with extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella species on outcome and hospitalization costs. J Hosp Infect 2015; 92:33-41. [PMID: 26597637 DOI: 10.1016/j.jhin.2015.10.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/05/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Extended-spectrum β-lactamase (ESBL)-producing bacteria are important sources of infection; however, Canadian data evaluating the impact of ESBL-associated infection are lacking. AIM To determine whether patients infected with ESBL-producing Escherichia coli or Klebsiella species (ESBL-EcKs) exhibit differences in clinical outcome, microbiological outcome, mortality, and/or hospital resource use compared to patients infected with non-ESBL-producing strains. METHODS A retrospective case-control study of 75 case patients with ESBL-EcKs matched to controls infected with non-ESBL-EcKs who were hospitalized from June 2010 to April 2013 was conducted. Patient-level cost data were provided by the institution's business office. Clinical data were collected using the electronic databases and paper charts. FINDINGS Median infection-related hospitalization costs per patient were greater for cases than controls (C$10,507 vs C$7,882; median difference: C$3,416; P = 0.04). The primary driver of increased costs was prolonged infection-related hospital length of stay (8 vs 6 days; P = 0.02) with patient location (ward, ICU) and indirect care costs (including costs associated with infection prevention and control) as the leading cost categories. Cases were more likely to experience clinical failure (25% vs 11%; P = 0.03), with a higher all-cause mortality (17% vs 5%; P = 0.04). Less than half of case patients were prescribed appropriate empiric antimicrobial therapy, whereas controls received adequate initial treatment in nearly all circumstances (48% vs 96%; P < 0.01). CONCLUSION Patients with infection caused by ESBL-EcKs are at increased risk for clinical failure and mortality, with additional cost to the Canadian healthcare system of C$3,416 per patient.
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Affiliation(s)
- J A Maslikowska
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - S A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - M Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - N Mittmann
- HOPE Research Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
| | - L Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - N Daneman
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - A Simor
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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18
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Kwee F, Walker SAN, Elligsen M, Palmay L, Simor A, Daneman N. Outcomes in Documented Pseudomonas aeruginosa Bacteremia Treated with Intermittent IV Infusion of Ceftazidime, Meropenem, or Piperacillin-Tazobactam: A Retrospective Study. Can J Hosp Pharm 2015; 68:386-94. [PMID: 26478584 DOI: 10.4212/cjhp.v68i5.1485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa, one of the leading causes of nosocomial gram-negative bloodstream infections, is particularly difficult to treat because of its multiple resistance mechanisms combined with a lack of novel antipseudomonal antibiotics. Despite knowledge of time-dependent killing with ß-lactam antibiotics, most hospitals in Canada currently administer ß-lactam antibiotics by intermittent rather than extended infusions. OBJECTIVES To determine clinical outcomes, microbiological outcomes, total hospital costs, and infection-related costs for patients with P. aeruginosa bacteremia who received intermittent IV administration of antipseudomonal ß-lactam antibiotics in a tertiary care institution. METHODS For this retrospective descriptive study, data were collected for patients who were admitted between March 1, 2005, and March 31, 2013, who had P. aeruginosa bacteremia during their admission, and who received at least 72 h of treatment with ceftazidime, meropenem, or piperacillin-tazobactam. Clinical and microbiological outcomes were determined, and total and infection-related hospital costs were calculated. RESULTS A total of 103 patients were included in the analysis, of whom 79 (77%) experienced clinical cure. In addition, bacterial eradication was achieved in 41 (87%) of the 47 patients with evaluable data for this outcome. Twenty-eight (27%) of the 103 patients died within 30 days of discontinuation of antipseudomonal ß-lactam antibiotic therapy. The median total cost of the hospital stay was $121 718, and the median infection-related cost was $29 697. CONCLUSIONS P. aeruginosa bacteremia is a clinically significant nosocomial infection that continues to cause considerable mortality and health care costs. To the authors' knowledge, no previous studies have calculated total and infection-related hospital costs for treatment of P. aeruginosa bacteremia with intermittent infusion of antipseudomonal ß-lactam antibiotics, with characterization of cost according to site of acquisition of the infection. This study may provide important baseline data for assessing the impact of implementing extended-infusion ß-lactam therapy, antimicrobial stewardship, and infection control strategies targeting P. aeruginosa infection in hospitalized patients.
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Affiliation(s)
- Francine Kwee
- BSc(Hons), BScPhm, ACPR, was, at the time of this study, a General Practice Pharmacy Resident at Sunnybrook Health Sciences Centre, Toronto, Ontario. She is now with the Department of Pharmacy, St Michael's Hospital, Toronto, Ontario
| | - Sandra A N Walker
- BSc, BScPhm, ACPR, PharmD, FCSHP, is with the Department of Pharmacy, and Division of Infectious Diseases, Sunnybrook Health Sciences Centre, and the Leslie L Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Marion Elligsen
- BScPhm, ACPR, is with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Lesley Palmay
- BSc, BScPhm, MSc, ACPR, is with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Andrew Simor
- MD, FRCPC, is with the Department of Microbiology and the Division of Infectious Diseases, Sunnybrook Health Sciences Centre, and the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Nick Daneman
- MD, MSc, FRCPC, is with the Division of Infectious Diseases, Sunnybrook Health Sciences Centre, and the Faculty of Medicine, University of Toronto, Toronto, Ontario
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19
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Lee C, Walker SAN, Daneman N, Elligsen M, Palmay L, Coburn B, Simor A. Point prevalence survey of antimicrobial utilization in a Canadian tertiary-care teaching hospital. J Epidemiol Glob Health 2014; 5:143-50. [PMID: 25922323 PMCID: PMC7320490 DOI: 10.1016/j.jegh.2014.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 11/18/2022] Open
Abstract
Objectives: Inappropriate antimicrobial use can promote antimicrobial resistance, which is associated with increased patient morbidity and mortality. Identifying the pattern of antimicrobial use can provide data from which targeted antimicrobial stewardship interventions can be made. The primary objective was to identify the prevalence of antimicrobial use at a tertiary care teaching hospital with both acute and long-term care patients. Methods: A point prevalence study was conducted on July 19th, 2012. Data on antimicrobial utilization, indication for prescribing, duration of therapy, and frequency of infectious disease or antimicrobial stewardship consultations were collected using a customized integrated stewardship database (SPIRIT) and prospective chart review. Results: One or more antimicrobial agents were ordered in 31% and 4% of acute care and long-term care patients, respectively. Respiratory and urinary tract infections were the most common indication for antimicrobial therapy in both acute and long-term care. About 25% of surgical prophylaxis orders were prescribed for greater than 24 h. Conclusion: This prospective point prevalence survey provided important baseline information on antimicrobial use within a large tertiary care teaching hospital and identified potential targets for future antimicrobial stewardship initiatives. A multi-center point prevalence survey should be considered to identify patterns of antimicrobial use in Canada and to establish the first steps toward international antimicrobial surveillance.
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Affiliation(s)
- Colin Lee
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nick Daneman
- Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bryan Coburn
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Simor
- Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Walker SAN, Lo JK, Compani S, Ko E, Le MH, Marchesano R, Natanson R, Pradhan R, Rzyczniak G, Teo V, Vyas A. Identifying barriers to medication discharge counselling by pharmacists. Can J Hosp Pharm 2014; 67:203-12. [PMID: 24970940 DOI: 10.4212/cjhp.v67i3.1357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Medication errors may occur more frequently at discharge, making discharge counselling a vital facet of medication reconciliation. Discharge counselling is a recognized patient safety initiative for which pharmacists have appropriate expertise, but data are lacking about the barriers to provision of this service to adult inpatients by pharmacists. OBJECTIVES To determine the proportion of eligible patients who received discharge counselling, to quantify perceived barriers preventing pharmacists from performing discharge counselling, and to determine the relative frequency of barriers and associated time expenditures. METHODS In this prospective study, 8 pharmacists working in general medicine, medical oncology, or nephrology wards of an acute care hospital completed a survey for each of the first 50 patients eligible for discharge counselling on their respective wards from June 2010 to February 2011. Patients discharged to another facility (rehabilitation, palliative care, or long-term care), those with hospital stay less than 48 h before discharge, and those whose medications were unchanged from hospital admission were ineligible. RESULTS Discharge counselling was performed for 116 (29%) of the 403 eligible patients and involved a median preparation time of 25 min and median counselling time of 15 min per patient. At least one documented barrier to discharge counselling existed for 295 (73%) of the patients. Several barriers to discharge counselling occurred significantly more frequently on the general medicine and oncology wards than on the nephrology ward (p < 0.05). The most common barrier was failure to notify the pharmacist about impending patient discharge (130/313 [41%]). Time constraints existed for 130 (32%) of the patients, the most common related to clarification of prescriptions (96 [24%]), creation of a medication list (69 [17%]), and faxing of prescriptions (64 [16%]). CONCLUSION This study generated objective data about the barriers to and time constraints associated with medication discharge counselling by pharmacists. These findings should raise awareness of the challenges faced by pharmacists in busy hospital positions and may support avenues of change for their hospital discharge counselling programs.
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Affiliation(s)
- Sandra A N Walker
- , BSc, BScPhm, ACPR, PharmD, FCSHP, is a Clinician Scientist and is the Pharmacy Lead in Infectious Diseases and Antimicrobial Stewardship, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Jennifer K Lo
- , HBSc, BScPhm, PharmD, was, at the time of this study, a pharmacy student at Sunnybrook Health Sciences Centre, Toronto, Ontario, and is now an Antimicrobial Stewardship Pharmacist (contract position) with the Department of Pharmacy at this institution
| | - Sara Compani
- , BScPhm, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Emily Ko
- , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Minh-Hien Le
- , HBSc, BScPhm, PharmD, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Romina Marchesano
- , BScPhm, ACPR, MScPhm, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Rimona Natanson
- , BPharm, ACPR, is a Clinical Pharmacist, Sunny-brook Health Sciences Centre, Toronto, Ontario
| | - Rahim Pradhan
- , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Grace Rzyczniak
- , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Vincent Teo
- , BScPhm, ACPR, PharmD, is a Clinical Pharmacist, Sunny-brook Health Sciences Centre, Toronto, Ontario
| | - Anju Vyas
- , BScPhm, ACPR, is a Clinical Pharmacist, Sunnybrook Health Sciences Centre, Toronto, Ontario
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Palmay L, Elligsen M, Walker SAN, Pinto R, Walker S, Einarson T, Simor A, Rachlis A, Mubareka S, Daneman N. Hospital-wide rollout of antimicrobial stewardship: a stepped-wedge randomized trial. Clin Infect Dis 2014; 59:867-74. [PMID: 24928294 DOI: 10.1093/cid/ciu445] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Our objective was to rigorously evaluate the impact of an antimicrobial stewardship audit-and-feedback intervention, via a stepped-wedge randomized trial. An effective intensive care unit (ICU) audit-and-feedback program was rolled out to 6 non-ICU services in a randomized sequence. The primary outcome was targeted antimicrobial utilization, using a negative binomial regression model to assess the impact of the intervention while accounting for secular and seasonal trends. The intervention was successfully transitioned, with high volumes of orders reviewed, suggestions made, and recommendations accepted. Among patients meeting stewardship review criteria, the intervention was associated with a large reduction in targeted antimicrobial utilization (-21%, P = .004); however, there was no significant change in targeted antibiotic use among all admitted patients (-1.2%, P = .9), and no reductions in overall costs and microbiologic outcomes. An ICU day 3 audit-and-feedback program can be successfully expanded hospital-wide, but broader benefits on non-ICU wards may require interventions earlier in the course of treatment.
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Affiliation(s)
- Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre
| | | | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre Leslie L. Dan Faculty of Pharmacy, University of Toronto Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre
| | - Ruxandra Pinto
- Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Center
| | - Scott Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre Leslie L. Dan Faculty of Pharmacy, University of Toronto
| | | | - Andrew Simor
- Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto
| | - Anita Rachlis
- Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto
| | - Samira Mubareka
- Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto Sunnybrook Research Institute
| | - Nick Daneman
- Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto Sunnybrook Research Institute Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Kim J, Walker SAN, Iaboni DC, Walker SE, Elligsen M, Dunn MS, Allen VG, Simor A. Determination of vancomycin pharmacokinetics in neonates to develop practical initial dosing recommendations. Antimicrob Agents Chemother 2014; 58:2830-40. [PMID: 24614381 PMCID: PMC3993213 DOI: 10.1128/aac.01718-13] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 02/27/2014] [Indexed: 11/20/2022] Open
Abstract
Variability in neonatal vancomycin pharmacokinetics and the lack of consensus for optimal trough concentrations in neonatal intensive care units pose challenges to dosing vancomycin in neonates. Our objective was to determine vancomycin pharmacokinetics in neonates and evaluate dosing regimens to identify whether practical initial recommendations that targeted trough concentrations most commonly used in neonatal intensive care units could be determined. Fifty neonates who received vancomycin with at least one set of steady-state levels were evaluated retrospectively. Mean pharmacokinetic values were determined using first-order pharmacokinetic equations, and Monte Carlo simulation was used to evaluate initial dosing recommendations for target trough concentrations of 15 to 20 mg/liter, 5 to 20 mg/liter, and ≤20 mg/liter. Monte Carlo simulation revealed that dosing by mg/kg of body weight was optimal where intermittent dosing of 9 to 12 mg/kg intravenously (i.v.) every 8 h (q8h) had the highest probability of attaining a target trough concentration of 15 to 20 mg/liter. However, continuous infusion with a loading dose of 10 mg/kg followed by 25 to 30 mg/kg per day infused over 24 h had the best overall probability of target attainment. Initial intermittent dosing of 9 to 15 mg/kg i.v. q12h was optimal for target trough concentrations of 5 to 20 mg/liter and ≤20 mg/liter. In conclusion, we determined that the practical initial vancomycin dose of 10 mg/kg vancomycin i.v. q12h was optimal for vancomycin trough concentrations of either 5 to 20 mg/liter or ≤20 mg/liter and that the same initial dose q8h was optimal for target trough concentrations of 15 to 20 mg/liter. However, due to large interpatient vancomycin pharmacokinetic variability in neonates, monitoring of serum concentrations is recommended when trough concentrations between 15 and 20 mg/liter or 5 and 20 mg/liter are desired.
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Affiliation(s)
- Julianne Kim
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada
| | - Sandra A. N. Walker
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada
- University of Toronto, Leslie L. Dan Faculty of Pharmacy, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Department of Microbiology and Division of Infectious Diseases, Toronto, ON, Canada
| | - Dolores C. Iaboni
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Neonatal Intensive Care Unit, Toronto, ON, Canada
| | - Scott E. Walker
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada
- University of Toronto, Leslie L. Dan Faculty of Pharmacy, Toronto, ON, Canada
| | - Marion Elligsen
- Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, ON, Canada
| | - Michael S. Dunn
- Sunnybrook Health Sciences Centre, Neonatal Intensive Care Unit, Toronto, ON, Canada
- University of Toronto, Faculty of Medicine, Toronto, ON, Canada
| | - Vanessa G. Allen
- Sunnybrook Health Sciences Centre, Department of Microbiology and Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto, Faculty of Medicine, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Andrew Simor
- Sunnybrook Health Sciences Centre, Department of Microbiology and Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto, Faculty of Medicine, Toronto, ON, Canada
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Elligsen M, Walker SAN, Simor A, Daneman N. Prospective audit and feedback of antimicrobial stewardship in critical care: program implementation, experience, and challenges. Can J Hosp Pharm 2012; 65:31-6. [PMID: 22479110 DOI: 10.4212/cjhp.v65i1.1101] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Marion Elligsen
- , BScPhm, is with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
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van de Vijsel LM, Walker SAN, Walker SE, Yamashita S, Simor A, Hladunewich M. Initial vancomycin dosing recommendations for critically ill patients undergoing continuous venovenous hemodialysis. Can J Hosp Pharm 2012; 63:196-206. [PMID: 22478979 DOI: 10.4212/cjhp.v63i3.915] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delaying appropriate antimicrobial therapy for critically ill patients increases the risk of death. Currently, there are insufficient data to guide initial vancomycin dosing for patients undergoing continuous venovenous hemodialysis (CVVHD). OBJECTIVE To develop practical recommendations for initial dosing of vancomycin, based on the pharmacokinetics of this drug in critically ill patients undergoing CVVHD. METHODS A chart review was conducted for 24 critically ill adult patients who had undergone concurrent CVVHD and vancomycin therapy. Mean pharmacokinetic parameters were determined, along with practical recommendations for initial vancomycin dosing that targeted steady-state trough concentrations for patients receiving intermittent infusions and steady-state levels for those receiving continuous infusions between 15 and 20 mg/L. Monte Carlo simulation was used to develop the initial vancomycin dosing recommendations. RESULTS The mean (95% confidence interval) pharmacokinetic parameters for vancomycin (elimination rate constant 0.0315 [0.0254-0.0391], half-life 22.0 h [17.72-27.24 h], volume of distribution 0.96 L/kg [0.77-1.20 L/kg], and clearance 2.4 L/h [1.97-2.92 L/h]) indicated that initial intermittent IV dosing of 1.25-1.5 g q24h or 15 mg/kg q24h would be suitable. For continuous infusion, a 1.5-g IV loading dose followed by continuous infusion of 1-1.5 g IV over 24 h (42-62 mg/h) would be recommended. However, Monte Carlo simulation revealed that the probability of achieving desired concentrations between 15 and 20 mg/L with any of these initial regimens is low. CONCLUSIONS There was considerable variation in vancomycin pharmacokinetics in this patient population. The observations reported here raise concerns about the reliability of numerous empiric dosing recommendations derived from small pharmacokinetic studies in heterogeneous populations. Follow-up therapeutic drug monitoring is essential to ensure that concentrations remain within the target range.
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Elligsen M, Walker SAN, Pinto R, Simor A, Mubareka S, Rachlis A, Allen V, Daneman N. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol 2012; 33:354-61. [PMID: 22418630 DOI: 10.1086/664757] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We aimed to rigorously evaluate the impact of prospective audit and feedback on broad-spectrum antimicrobial use among critical care patients. DESIGN Prospective, controlled interrupted time series. SETTING Single tertiary care center with 3 intensive care units. PATIENTS AND INTERVENTIONS A formal review of all critical care patients on their third or tenth day of broad-spectrum antibiotic therapy was conducted, and suggestions for antimicrobial optimization were communicated to the critical care team. OUTCOMES The primary outcome was broad-spectrum antibiotic use (days of therapy per 1000 patient-days; secondary outcomes included overall antibiotic use, gram-negative bacterial susceptibility, nosocomial Clostridium difficile infections, length of stay, and mortality. RESULTS The mean monthly broad-spectrum antibiotic use decreased from 644 days of therapy per 1,000 patient-days in the preintervention period to 503 days of therapy per 1,000 patient-days in the postintervention period (P < .0001); time series modeling confirmed an immediate decrease (± standard error) of 119 ± 37.9 days of therapy per 1,000 patient-days (P = .0054). In contrast, no changes were identified in the use of broad-spectrum antibiotics in the control group (nonintervention medical and surgical wards) or in the use of control medications in critical care (stress ulcer prophylaxis). The incidence of nosocomial C. difficile infections decreased from 11 to 6 cases in the study intensive care units, whereas the incidence increased from 87 to 116 cases in the control wards (P = .04). Overall gram-negative susceptibility to meropenem increased in the critical care units. Intensive care unit length of stay and mortality did not change. CONCLUSIONS Institution of a formal prospective audit and feedback program appears to be a safe and effective means to improve broad-spectrum antimicrobial use in critical care.
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Affiliation(s)
- Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Affiliation(s)
- Claudia Summa
- BScPhm, ACPR, is a Clinical Pharmacist - General Internal Medicine, Department of Pharmacy, University Health Network -Toronto General Hospital, Toronto, Ontario
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