Impact of Mandatory Infectious Diseases Consultation and Real-time Antimicrobial Stewardship Pharmacist Intervention on Staphylococcus aureus Bacteremia Bundle Adherence

Background

The purpose of this study was to evaluate the impact of infectious diseases consultation (IDC) and a real-time antimicrobial stewardship (AMS) review on the management of Staphylococcus aureus bacteremia (SAB).

Methods

This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at 7 hospitals. Outcomes were compared between 3 time periods: before mandatory IDC and AMS review (period 1), after mandatory IDC and before AMS review (period 2), and after mandatory IDC and AMS review (period 3). The primary outcome was bundle adherence, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary end points included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality.

Results

A total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n = 241/371), 54% in period 2 (n = 47/87), and 76% in period 3 (n = 92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37–0.93; P = .02) and period 2 (OR, 0.37; 95% CI, 0.20–0.67; P = .0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < .001), source control (34% vs 45% vs 45%; P = .04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = .01). No differences were noted for readmission or mortality.

Conclusions

The addition of AMS pharmacist review to mandatory IDC was associated with significantly improved quality care bundle adherence.

Predictors of Time to Effective and Optimal Antimicrobial Therapy in Patients With Positive Blood Cultures Identified via Molecular Rapid Diagnostic Testing

Antimicrobial stewardship (AMS) programs integrated with rapid diagnostic tests optimize patient outcomes and reduce time to effective therapy (TTET) and time to optimal therapy (TTOT). This study identifies predictors of TTET and TTOT among patients with positive blood cultures and identifies limitations to current TTOT definitions and outcomes.

481. Implementation of a Prospective, Pharmacist-Driven Clostridium difficile PCR Pre-Authorization Process to Optimize Appropriate Testing

Background

Since the implementation of more sensitive molecular diagnostics such as the Clostridium difficile PCR assay, hospitals have reported 50–100% increases in C. difficile infection (CDI) rates.

Methods

This single-center, quasi-experimental study assessed appropriateness of C. difficile PCR testing pre- and post-implementation of a prospective, pharmacist-led, pre-authorization process. The antimicrobial stewardship team prospectively reviewed all adult CDI-PCR cases sent to the laboratory prior to specimen processing twice daily, 7 days a week to assess for clinical appropriateness based on guideline criteria. Bone marrow transplant and pediatric patients were excluded. If a patient lacked appropriate CDI clinical criteria, the provider was contacted to discontinue the PCR. CDI-PCR appropriateness was assessed for all patients with a CDI-PCR during the preceding year as a retrospective, comparative cohort. The primary objective was to assess appropriateness of the CDI-PCR pre- and postintervention. Secondary objectives included intervention sensitivity, specificity, safety, total CDI-PCRs processed, and protocol adherence.

Results

A total of 714 patients were included (n = 360, preintervention; n = 354, postintervention). There were significantly more hospital-onset CDI cases and antimicrobial use within the past 30 days in the preintervention group [(248 vs. 133, respectively; P < 0.001) and (277 vs. 197, respectively; P < 0.0001)]. Appropriateness of the CDI-PCR significantly improved postintervention [n = 138 (38.3%) vs. n = 209 (59.1%), respectively; P < 0.001]. Prospective pharmacist intervention was required for 146 inappropriate CDI-PCRs resulting in 79 discontinued and 66 processed CDI-PCRs (n = 1 positive; n = 65 negative). No patient with a cancelled CDI-PCR required additional testing or escalation of care. When compared with the preintervention, the CDI-PCRs with pharmacist intervention demonstrated a significant increase in the sensitivity (64.7% vs. 98%; P < 0.0001) and decrease in specificity (66% vs. 48.3%; P = 0.015) with an improved NPV (91.9% vs. 99.3%; P = 0.035) and PPV (23.9% to 24.6%; P = 0.869).

Conclusion

Implementation of a pharmacist-led prospective CDI-PCR review improved PCR appropriateness and had no adverse clinical consequences although the PPV criteria remain low.

Disclosures

All authors: No reported disclosures.

197. Implementation of a Prospective, Pharmacist-Led Methicillin-Resistant Staphylococcus aureus Nasal PCR Screening Pilot Protocol to Reduce Overutilization of Vancomycin

Background

The methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) has a negative predictive value of 95.2–99.2% for MRSA pneumonia. Negative MRSA nasal PCR results can be used as an effective tool to discontinue unnecessary empiric vancomycin therapy.

Methods

This single-center, pre–post quasi experimental pilot study evaluated the impact of a pharmacist-led MRSA nasal PCR screening protocol on vancomycin days of therapy (DOT) in patients with pneumonia. All adult patients with IV vancomycin ordered for pneumonia admitted to nonintensive care units were included. Patients who received nasal mupirocin, transitioned to hospice during admission, or had another indication requiring vancomycin were excluded. Pharmacists ordered an MRSA nasal PCR, per protocol, upon order verification. Negative results were used to recommend vancomycin discontinuation when appropriate. Prospective data were compared with a random retrospective cohort during a similar time frame the previous year. The primary outcome was vancomycin DOT before and after protocol implementation. Secondary outcomes included length of stay, quantity of vancomycin levels obtained, in-hospital mortality, acute kidney injury incidence, adherence to the protocol, and need for antimicrobial escalation.

Results

A total of 130 patients were included (n = 65, pre-intervention; n = 65, post-intervention). No statistically significant differences were observed in the demographics between the two groups. The median reduction in vancomycin DOT was 1.4 days [2.9 days (IQR 1.8–4.1) vs. 1.5 days (IQR 0.7–2.3); P < 0.001]. The percentage of IV vancomycin ordered for pneumonia was reduced by 5.2% (19.6% vs. 14.4%; P = 0.036). The protocol also resulted in a decreased median number of serum vancomycin levels (P < 0.001). No statistically significant differences were observed in the secondary outcomes, and there were no adverse clinical outcomes. Protocol adherence was 67.9% overall.

Conclusion

Implementation of a pharmacist-led MRSA surveillance protocol significantly reduced vancomycin days of therapy, reduced serum vancomycin levels, and had no unintended adverse consequences for respiratory tract infections. Results from this pilot project will be used to expand this protocol systemwide.

Disclosures

All authors: No reported disclosures.

Development of a urinary-specific antibiogram for gram-negative isolates: impact of patient risk factors on susceptibility

BACKGROUND

Traditional antibiograms guide clinicians in selecting appropriate empiric antimicrobials, but they lack data on syndrome/disease-specific susceptibility, isolate location, polymicrobial infections, and patient risk factors. The aim of this study was to develop a urinary-specific antibiogram and to evaluate the impact of risk factors on antimicrobial susceptibility.

METHODS

This retrospective descriptive study used culture and susceptibility data from January 1 to December 31, 2012. A urinary antibiogram specific for Escherichia coli (EC), Proteus mirabilis (PM), Klebsiella pneumoniae (KP), and Pseudomonas aeruginosa (PA) was developed. Urinary and standard antibiogram susceptibilities were compared. Urinary isolates were then stratified by risk factors-residence before admission, age, systemic antimicrobial use for ≤30 days, hospitalization for ≤30 days, and hospital unit-to determine the impact on antimicrobial susceptibility.

RESULTS

There were 2,284 urinary isolate encounters. Overall antimicrobial susceptibility was increased, and the prevalence of extended-spectrum β-lactamase-producing isolates was significantly greater (KP, 14% vs 7% [P = .001]; EC, 13% vs 9% [P < .001]; PM, 18% vs 10% [P = .004]) in the urinary antibiogram vs the standard antibiogram. Health care facility residence had the greatest impact on susceptibility for all urinary isolates, especially on fluoroquinolone susceptibility for EC and PM.

CONCLUSIONS

Using a syndromic antibiogram and incorporating patient risk factors into susceptibility data may be more useful in guiding clinicians in selecting more appropriate empiric therapy.

Behind closed doors: medication storage and disposal in the home

BACKGROUND

More than half of all medications are inappropriately prescribed, dispensed, or sold and only 50% of patients take their medications correctly. Oftentimes, unwanted or expired medications are saved for later use, stored indefinitely, or disposed via the sink, toilet, or garbage.

OBJECTIVE

To determine how residents in Cook County, Illinois, use, store, and dispose of their medications to assess the possible impact of these medications on health care and the environment.

METHODS

Researchers at the University of Illinois conducted a survey of Cook County residents over a 13-week period. Residents were surveyed regarding their use, storage, and disposal of prescription and nonprescription medications.

RESULTS

From 3954 telephone numbers generated through random-digit dialing, 445 telephone interviews were completed. Eighty-one and a half percent of respondents had prescription medications and 92.4% had nonprescription medications in their homes. On average, respondents possessed 4.4 distinct prescription and 5.5 distinct nonprescription medications. Despite possessing a number of medications, approximately 30% of respondents stated that they took no medication on a regular basis; 59% of respondents reported disposing medications in the household gar bage and 31% flushed them down the toilet or sink. Over 80% of respondents stated that they had never received information about proper medication disposal. Thirty-seven percent reported having leftover unexpired medications from a previous illness. Of these, 63% stopped taking their medications because they believed that they no longer needed them or because they felt better. Thirty-two percent of respondents expected to have leftover prescription medications within the next 6 months.

CONCLUSIONS

Almost all respondents had excess and leftover medications in their homes. This may be a result of both overprescribing and poor medication adherence. In addition to the potential human health risk of nonadherence, disposal of excess medication raises concerns about their environmental impact and safety.