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Neuner EA, Atkinson A, Ilges D, Krekel T, Ritchie DJ, Bewley AF, Durkin MJ, Hsueh K, Sayood S. Mixed methods evaluation of handshake antimicrobial stewardship on adult inpatient medicine floors. Antimicrob Steward Healthc Epidemiol 2023; 3:e210. [PMID: 38156212 PMCID: PMC10753471 DOI: 10.1017/ash.2023.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 12/30/2023]
Abstract
Objective To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital. Design Retrospective observational study. Setting 1,278-bed academic hospital. Patients Adults admitted to non-ICU medicine services. Interventions A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention. Results The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality. Conclusion The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.
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Affiliation(s)
| | - Andrew Atkinson
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Dan Ilges
- Department of Pharmacy, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - David J. Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Alice F. Bewley
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michael J. Durkin
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kevin Hsueh
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sena Sayood
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
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2
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Ilges D, Ritchie DJ, Krekel T, Neuner EA, Hampton N, Kollef MH, Micek S. Assessment of Antibiotic De-escalation by Spectrum Score in Patients With Nosocomial Pneumonia: A Single-Center, Retrospective Cohort Study. Open Forum Infect Dis 2021; 8:ofab508. [PMID: 34805436 PMCID: PMC8600177 DOI: 10.1093/ofid/ofab508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) cause significant mortality. Guidelines recommend empiric broad-spectrum antibiotics followed by de-escalation (DE). This study sought to assess the impact of DE on treatment failure. METHODS This single-center retrospective cohort study screened all adult patients with a discharge diagnosis code for pneumonia from 2016 to 2019. Patients were enrolled if they met predefined criteria for HAP/VAP ≥48 hours after admission. Date of pneumonia diagnosis was defined as day 0. Spectrum scores were calculated, and DE was defined as a score reduction on day 3 versus day 1. Patients with DE were compared to patients with no de-escalation (NDE). The primary outcome was composite treatment failure, defined as all-cause mortality or readmission for pneumonia within 30 days of diagnosis. RESULTS Of 11860 admissions screened, 1812 unique patient-admissions were included (1102 HAP, 710 VAP). Fewer patients received DE (876 DE vs 1026 NDE). Groups were well matched at baseline, although more patients receiving DE had respiratory cultures ordered (56.6% vs 50.6%, P = .011). There was no difference in composite treatment failure (35.0% DE vs 33.8% NDE, P = .604). De-escalation was not associated with treatment failure on multivariable Cox regression analysis (hazard ratio, 1.13; 95% confidence interval, 0.96-1.33). Patients receiving DE had fewer antibiotic days (median 9 vs 11, P < .0001), episodes of Clostridioides difficile infection (2.2% vs 3.8%, P = .046), and hospital days (median 20 vs 22 days, P = .006). CONCLUSIONS De-escalation and NDE resulted in similar rates of 30-day treatment failure; however, DE was associated with fewer antibiotic days, episodes of C difficile infection, and days of hospitalization.
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Affiliation(s)
- Dan Ilges
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - David J Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Nicholas Hampton
- Center for Clinical Excellence, BJC HealthCare, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
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3
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Bohn BC, Neuner EA, Athans V, Rivard KR, Riffle AR, Richter SS, Fraser TG, Gordon SM. The Implementation and Effect of Weekend Pharmacy-Driven Antimicrobial Stewardship Services at a Large Academic Medical Center. J Pharm Pract 2021; 35:541-545. [PMID: 33648376 DOI: 10.1177/0897190021997008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In September 2018, pharmacy antimicrobial stewardship (AMS) services were expanded to include weekends at this academic medical center. Activities performed by AMS pharmacists on the weekends include blood culture rapid diagnostic (RDT) review, antiretroviral therapy (ART) review, prospective audit and feedback (PAF) utilizing clinical decision support, vancomycin dosing, and operational support. The purpose of this study was to assess the operational and clinical impact of these expanded AMS services. METHODS This single-center, quasi-experimental study included data from weekends before (9/2017-11/2017) and after (9/2018-11/2018) implementation. The descriptive primary outcome was the number of activities completed for each AMS activity type in the post-implementation group only. Secondary outcomes were time to AMS opportunity resolution, time to escalation or de-escalation following PAF or RDT alert, time to resolution of miscellaneous AMS related opportunities, length of stay (LOS), and antimicrobial use outcomes. RESULTS During the post-implementation period 1258 activities were completed, averaging 97/weekend. Inclusion criteria for time to resolution outcomes were met by 72 patients pre-implementation and 59 patients post. The median (IQR) time to AMS opportunity resolution decreased from 18.5 hours pre-intervention (7.7-35.7) to 8.5 hours post-intervention (IQR 1.8-14.0), p < 0.01. Time to escalation was 11.6 hours compared to 1.7 hours (p = 0.1), de-escalation 16.7 hours compared to 10.8 hours (p = 0.03), and miscellaneous opportunity 40.8 hours compared to 13.2 hours (p = 0.01). No differences were observed in LOS or antimicrobial use outcomes. CONCLUSION Presence of pharmacist-driven weekend AMS services significantly reduced time to resolution of AMS opportunities. These data support the value of weekend AMS services.
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Affiliation(s)
- Brian C Bohn
- Department of Pharmacy, Norton Healthcare, Louisville, KY, USA
| | | | - Vasilios Athans
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Thomas G Fraser
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Steven M Gordon
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
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4
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Eudy JL, Pallotta AM, Neuner EA, Brummel GL, Postelnick MJ, Schulz LT, Spivak ES, Wrenn RH. Antimicrobial Stewardship Practice in the Ambulatory Setting From a National Cohort. Open Forum Infect Dis 2020; 7:ofaa513. [PMID: 33269298 PMCID: PMC7686658 DOI: 10.1093/ofid/ofaa513] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 09/01/2020] [Accepted: 10/20/2020] [Indexed: 11/12/2022] Open
Abstract
Background The majority of antimicrobial use occurs in the ambulatory setting. Antimicrobial stewardship programs (ASPs) are effective in improving appropriate prescribing and are now required by accreditation bodies. Methods This was a cross-sectional, multicenter survey describing the current state of ambulatory ASPs in a national cohort of Vizient member hospitals with ambulatory healthcare settings and serves as a benchmark for stewardship strategies related to program effectiveness. Results One hundred twenty-nine survey responses from a variety of institution types across 44 states were received. Survey respondents reported a fully functioning ASP in 7% (9 of 129) of ambulatory practices compared with 88% (114 of 129) of inpatient institutions. Effectiveness in at least 1 antibiotic use-related outcome (ie, utilization, resistance, Clostridioides difficile infection, or cost) in the past 2 years was reported in 18% (18 of 100) of ambulatory and 84% (103 of 123) of inpatient ASPs. Characteristics of ambulatory ASPs demonstrating effectiveness were institution guidelines (89%, 16 of 18), rapid diagnostic testing for respiratory viruses or group A Streptococcus (89% 16 of 18), outpatient antibiograms (78% 14 of 18), and dedicated pharmacist support (72%, 13 of 18). Ambulatory ASP effectiveness was shown to increase as programs met more of the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antimicrobial Stewardship (P < .001). Conclusions Antimicrobial stewardship programs are needed in the ambulatory setting, but they are not common. Currently, few ambulatory ASPs in this survey self-identify as fully functioning. The CDC Core Elements of antimicrobial stewardship should remain foundational for ASP development and expansion.
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Affiliation(s)
- Joshua L Eudy
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | | | | | - Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Health, Madison, Wisconsin, USA
| | - Emily S Spivak
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
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5
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Lehman B, Neuner EA, Heh V, Isada C. A Retrospective Multisite Case-Control Series of Concomitant Use of Daptomycin and Statins and the Effect on Creatine Phosphokinase. Open Forum Infect Dis 2019; 6:ofz444. [PMID: 31723571 PMCID: PMC6837837 DOI: 10.1093/ofid/ofz444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 04/10/2019] [Accepted: 10/28/2019] [Indexed: 02/02/2023] Open
Abstract
Objective Daptomycin has been associated with increased creatine phosphokinase (CPK) due to muscle injury leading to myalgias and muscle weakness. Statins have been proven to cause the same effects and it is recommended to discontinue the use of statins while on daptomycin. Evidence regarding this drug interaction is mixed. This study evaluated the risk of CPK elevation in concomitant use of daptomycin and statins compared to daptomycin alone. Method This is a multisite retrospective case-control study of patients who received daptomycin therapy with monitoring of CPK. Rates of CPK elevations were compared in patients receiving daptomycin with a statin versus daptomycin alone. To estimate the association between CPK elevation and daptomycin therapy controlling for other risk factors, logistic regression was used to analyze data. Statistical significance was determined at ɑ of 0.05. Results A total of 3658 patients were included in the study, with 2787 on daptomycin therapy alone and 871 with concurrent statin use. The incidence of CPK elevation was 90 events (3.2%) in the daptomycin group and 26 events (3.0%) in the concurrent statin group. Patients who received daptomycin therapy in addition to statins had no statistically significant difference from patients on daptomycin alone (hazard ratio, 1.05; P = .85; 95% confidence interval, 0.61-1.84). After adjusting for potential risk factors, the hazards ratio remained almost the same. Conclusions Concomitant use of daptomycin and statin did not show an increase risk of CPK elevation. Clinicians may consider concomitant use of daptomycin and statin therapy with weekly CPK monitoring.
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Affiliation(s)
- Bethany Lehman
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Victor Heh
- CORE Research Office, Ohio University Heritage College of Osteopathic Medicine, Dublin, Ohio, USA
| | - Carlos Isada
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Bohn BC, Neuner EA, Athans V, Wesolowski J, Fraser TG, Gordon SM. 2098. Applying Antimicrobial Consumption Metrics to Characterize Inpatient Stewardship Opportunities. Open Forum Infect Dis 2019. [PMCID: PMC6808789 DOI: 10.1093/ofid/ofz360.1778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
| | | | - Vasilios Athans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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7
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Miller R, Morillas JA, Sitaras J, Bako J, Neuner EA, Gordon SM, Brizendine KD, Fraser TG. 2373. Impact of a Change in Testing Strategy for Clostridioides difficile Infection on a Publicly Reported Metric and Treatment Days of Therapy. Open Forum Infect Dis 2019. [PMCID: PMC6810230 DOI: 10.1093/ofid/ofz360.2051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background In an effort to optimize diagnostic testing for Clostridioides difficile infection (CDI) our health system changed from stand-alone PCR testing to a “2-step” approach wherein all positive PCR results reflexed to an EIA. We report the effects of this change on publicly reported CDI metrics and treatment days of therapy (DOT). Methods The setting includes 10 Cleveland Clinic Health System hospitals in northeast Ohio and one in Florida. On June 12, 2018, 9 NE Ohio hospitals changed from PCR alone to PCR followed by EIA. Stand-alone PCR testing remained at one and GDH / EIA / PCR for discordant for another. Testing volumes were obtained from the microbiology laboratory. C. difficile LabID event SIRs were obtained from NHSN. Public reporting interpretative categories were identified based on SIR for second half of 2018. DOT for CDI agents were obtained from an antimicrobial stewardship database. Results Among hospitals that changed strategy the volume of PCR testing and the percent PCR + was similar between time periods. EIA positivity ranged from 23% to 53%. 4/11 hospitals improved their public reporting category: 3/9 that changed testing strategy and 1/2 that did not (Table 1). Two of 3 that changed strategy and improved public reporting also had a decrease in DOT. DOT increased in the 2 hospitals that did not change strategy. Conclusion Six months after adopting a 2-step CDI testing strategy 7 of 9 hospitals had a lower SIR with 3 also demonstrating an improvement in public reporting category favorably impacting reputational and reimbursement risk for our healthcare system. CDI agent DOT was similar before and after the change. The impact of choice of test on publicly reported metrics demonstrates the difficulty of utilizing a proxy for hospital onset CDI, the CDI LabID event, as a measure of quality of care provided. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Ryan Miller
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | | - Jacob Bako
- Cleveland Clinic Foundation, Cleveland, Ohio
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8
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Wu J, Rivard KR, Neuner EA, Athans V, Sabella C, Estridge R, Curtis R, Fraser TG. 1958. Assessment of Guideline-Concordant Antimicrobial Prescribing in Urgent Care Centers. Open Forum Infect Dis 2019. [PMCID: PMC6808827 DOI: 10.1093/ofid/ofz359.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
In the United States in 2014, 266 million outpatient antibiotic prescriptions were dispensed. The Center for Disease Control and Prevention estimates that 30% of outpatient antibiotic prescriptions are inappropriate. These inappropriate prescriptions contribute to increased resistance, adverse events, and healthcare costs.
Methods
This was a retrospective study of patients presenting to 22 urgent care centers within a large healthcare system between September 1, 2018 and February 28, 2019. Data were collected from a dashboard designed to track antimicrobial prescribing data by indication, location, and provider. ICD-9 and -10 codes associated with otitis media, pharyngitis, sinusitis, cystitis, and upper respiratory infections (URI) were included. Guideline-concordant antimicrobial prescribing was determined based on compliance with national guideline recommendations, after taking patient allergies into account. The URI category includes disease states in which antimicrobials are rarely appropriate (e.g., acute rhinitis, nasopharyngitis, and acute bronchitis).
Results
A total of 57,799 encounters were included in this analysis (19,242 pediatric and 38,557 adult) and 60% of patients received an antibiotic prescription. Overall antimicrobial guideline concordance was higher in pediatrics (84%) than adults (62%). Rates of guideline-concordant antimicrobial selection are shown in Table 1. The most common guideline-discordant prescriptions were tetracyclines (39%), amoxicillin/clavulanate (26%), and macrolides (17%) in adult patients with sinusitis, pharyngitis, or otitis media. In pediatric patients, the most common discordant prescriptions were macrolides (32%), third-generation cephalosporins (30%), and amoxicillin/clavulanate (19%). Unnecessary antimicrobial prescribing for URI occurred in 23% of pediatric patients and 36% of adult patients.
Conclusion
Guideline-discordant antimicrobial prescribing is common in urgent care centers, particularly in adult patients. In addition to encouraging utilization of order sets, emphasis on education and feedback may be important to improve and sustain guideline-concordant prescribing rates and reduce prescribing for URI.
Disclosures
All Authors: No reported Disclosures.
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Affiliation(s)
- Janet Wu
- Cleveland Clinic, Cleveland, Ohio
| | | | | | - Vasilios Athans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Neuner EA, Wesolowski J, Rivard KR, Srinivas P, Pallotta A, Athans V, Gordon SM, Fraser TG. 1097. An Antimicrobial Stewardship Intervention to Optimize Cefazolin Dosing for Surgical Prophylaxis. Open Forum Infect Dis 2019. [PMCID: PMC6811029 DOI: 10.1093/ofid/ofz360.961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Guidelines for antimicrobial prophylaxis in surgery recommend cefazolin dose be adjusted based on patient weight. Adults weighing ≥120 kg should receive a 3 g dose, all other adult patients should receive a 2 g dose pre-operatively. To promote guideline adherence, an antimicrobial stewardship pharmacist-driven dose optimization intervention was implemented. Methods Retrospective, pre (February 1, 2017–March 31, 2017)/post (February 1, 2018–March 31, 2018) study evaluating the impact of a pharmacist-driven cefazolin dose optimization intervention at a large health system. An alert within the electronic health record notified pharmacists during order verification when cefazolin dose from a surgical prophylaxis order set did not match weight-based recommendations. All patients with cefazolin orders for surgical prophylaxis were included; pediatric and pregnant patients were excluded. Results Pre-group included 9,830 patients, post-group 10,025 patients. In both groups, the mean age was 58 years, mean weight 87 kg, and 8% of patients weighed ≥120 kg. Approximately 21% of patients were seen at the academic medical center, 8% at ambulatory surgery centers, and the remainder amongst 10 community hospitals. Most common surgical procedure types were orthopedic (26%), general surgery (21%) and urologic (10%). Primary cefazolin dose was 2 g in 89.8% vs. 88.7%, followed by 3 g 6.6% vs. 6.9% and 1 g in 3.9% vs. 4.4%, pre- and post-intervention, respectively. Overall adherence to weight-based cefazolin dosing was 92.2% pre-group and 92.4% post-group. In patients weighing ≥120 kg, adherence improved from 62% (514/827) to 71% (582/817) post-intervention, P < 0.001. Adherence was better both pre- and post-intervention when an order set was used (pre: order set 95.0% vs. no order set 85.9%, P < 0.001; post: order set 96.4% vs. no order set 84.8%, P < 0.001). There were no differences between surgical services or hospital locations. Investigation of guideline nonadherent cases found order sets without updated dosing recommendations and allowed for targeted education efforts. Conclusion Overall adherence to cefazolin weight-based dosing recommendations for surgical prophylaxis was high, especially with the use of order sets. Pharmacist-driven dose optimization intervention improved guideline adherence in patients weighing ≥120 kg. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | | | | | | | | | - Vasilios Athans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Srinivas P, Wu J, Neuner EA, Pallotta A, Richter SS, Tsigrelis C. 2266. Management of Ertapenem-Resistant, Meropenem-Susceptible Enterobacteriaceae. Open Forum Infect Dis 2019. [PMCID: PMC6810591 DOI: 10.1093/ofid/ofz360.1944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Carbapenemases are the most frequent mechanism of carbapenem resistance in Enterobacteriaceae. However, alternative mechanisms such as loss of porin channels or up-regulation of efflux pumps can cause intermediate- to high-level resistance to ertapenem (ERTA) and possibly reduced susceptibilities to meropenem (MERO) leading to discordant phenotypic profiles. Clinical implications of discordant carbapenem susceptibilities and optimal therapy options are yet unknown. We sought to describe our experience with carbapenem-discordant Enterobacteriaceae (CDE). Methods Descriptive study of hospitalized adult patients with a CDE positive culture from December 1/16 - December 1/18. Discordance was defined as Enterobacteriaceae with an ERTA-resistant and MERO-susceptible phenotype. Primary objective was to describe antibiotic use patterns for CDE infections. Secondary outcomes included infectious diseases (ID) involvement and clinical outcomes. Clinical failure was defined as a composite of in-hospital mortality, switch of definitive therapy due to clinical worsening, re-hospitalization within 30 days for re-infection, or failure to achieve blood culture clearance for ≥7 days. Results A total of 55 patients with CDE were identified. Most common organisms were Enterobacter cloacae complex (72%) and Klebsiella pneumoniae (9%). Of 21 isolates tested, 1 (4.8%) was positive for a carbapenemase. Mean age of patients was 61 ± 16 years, 51% were admitted to a medicine service, and 18% were immunocompromised. ID was involved in 82% of CDE cases. Most common sites were urine (33%), wound/tissue (27%), and respiratory (18%). 43/55 (78%) patients were treated – 17/43 (40%) with MERO, 14/43 (33%) with fluoroquinolones. Ceftazidime/avibactam and tigecycline were used in 4 (9%) patients each. Combination therapy was used in 8 (19%) patients, most commonly with MERO or tigecycline. Clinical failure occurred in 21/43 (49%) patients – 8/43 (19%) were receiving MERO-based therapy, 13/43 (30%) were receiving a non-MERO-based therapy. Conclusion Discordance between ERTA and MERO susceptibility was more common in Enterobacter spp. Majority of isolates tested negative for a carbapenemase. MERO and fluoroquinolones were the most frequently used antibiotics for treatment of CDE infections. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Janet Wu
- Cleveland Clinic, Cleveland, Ohio
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11
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Bohn BC, Neuner EA, Athans V, Rivard KR, Riffle AR, Richter SS, Fraser TG, Gordon SM. 1050. Impact of Weekend Infectious Diseases and Antimicrobial Stewardship Pharmacy Services. Open Forum Infect Dis 2019. [PMCID: PMC6810952 DOI: 10.1093/ofid/ofz360.914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background In September 2018, pharmacy antimicrobial stewardship services were expanded to include weekends at Cleveland Clinic. Activities performed by antimicrobial stewardship (AMS) pharmacists on the weekend include blood culture rapid diagnostic (RDT) review, antiretroviral therapy (ART) review, prospective audit and feedback (PAF) utilizing clinical decision support, vancomycin dosing, and operational support. The purpose of this study was to assess the operational and clinical impact of these expanded AMS services. Methods This single-center, the quasi-experimental study included data from 13 weekends before (9/2017 – November 2017) and after (9/2018 – November 2018) implementation of weekend services. The primary outcome was the number of reviews relating to each stewardship activity. Secondary outcomes were time to AMS opportunity resolution, time to escalation or de-escalation following PAF or RDT alert, time to resolution of other AMS-related opportunities, length of stay (LOS), and antimicrobial use outcomes. Patients were included in time to resolution outcomes if they had an RDT, ART, or select PAF review requiring intervention. Time to opportunity resolution was defined as the time from AMS alert to implementation of the recommendation in the electronic health record. Results During the post-intervention period 1261 reviews were conducted, averaging 97/weekend. This included 187 RDT, 432 PAF, 124 ART, 331 vancomycin dosing notes and 187 other. Inclusion criteria for time to resolution outcomes were met by 72 patients pre-intervention compared with 59 patients post. No significant differences were seen in baseline characteristics between groups with 43% of patients requiring ID consultation and 58% requiring ICU admission. The median time to opportunity resolution improved significantly overall (P < 0.01), with de-escalation (P = 0.03), and with time to other AMS opportunity (P = 0.01) (Figure 1). A numerical reduction was seen with time to escalation (P = 0.1). LOS was a median of 13 and 14 days pre- and post-intervention, respectively (P = 0.4). No differences were seen in antimicrobial use outcomes. Conclusion Presence of pharmacist-driven weekend AMS services significantly reduced time to resolution of AMS interventions. These data support the value of weekend AMS services. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | | | - Vasilios Athans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Srinivas P, Rivard KR, Pallotta AM, Athans V, Martinez K, Loutzenheiser S, Lam SW, Procop GW, Richter SS, Neuner EA. Implementation of a Stewardship Initiative on Respiratory Viral PCR‐based Antibiotic Deescalation. Pharmacotherapy 2019; 39:709-717. [DOI: 10.1002/phar.2268] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Pavithra Srinivas
- Department of Pharmacy Cleveland Clinic Cleveland Ohio
- Department of Pharmacy Cleveland Clinic Avon Hospital Avon Ohio
| | | | - Andrea M. Pallotta
- Department of Pharmacy Cleveland Clinic Cleveland Ohio
- Department of Pharmacy Cleveland Clinic Medina Hospital Medina Ohio
| | | | - Kristin Martinez
- Department of Pharmacy Cleveland Clinic Fairview Hospital Cleveland Ohio
| | | | - Simon W. Lam
- Department of Pharmacy Cleveland Clinic Cleveland Ohio
| | - Gary W. Procop
- Department of Laboratory Medicine Cleveland Clinic Cleveland Ohio
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Spinner ML, Stephany BR, Cerrato PM, Lam SW, Neuner EA, Patel KS. Risk factors associated with Clostridium difficile infection in kidney transplant recipients. Transpl Infect Dis 2018; 20:e12918. [PMID: 29797632 DOI: 10.1111/tid.12918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 02/12/2018] [Revised: 04/12/2018] [Accepted: 05/12/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Solid organ transplant recipients are especially vulnerable to Clostridium difficile infection (CDI) due to cumulative risk factors including increased exposure to healthcare settings, persistent immunosuppression, and higher rates of antimicrobial exposure. We aimed to identify risk factors associated with CDI development in kidney transplant recipients including implications of immunosuppressive therapies and acid-suppressing agents. METHODS This was a single-center, non-interventional, retrospective case-control study of adult subjects between June 1, 2009 and June 30, 2013. During this time, 728 patients underwent kidney transplantation. Overall, 22 developed CDI (cases) and were matched 1:3 with 66 controls. Cases and controls were also matched for induction agent, kidney allograft type (living or deceased), and time from transplant to CDI result (±60 days). RESULTS The majority of subjects received a deceased donor kidney (77.3%) and basiliximab induction therapy (86.4%). The overall CDI incidence was 3%. Factors independently associated with CDI were average tacrolimus trough (AOR = 1.25, 95% CI = 1.00-1.56, P = .048) and antibiotic exposure for urinary tract infections (UTI) (AOR = 4.17, 95% CI = 1.12-15.54, P = .034). Proton pump inhibitor use was not associated with CDI (OR = 0.81, 95% CI = 0.29-2.29, P = .691). CONCLUSION Maintaining a clinically appropriate tacrolimus trough and judicious antibiotic use and selection for UTI treatment could potentially reduce CDI in the kidney transplant population.
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Affiliation(s)
- M L Spinner
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - B R Stephany
- Departments of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | - P M Cerrato
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - S W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - E A Neuner
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - K S Patel
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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Eckardt JL, Wanek MR, Udeh CI, Neuner EA, Fraser TG, Attia T, Roselli EE. Evaluation of Prophylactic Antibiotic Use for Delayed Sternal Closure After Cardiothoracic Operation. Ann Thorac Surg 2018; 105:1365-1369. [DOI: 10.1016/j.athoracsur.2017.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 12/07/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
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15
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Ghamrawi RJ, Kantorovich A, Bauer SR, Pallotta AM, Sekeres JK, Gordon SM, Neuner EA. Evaluation of Antimicrobial Stewardship-Related Alerts Using a Clinical Decision Support System. Hosp Pharm 2017; 52:679-684. [PMID: 29276239 DOI: 10.1177/0018578717726869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Information technology, including clinical decision support systems (CDSS), have an increasingly important and growing role in identifying opportunities for antimicrobial stewardship-related interventions. Objective: The aim of this study was to describe and compare types and outcomes of CDSS-built antimicrobial stewardship alerts. Methods: Fifteen alerts were evaluated in the initial antimicrobial stewardship program (ASP) review. Preimplementation, alerts were reviewed retrospectively. Postimplementation, alerts were reviewed in real-time. Data collection included total number of actionable alerts, recommendation acceptance rates, and time spent on each alert. Time to de-escalation to narrower spectrum agents was collected. Results: In total, 749 alerts were evaluated. Overall, 306 (41%) alerts were actionable (173 preimplementation, 133 postimplementation). Rates of actionable alerts were similar for custom-built and prebuilt alert types (39% [53 of 135] vs 41% [253 of 614], P = .68]. In the postimplementation group, an intervention was attempted in 97% of actionable alerts and 70% of interventions were accepted. The median time spent per alert was 7 minutes (interquartile range [IQR], 5-13 minutes; 15 [12-17] minutes for actionable alerts vs 6 [5-7] minutes for nonactionable alerts, P < .001). In cases where the antimicrobial was eventually de-escalated, the median time to de-escalation was 28.8 hours (95% confidence interval [CI], 10.0-69.1 hours) preimplementation vs 4.7 hours (95% CI, 2.4-22.1 hours) postimplementation, P < .001. Conclusions: CDSS have played an important role in ASPs to help identify opportunities to optimize antimicrobial use through prebuilt and custom-built alerts. As ASP roles continue to expand, focusing time on customizing institution specific alerts will be of vital importance to help redistribute time needed to manage other ASP tasks and opportunities.
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Affiliation(s)
- Riane J Ghamrawi
- University of Cincinnati- West Chester Hospital, OH, USA.,University of Cincinnati- Daniel Drake Center for Post-Acute Care, OH, USA
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16
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Ammar AA, Lam SW, Duggal A, Neuner EA, Bass SN, Guzman JA, Wang XF, Han X, Bauer SR. Compliance with Procalcitonin Algorithm Antibiotic Recommendations for Patients in Medical Intensive Care Unit. Pharmacotherapy 2017; 37:177-186. [PMID: 27997675 DOI: 10.1002/phar.1887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
STUDY OBJECTIVES To describe compliance with antibiotic recommendations based on a previously published procalcitonin (PCT)-guided algorithm in clinical practice, to compare PCT algorithm compliance rates between PCT assays ordered in the antibiotic initiation setting (PCT concentration measured less than 24 hours after antibiotic initiation or before antibiotic initiation) with those in the antibiotic continuation setting (PCT concentration measured 24 hours or more after antibiotic initiation), and to evaluate patient- and PCT-related factors independently associated with algorithm compliance in patients in the medical intensive care unit (MICU). DESIGN Single-center retrospective cohort study. SETTING Large MICU in a tertiary care academic medical center. PATIENTS A total of 527 adults admitted to the MICU unit over a 2-year period (November 1, 2011-October 31, 2013) who had a total of 957 PCT assays performed. PCT assays whose results were determined in the MICU were allocated retrospectively to either the initiation setting cohort or the continuation setting cohort based on timing of the PCT assay. MEASUREMENTS AND MAIN RESULTS Each PCT assay was treated as a separate episode. Antibiotic regimens were compared between the 24-hour periods before and after the results of each PCT assay and evaluated against an algorithm to determine compliance. Clinical, laboratory, PCT-related, and microbiologic variables were assessed during the 24-hour period after the PCT assay results to determine their influence on PCT algorithm compliance. A larger proportion of PCT episodes occurred in the initiation setting (540 [56.4%]) than in the continuation setting (417 [43.5%]). Overall, compliance with PCT algorithm recommendations was low (48.5%) and not significantly different between the initiation setting and the continuation setting (49.1% vs 47.7%, p=0.678). No patient-related or PCT-related factors were independently associated with PCT algorithm compliance on multivariable logistic regression. CONCLUSION Compliance with PCT algorithm antibiotic recommendations in both the initiation and continuation settings was lower than that reported in published randomized studies. No factors were independently associated with PCT algorithm compliance. Institutions using PCT assays to guide antibiotic use should assess compliance with algorithm antibiotic recommendations. Inclusion of a formalized antimicrobial stewardship program along with a PCT-guided algorithm is highly recommended.
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Affiliation(s)
| | - Simon W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Abhijit Duggal
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Jorge A Guzman
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Xiao-Feng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Xiaozhen Han
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
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Neuner EA, Gallagher JC. Pharmacodynamic and pharmacokinetic considerations in the treatment of critically Ill patients infected with carbapenem-resistant Enterobacteriaceae. Virulence 2016; 8:440-452. [PMID: 27589330 DOI: 10.1080/21505594.2016.1221021] [Citation(s) in RCA: 24] [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] [Indexed: 01/20/2023] Open
Abstract
Carbapenem-Resistant Enterobacteriaceae (CRE) are an emerging healthcare crisis. Infections due to CRE are associated with high morbidity and mortality, especially in critically ill patients. Due to the multi-drug resistant nature of these infections only limited treatment options are available. Antimicrobials that have been described for the treatment of CRE infections include carbapenems, polymyxins, fosfomycin, tigecycline, aminoglycosides, and ceftazidime-avibactam. Given the limited treatment options it is imperative the pharmacokinetic and pharmacodynamics (PK-PD) characteristics of these agents are considered to optimize treatment regimens. This review will focus on the PK-PD challenges of the current treatment options for CRE infections.
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Affiliation(s)
| | - Jason C Gallagher
- b Department of Pharmacy Practice, Infectious Diseases , Temple University , Philadelphia , PA , USA
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18
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Bombatch C, Pallotta A, Neuner EA, Taege AJ. Evaluation of Herpes Zoster Vaccination in HIV-Infected Patients 50 Years of Age and Older. Ann Pharmacother 2016; 50:326-7. [PMID: 26861991 DOI: 10.1177/1060028016632262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Popa D, Loewenstein L, Lam SW, Neuner EA, Ahrens CL, Bhimraj A. Therapeutic drug monitoring of cerebrospinal fluid vancomycin concentration during intraventricular administration. J Hosp Infect 2015; 92:199-202. [PMID: 26654472 DOI: 10.1016/j.jhin.2015.10.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [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: 07/19/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022]
Abstract
Limited data are available on intraventricular vancomycin dosing for meningitis. This study explored clinical characteristics that correlated with cerebrospinal fluid (CSF) concentrations. Over a nine-year period, 13 patients with 34 CSF vancomycin concentrations were evaluated. CSF output and time from dose correlated with CSF vancomycin concentration. No relationship was seen with regards to CSF protein, white blood cell count or glucose.
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Affiliation(s)
- D Popa
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.
| | - L Loewenstein
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - S W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - E A Neuner
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - C L Ahrens
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - A Bhimraj
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
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Welch SC, Lam SW, Neuner EA, Bauer SR, Bass SN. High-dose versus standard dose oseltamivir for treatment of severe influenza in adult intensive care unit patients. Intensive Care Med 2015; 41:1365-6. [PMID: 25952823 DOI: 10.1007/s00134-015-3816-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Sarah C Welch
- Deparment of Pharmacy, Cleveland Clinic, 9500 Euclid Ave HB-105, Cleveland, OH, 44195, USA,
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21
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Fedorenko M, Lam SW, Harinstein LM, Neuner EA, Demirjian S, Bauer SR. Compliance With Institutional Antimicrobial Dosing Guidelines in Patients Receiving Continuous Venovenous Hemodialysis. J Pharm Pract 2014; 28:380-6. [DOI: 10.1177/0897190013519679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Describe the rate of compliance with institutional antimicrobial dosing guidelines in patients on concomitant continuous venovenous hemodialysis (CVVHD). Methods: This single-center retrospective chart review evaluated adult patients receiving concomitant intravenous antimicrobials and CVVHD for at least 24 hours over a 2-month period. Results: A total of 42 patients, 76 antimicrobial courses, and 208 study days (24 hours of concomitant therapy) were evaluated. Overall, antimicrobials were dosed according to the institutional guidelines on 162 (78%) of 208 study days. All nonconcordant doses were below recommendations. The recommended dose was never received prior to antibiotic or CVVHD discontinuation in 22% of the cases. In cases where antimicrobials were initiated when the patient was already on CVVHD, 74% of the initial doses met guideline criteria. Pharmacist recommendation was associated with increased dosing compliance (94% vs 73% of study days, P = .001). During transition from CVVHD to intermittent hemodialysis (IHD), only 62% of antimicrobial doses were decreased by the first IHD day. Conclusions: Antimicrobial dosing in patients on CVVHD was below institutional guideline recommendations in many cases. Pharmacist recommendation was associated with compliance. Centers should evaluate their own compliance rate with institutional guideline recommendations for CVVHD and implement initiatives to improve dosing practices.
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Affiliation(s)
| | - Simon W. Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Sevag Demirjian
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Seth R. Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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22
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Bass SN, Lam SW, Bauer SR, Neuner EA. Comparison of oral vancomycin capsule and solution for treatment of initial episode of severe Clostridium difficile Infection. J Pharm Pract 2013; 28:183-8. [PMID: 24375999 DOI: 10.1177/0897190013515925] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Vancomycin is recommended as a first-line therapy for severe Clostridium difficile infection (CDI). Due to the high cost of commercially available vancomycin capsules, hospitals frequently compound oral solution despite a lack of data comparing outcomes. This study was conducted to determine treatment outcome differences based on oral vancomycin formulation. METHODS Medical charts of 76 patients with an initial episode of severe CDI receiving oral vancomycin as a commercially available capsule or a compounded oral solution for at least 72 hours were retrospectively reviewed. The primary objective was to compare the time to clinical cure of CDI. RESULTS Baseline characteristics between groups were similar except for the median lactate, which was higher in compounded oral solution group (1.5 vs 0.6 mmol/L, P < .001). There was no difference in clinical cure at day 10 (64% solution vs 59% capsules, P = .664). Median time to clinical cure was 8 days for solution and 7 for capsules (P = .597). After adjustment, the hazard ratio of time to clinical cure for solution compared to capsules was 1.15 (P = .69). No significant differences in mortality, recurrence, or complications were noted. CONCLUSION Formulation of oral vancomycin did not impact treatment outcomes in this retrospective study.
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Affiliation(s)
| | - Simon W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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Lam SW, Bass SN, Neuner EA, Bauer SR. Effect of vancomycin dose on treatment outcomes in severe Clostridium difficile infection. Int J Antimicrob Agents 2013; 42:553-8. [DOI: 10.1016/j.ijantimicag.2013.08.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/07/2013] [Accepted: 08/09/2013] [Indexed: 12/27/2022]
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24
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van Duin D, Kaye KS, Neuner EA, Bonomo RA. Carbapenem-resistant Enterobacteriaceae: a review of treatment and outcomes. Diagn Microbiol Infect Dis 2013; 75:115-20. [PMID: 23290507 DOI: 10.1016/j.diagmicrobio.2012.11.009] [Citation(s) in RCA: 238] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 11/13/2012] [Indexed: 02/06/2023]
Abstract
The emergence of carbapenem resistance in Enterobacteriaceae is an important threat to global health. Reported outcomes of infections with carbapenem-resistant Enterobacteriaceae (CRE) are poor. Very few options remain for the treatment of these virulent organisms. Antibiotics which are currently in use to treat CRE infections include aminoglycosides, polymyxins, tigecycline, fosfomycin, and temocillin. In addition, the role of combination therapy, including carbapenem containing regimens, remains to be defined. There are several important concerns regarding all of these treatment options such as limited efficacy, increasing reports of resistance, and specific toxicities. Data from retrospective studies favor combination therapy over single-agent therapy for the treatment of CRE bloodstream infections. In summary, new antibiotics are greatly needed, as is additional prospective research.
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Affiliation(s)
- David van Duin
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA.
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Vicari G, Bauer SR, Neuner EA, Lam SW. Association Between Colistin Dose and Microbiologic Outcomes in Patients With Multidrug-Resistant Gram-Negative Bacteremia. Clin Infect Dis 2012; 56:398-404. [DOI: 10.1093/cid/cis909] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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26
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Alexander BT, Marschall J, Tibbetts RJ, Neuner EA, Dunne WM, Ritchie DJ. Treatment and clinical outcomes of urinary tract infections caused by KPC-producing Enterobacteriaceae in a retrospective cohort. Clin Ther 2012; 34:1314-23. [PMID: 22691610 DOI: 10.1016/j.clinthera.2012.05.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/01/2012] [Accepted: 05/10/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Optimal treatment regimens for infections caused by Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae are not well-defined. OBJECTIVES This study describes the treatment and outcomes in patients with urinary tract infection (UTI) caused by KPC-producing Enterobacteriaceae. METHODS This retrospective cohort study analyzed data from adult inpatients with bacteriuria caused by KPC-positive organisms treated at Barnes-Jewish Hospital from June 1, 2006, to February 1, 2008. KPC-positive isolates were identified utilizing disk-diffusion susceptibility testing and confirmed to contain bla(KPC) via molecular methods. RESULTS Twenty-one patients met the inclusion criteria and all were classified as having symptomatic UTI. The majority of patients were female (15/21 [71%]), and the mean (SD) age was 62.4 (15.2) years. Successful clinical and microbiologic responses were observed in 16 patients (76%) for both outcomes. Patients with urinary catheters had them removed or replaced in 9 of 15 cases (60%). Antibiotics active against the isolated pathogen were provided in 14 of 21 cases (67%), often after considerable delay (median, 72.5 hours [range, 4-312 hours]). All 7 patients receiving aminoglycoside therapy had successful clinical and microbiologic responses, and in vitro testing of an extended antibiotic panel revealed high susceptibility rates for tigecycline (28/29 [97%]), minocycline (22/29 [76%]), and fosfomycin (25/29 [86%]) against the KPC-positive isolates. CONCLUSIONS Although receipt of appropriate therapy was delayed in many cases, clinical outcomes investigated revealed [corrected] high rates of successful response in this defined group of patients Aminoglycosides and tetracycline derivatives suggested therapeutic promise in the treatment of KPC-producing Enterobacteriaceae UTI.
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Affiliation(s)
- Bryan T Alexander
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO 63110, USA
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Lam SW, Bauer SR, Neuner EA. Predictors of septic shock in patients with methicillin-resistant Staphylococcus aureus bacteremia. Int J Infect Dis 2012; 16:e453-6. [DOI: 10.1016/j.ijid.2012.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 02/02/2012] [Indexed: 01/01/2023] Open
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Neuner EA, Ahrens CL, Groszek JJ, Isada C, Vogelbaum MA, Fissell WH, Bhimraj A. Use of therapeutic drug monitoring to treat Elizabethkingia meningoseptica meningitis and bacteraemia in an adult. J Antimicrob Chemother 2012; 67:1558-60. [PMID: 22357803 DOI: 10.1093/jac/dks053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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29
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Neuner EA, Sekeres J, Ristich A, Skok J, Rosenblatt M, Fatica C, Fraser TG. Implementation of a pharmacy-driven program to improve nasal mupirocin use. Am J Health Syst Pharm 2011; 68:2222, 2224, 2226, 2228. [PMID: 22095809 DOI: 10.2146/ajhp110021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Elizabeth A Neuner
- Infectious Diseases Clinical Pharmacist, Department of Pharmacy, Cleveland Clinic, OH 44195, USA.
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Neuner EA, Yeh JY, Hall GS, Sekeres J, Endimiani A, Bonomo RA, Shrestha NK, Fraser TG, van Duin D. Treatment and outcomes in carbapenem-resistant Klebsiella pneumoniae bloodstream infections. Diagn Microbiol Infect Dis 2011; 69:357-62. [PMID: 21396529 DOI: 10.1016/j.diagmicrobio.2010.10.013] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 10/12/2010] [Accepted: 10/22/2010] [Indexed: 11/25/2022]
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CR-Kp) is an emerging multidrug-resistant nosocomial pathogen. This is a retrospective chart review describing the outcomes and treatment of 60 cases of CR-Kp bloodstream infections. All CR-Kp isolated from blood cultures were identified retrospectively from the microbiology laboratory from January 2007 to May 2009. Clinical information was collected from the electronic medical record. Patients with 14-day hospital mortality were compared to those who survived 14 days. The all-cause in-hospital and 14-day mortality for all 60 CR-Kp bloodstream infections were 58.3% and 41.7%, respectively. In this collection, 98% of tested isolates were susceptible in vitro to tigecycline compared to 86% to colistimethate, 45% to amikacin, and 22% to gentamicin. Nine patients died before cultures were finalized and received no therapy active against CR-Kp. In the remaining 51 patients, those who survived to day 14 (n = 35) were compared to nonsurvivors at day 14 (n=16). These patients were characterized by both chronic disease and acute illness. The 90-day readmission rate for hospital survivors was 72%. Time to active therapy was not significantly different between survivors and nonsurvivors, and hospital mortality was also similar regardless of therapy chosen. Pitt bacteremia score was the only significant factor associated with mortality in Cox regression analysis. In summary, CR-Kp bloodstream infections occur in patients who are chronically and acutely ill. They are associated with high 14-day mortality and poor outcomes regardless of tigecycline or other treatment regimens selected.
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Bonilla MF, Avery RK, Rehm SJ, Neuner EA, Isada CM, van Duin D. Extreme alkaline phosphatase elevation associated with tigecycline. J Antimicrob Chemother 2011; 66:952-3. [PMID: 21393193 DOI: 10.1093/jac/dkr015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Abstract
Current antibiotics available for the treatment of healthcare-associated pneumonia (HCAP) may result in clinical failure due to resistance development, side effect intolerance, or poor pharmacokinetic-pharmacodynamic profiles. New agents active against common HCAP pathogens are needed. The mechanism of action, spectrum of activity, pharmacokinetics, adverse effects, and clinical efficacy of seven new agents in clinical development or recently approved with either methicillin-resistant Staphylococcus aureus (MRSA) or pseudomonal activity are reviewed. They include doripenem, a new antipseudomonal carbapenem; ceftobiprole and ceftaroline, two anti-MRSA cephalosporins; iclaprim, a selective dihydrofolate reductase antagonist; and three glycopeptides, dalbavancin, telavancin, and oritavancin.
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Affiliation(s)
- Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri 63110, USA
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