Optimizing Empiric Vancomycin Use in Febrile Neutropenia Patients

Introduction: Febrile neutropenia (FN) is a complication of chemotherapy resulting in a temperature 100.4⁰F or greater plus an absolute neutrophil count (ANC) below 500 cells/mm3 or an ANC below 1000 cells/mm3 and expected to decrease below 500 cells/mm3 within 48 hours. Timely administration of broad-spectrum antimicrobial therapy is a cornerstone for the initial management of FN. However, prolonged empiric antimicrobial treatment can lead to resistance and toxicity. National guidelines and published literature do not support vancomycin as a routine part of empiric antimicrobial regimens in FN; it is only recommended in patients with specific clinical indications. This study aims to evaluate current use of vancomycin in FN and improve compliance with a guideline-driven algorithm (GDA) to ensure appropriate prescribing and therapy duration in a community hospital. Methods: This single-center, biphasic, quality improvement project includes both retrospective (Phase 1) and prospective (Phase II) review of adult patients receiving empiric vancomycin therapy for FN at Baptist Hospital. Phase I took place from January to December 2019, while Phase II took place from January to March 2021. Data collection points included patient demographics, indication, pertinent labs and cultures, therapy duration and compliance with the GDA. In Phase II, pharmacist interventions were made to recommend de-escalation or discontinuation of vancomycin as warranted. Primary outcomes included percent compliance with the GDA and duration of vancomycin therapy, while secondary outcomes included number of pharmacy interventions made and accepted in Phase II. Results: A total of 48 patients were reviewed during phase I of the study while 32 patients were reviewed during phase II. The percent compliance with the GDA increased from 15% in phase I to 38% in phase II. The average duration of therapy in phase I was 4.77 days (ranging from 1-16) vs 2.69 days in phase II (ranging from 1-9). The percentage of patients continued on vancomycin beyond 48 hours decreased from 81% in phase I to 34% in phase II. A total of 18 pharmacist interventions were made in phase II with an acceptance rate of 100%. Discussion: Pharmacist intervention had an impact in increasing compliance to national guideline recommendations and decreasing the duration of empiric vancomycin therapy in patients with FN

Optimizing Empiric Vancomycin Use in Febrile Neutropenia Patients

Introduction: National guidelines do not support routine empiric vancomycin use in the initial management of febrile neutropenia (FN) and only recommend it in patients with specific clinical indications. This bi-phasic quality improvement project aimed to evaluate current vancomycin use in FN and improve compliance with a guideline-driven algorithm (GDA) to ensure appropriate prescribing and therapy duration in a community hospital. Methods: Phase I was a retrospective review of charts of adults receiving empiric vancomycin therapy for FN at a community hospital. Phase II was a prospective review of charts of patients with FN, who received pharmacist-led interventions, to improve de-escalation of vancomycin as warranted. Results: A total of 48 and 32 patients were included in phase I and phase II, respectively. While initiation of vancomycin therapy according to guideline-recommended clinical indications was comparable among phases, appropriate de-escalation of vancomycin increased from 23% in phase I to 78% in phase II. Overall compliance with the GDA increased from 15% in phase I to 38% in phase II. Average duration of therapy in phase I was 4.77 days versus 2.69 days in phase II and there were less patients who continued vancomycin beyond 48 hours in phase II. The pharmacy intervention rate was 56% (18 of 32) and the health-care practitioner acceptance rate was 100%. Discussion: Pharmacist interventions had an impact in increasing compliance with national guideline recommendations and decreasing the duration of empiric vancomycin therapy in patients with FN

Evaluation and optimization of medication related fall risk at a community hospital

Background: Falls occur commonly in older adults at a rate of 3-5 per 1000 beds in healthcare settings. They can results in increased length of stay, morbidity and mortality, and healthcare costs. Some risk factors include older age, environmental hazards and medications. Currently at BHM, patient’s risk for falling is assessed based on Morse Fall Scale (MFS), which does include drugs as part of its assessment. The purpose of this project is to integrate medication risk evaluation into our current fall assessment. Methodology: single-centered, retrospective, IRB-reviewed quality improvement project at BHM. We included patients over age 18 who fell with at least a minor injury (F2 level) in 2019. Our primary outcome was to determine prevalence of common high-fall-risk medications administered in patients who fell and our secondary outcome was to identify pharmacy-led interventions to decrease fall risk. Since MFS does not include medications as part of its score, we then evaluated each patient using a medication scoring system with point value of 1-3 for high-fall-risk medications (point value of 3 is assigned to high-fall-risk medications and point value of 1 is assigned to low fall risk medications). Any patient with a cumulative score of higher than 6 is recognized to be at high fall risk. Results: Primary outcome showed that cardiac agents, followed by opioids, and by benzodiazepines/sleep aids were the highest administered medications in our patients who fell. Based on those findings, we identified 29 opportunities where patient could have received lower doses and/or have had medication scheduling changes in order to reduce fall risk. We are proposing automatic dose adjustments similar to hydromorphone and zolpidem/temazepam protocols where pharmacists can reduce starting doses to lowest dose possible for drug naïve patients. In addition, we are proposing to have medication scoring system to be implemented into our software so pharmacists are notified if a patient is high risk for falls based on MFS score and medication score system. Conclusion: Pharmacists can play a huge role in reducing falls in inpatient settings. Based on our findings, some opportunities where pharmacists can intervene to reduce risk of falling include scheduling and automatic dose reductions with medications such as cardiac agents, opioids, and benzodiazepine/sleep aids

Optimization of albumin 5% use in a community hospital

Background: The debate surrounding the use of crystalloids versus colloids remains a source of controversy due to limited and conflicting evidence. Emerging data favors the use of crystalloids over colloids in addition to cost benefits. Baptist Hospital of Miami (BHM) has evidence-based guidance for albumin 5%, but it is unclear the degree of appropriate usage. The purpose of this study is to assess the prescribing practices of albumin 5% at BHM and optimize appropriate use through pharmacy driven interventions. Methodology: A single-center, IRB-reviewed, bi-phasic study was conducted within a community hospital. In phase I, a retrospective chart review of patients who received albumin 5% during 2019 was conducted to evaluate prescribing patterns. Phase II was performed after pharmacy driven education was completed to increase appropriate use. A pharmacist was on-call for the prospective chart review to assess appropriateness of albumin 5% orders in patients who met inclusion criteria. The primary outcome is the comparison of appropriate usage of albumin 5% before and after education. Secondary outcomes include pharmacist interventions and the financial impact. Results: After implementation of the albumin 5% stewardship initiative, inappropriate use of albumin 5% was decreased significantly by 54%. Through the 30-day interventional phase, a total of 13 pharmacy interventions were performed with 100% acceptance rate including optimization of crystalloid resuscitation or discontinuation of fluids completely. These interventions along with provider education resulted in at least 72 albumin 5% doses avoided during the phase II study period, which amounts to an extrapolated annual cost savings of ~ $32,400. Conclusion: Introduction of evidence-based guidance in conjugation with prospective pharmacist review and intervention can facilitate the optimization of albumin 5% use. These results demonstrate shifting towards a more evidence-based practice, which ultimately will increase patient’s safety and enhance quality of care

Evaluation of Antiplatelet-Related Bleeding Events in a Community Hospital

Background:Bleeding rate among patients who take high-dose aspirin is approximately 1.92% with an expected 2-3 fold increase after a second antiplatelet is added. Similarly, the addition of an anticoagulant to single or dual antiplatelet therapy results in increased bleeding rates of approximately 13.9% and 15.7% respectively. The concomitant use of antiplatelets and anticoagulants has become a common practice due to the high incidence of clinical conditions for which these agents are used. Hence, reversal of antithrombotic agents is often needed during major bleeding events or invasive procedures. However, the use of antiplatelet reversal is still under-utilized, and its efficacy on patient outcomes remains to be tested. The purpose of this project is to assess the incidence of bleeding, reversal strategies, mortality rates, and thrombotic events in patients with a major bleeding event receiving antiplatelets with or without concomitant anticoagulants. Methods: A retrospective chart review was conducted over a one-year period. Patients 18 years and older taking an antiplatelet excluding low dose aspirin alone at the time of the major bleeding event were included in the study. A major bleeding event was defined as bleeding into a critical area/organ, fall in hemoglobin of ≥ 20 g/L, or transfusion of \u3e 2 units of blood. Subjects were divided into two groups: intracranial and non-intracranial hemorrhage. Patient outcomes will be analyzed based on bleeding severity, causative agents, and reversal strategies utilized. Results: We identified 21 patients with ICH and 38 with Non-ICH. Bleeding rates among patients who had a major bleeding event were as follows: 12.4% of patients on antiplatelet therapy, 2.4% on APT monotherapy, 5.4% on DAPT, and 4% on APT plus an anticoagulant. A reversal strategy was utilized 68% of the time for the reversal of antiplatelets in the setting of an ICH compared to 18% in the Non-ICH group. Our findings suggest that mortality, readmission, and thrombotic events are not affected by bleeding severity or reversal strategy utilized. Discussion: Antiplatelet therapy with or without anticoagulation could increase the risk for a major bleeding event. At Baptist Hospital of Miami, antiplatelet reversal is conducted in accordance with current societal guideline recommendations. However, there is opportunity for improvement in the reversal of antiplatelet agents when utilized concomitantly with an anticoagulant

Evaluation of Four-Factor Prothrombin Complex Concentrate Dosing Strategies for the Reversal of Bleeding Associated with Apixaban or Rivaroxaban

In clinical practice, 4F-PCC is commonly used off-label as a non-specific reversal agent for factor Xa inhibitors apixaban and rivaroxaban. While the hemostatic effectiveness of 4F-PCC in patients taking apixaban and rivaroxaban has been studied in the literature, the optimal dose remains unclear. This was a multicenter, retrospective observational study designed to evaluate the hemostatic effectiveness and safety of 4F-PCC dosed at 2000 units, 35 units/kg, and 50 units/kg for the reversal of bleeding associated with apixaban or rivaroxaban. The primary outcome was hemostatic effectiveness as defined by the Internal Society of Thrombosis and Hemostasis and secondary outcomes were rates of all-cause in-hospital mortality and thrombosis at 30 days or discharge. Out of 278 patients who received 4F-PCC for reversal of bleeding associated with apixaban or rivaroxaban, 72 patients were included in the final analysis. The 2000-unit, 35 unit/kg, and 50 unit/kg dosing strategies were used in 12, 36, and 24 patients, respectively. Hemostatic effectiveness was achieved in 86%, 67%, and 70% of intracerebral hemorrhages (p = 0.762) and 60%, 71%, 86% of gastrointestinal hemorrhages (p = 0.422). Neither dosing strategy was associated with a statistically significantly higher rate of hemostatic effectiveness nor lower rates of all-cause mortality or thrombosis

Evaluation of the Impact of an Antibiotic Time-out for Transition of IV Vancomycin to Oral Linezolid in Hospitalized Patients

Background: Oral linezolid is a broad-spectrum oxazolidinone antibiotic that offers advantages compared to intravenous (IV) vancomycin including no requirement for therapeutic drug monitoring, no need for home health or peripherally inserted central catheter (PICC) line placement, and opportunities for earlier hospital discharge due to the ease of continuing therapy outpatient. A medication use evaluation investigated if opportunities existed for oral linezolid over IV vancomycin among a randomized cohort of 100 patients initiated on IV vancomycin. Reviewers identified 15 patients who were candidates for transition to oral linezolid and calculated a potential cost avoidance of $125 per day of antibiotic therapy. The purpose of this study is to assess the feasibility of implementing an interdisciplinary approach for transitioning IV vancomycin to oral linezolid based on pharmacist-led transition criteria. Methods: This is an IRB-reviewed, single-center, quasi-experimental study at Baptist Hospital of Miami, a 900-bed tertiary community hospital. Included patients were \u3e18 years old, receiving IV vancomycin for \u3e48 hours, and admitted between January 10, 2023 and March 31, 2023. Patients were excluded if they had an active vasopressor order, were immunocompromised, or if the patient was receiving antibiotics for meningitis, endocarditis, febrile neutropenia, or surgical prophylaxis. A pharmacy resident was on-call to assess for oral linezolid candidates using antibiotic timeout criteria and intervened as appropriate. Continuous and categorical variables were evaluated using the Mann-Whitney U test and Fisher’s exact test, respectively. The primary outcome was total cost avoidance in patients transitioned from IV vancomycin to oral linezolid. Secondary outcomes included median hospital length of stay, median antibiotic treatment days, and incidence of thrombocytopenia and acute kidney injury, and pharmacist intervention acceptance rate. Results: Investigators screened 317 patients for study inclusion and 94 patients met criteria. 66 (70$5,538, with a total of $21 and$70 saved per inpatient and outpatient antibiotic treatment day, respectively. Median length of antibiotic treatment days was 6 days between both groups (p=0.3524). No statistically significant differences were observed between length of stay, length of antibiotic treatment days, or safety outcomes between the 2 groups. Acute kidney injury occurred in 1 patient receiving linezolid and 1 patient receiving IV vancomycin. Thrombocytopenia, defined as a \u3e50% drop in platelet count from baseline, occurred in 1 patient receiving provider-driven linezolid therapy. Conclusion: Pharmacist-driven transition criteria from IV vancomycin to linezolid therapy resulted in a positive cost avoidance strategy, with similar effect on hospital antibiotic treatment days and no difference in incidence of adverse effects. These results demonstrate the practicality of a pharmacist prospective antibiotic timeout and intervention strategy for patients receiving empiric or targeted Methicillin-resistant Staphylococcus aureus (MRSA) therapy

Implementation of 4T score documentation on PF4 testing in patients with Suspected heparin induced thrombocytopenia (HIT)

Purpose: Heparin-induced thrombocytopenia (HIT) is a severe complication of heparin therapy. Diagnosis requires clinical evaluation and laboratory testing. The 4T score is a pretest clinical scoring system used to assess the probability of HIT. A non-profit community hospital implemented mandatory 4T score documentation prior to ordering PF4 tests for suspected HIT patients, following a pharmacy-driven approach to optimize the prescribing of argatroban. The purpose of this performance improvement project is to evaluate the implementation of 4T score documentation on PF4 testing and argatroban utilization. Methods: In a retrospective, multi-site chart review study conducted, electronic records of patients were reviewed to assess the effects of 4T score documentation on PF4 testing orders. The study included adult patients who were admitted to one of the five practice sites between January 2020 and November 2022 and had a suspicion HIT with a PF4 test ordered. The primary outcomes assessed the number of PF4, and SRA tests ordered and the percentage of positive results for HIT annually. Secondary outcomes included the number of SRA orders and results, reporting of heparin allergy in patients with negative SRA results, time taken for SRA results, and the utilization of argatroban. Data collected from each patient\u27s medical record included baseline demographics, SRA results, documentation of heparin allergy, initial anticoagulant prescribed, platelet trend, ordering provider, and argatroban utilization. The analysis involved using χ2 test and Fisher\u27s exact test for the primary outcomes. Results: A total of 42 patients with a positive PF4 test were included in the analysis Mandatory 4T score documentation significantly reduced PF4 orders by 68% over two years (p Conclusion: Implementation of mandatory 4T score documentation significantly reduced PF4 orders and improved HIT diagnostic testing. Challenges remain in heparin allergy reporting and appropriate discontinuation of argatroban. The results of this project have demonstrated that standardized documentation is essential for optimizing HIT diagnosis and management protocols. Future efforts will focus on improving heparin allergy reporting practices and providing clear recommendations for discontinuing alternative anticoagulant therapy through a multi-disciplinary approach