Antibiotic prescriptions upon hospital discharge: A blind spot of antimicrobial stewardship

Background: Transitions of care are a known source of patient vulnerability. The incidence of medication errors during transitions of care is well-documented.1 Discharge from the hospital has proven to be one area where antimicrobial stewardship is absent or lacking and can result in: poor clinical outcomes, adverse drug events, and emergence of multidrug resistant organisms. In one study, 53% of cases reviewed found antibiotics prescribed at discharge were inappropriate.1 Large discrepancies exist between guideline recommendations and antimicrobials prescribed upon hospital discharge.2 At this time, no prior study at OSU Medical Center has analyzed the impact of antimicrobial stewardship at hospital discharge.Methods: This study will be a retrospective chart review based on a report of patients age 18 years and older discharged from OSUMC from 7/1/2018 to 6/30/2019 with CAP or uncomplicated UTI. This data will be used to determine whether optimal antibiotic therapy was prescribed upon hospital discharge. Optimal therapy is defined as: prescription in accordance with nationally-approved guidelines for the management of CAP and UTI; effective and narrowest spectrum of activity; correct dose for indication, organ dysfunction, and medication allergies; and correct duration of therapy. This study will also the assess antibiotic classes most frequently involved in errors, as well as the most commonly occurring types of errors (incorrect drug, dose, or duration). Patients with multiple types of infection will be excluded from the study. Data collected will be organized and evaluated using REDCapTM. The following data will be obtained: date of discharge, days of optimal inpatient antibiotic therapy, discharge antibiotics regimen, infection type (CAP vs. uncomplicated UTI), pertinent laboratory and microbiology data, and bacteria cultured with source and date results finalized.Results: Data collection is still ongoing. At this time, 1402 patient charts have been reviewed, and 168 patient charts met inclusion criteria. Of those included, patients were primarily female (63%) with an average age of 62 (range 21-95), and 43% were discharged on a suboptimal antibiotic regimen. The most common reason for a suboptimal regimen was an inappropriate duration of therapy (92%) followed by an incorrect medication dose (26%).Conclusions: At the time of this writing, duration of therapy far outweighs any other cause for a suboptimal discharge antibiotic regimen. By completing this study, we hope to gain more insight into how we can better serve our institution by educating physicians, reducing errors, and optimizing transitions of care

Impact of an A ntimicrobial S tewardship P rogram C omprehensive C are B undle on M anagement of C andidemia

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96246/1/phar1186.pd

Impact of BioFire FilmArray blood culture identification panel 2 (BCID2) and antimicrobial stewardship interventions on time to optimal antimicrobial therapy in patients with positive blood cultures

Background: Delayed treatment of bloodstream infections (BSI) is associated with increased morbidity and mortality. Conventional methods for organism identification and susceptibility data from blood cultures can take on average 2-5 days, with pathogen identification taking longer. Technological advancements in gene-based polymerase chain reaction (PCR) tests amplify DNA targets from positive blood cultures which can shorten the identification time of certain organisms and resistance genes, aiding in optimization of antimicrobial therapy. Our goal is to evaluate the impact of the Biofire FilmArray Blood Culture Identification Panel 2 (BCID2) combined with real-time ASP intervention on time to optimal antimicrobial therapy and clinical outcomes.Methods: This study has a letter of determination from the Oklahoma State University (OSU) Center for Health Sciences IRB as a multidisciplinary quality improvement initiative. This pre/post quasiexperimental study conducted at OSU Medical Center in Tulsa, Oklahoma, will include adult inpatients with at least 1 positive blood cultures from a 6-month period prior to implementation of the BCID2 panel and for 6 months post-implementation. Patients less than 18 years of age, those with identical positive blood cultures within previous 7 days, positive blood cultures at an outlying facility, transitioned to CMO or died within 24 hours of positive blood cultures and patients with BSI with an organism not included on the BCID2 panel were excluded. Demographic information will be collected including comorbid health conditions, risk factors for BSI, infection source, and clinical status. The primary endpoints include time to effective therapy and time to optimal therapy. Secondary outcomes include: 30-day all-cause mortality, hospital length of stay, and microbiologic clearance and 30-day readmission with bacteremia.Results: The pre-intervention group has a final included patient population of 125 for demographic, primary, and secondary endpoints, while the post-intervention group has 89 included for demographic and primary endpoints and 62 included in secondary outcomes with final number pending. Primary endpoint data between the two groups shows a 22-hour difference in average time to pathogen ID (51 hours (pre) vs. 29 hours (post)), a 1.6-hour difference in average time to effective therapy (17.4 hours (pre) vs. 15.8 hours (post)), and a 15.1-hour difference in average time to optimal therapy (61.4 hours (pre) vs. 45.3 hours (post)). Secondary endpoint data has shown decreased time to microbiologic cure (55.6 hours (pre) vs. 49.1 hours (post)) and decreased length of stay in the intensive care unit (ICU) (3.9 days (pre) vs. 2.4 days (post)) and in the hospital total (10.8 days (pre) vs. 9 (post)). Adverse event data has shown similar rates of 30-day mortality (11.2% (pre) vs. 12.9% (post)), but a possible increase in 30- day readmission with bacteremia (0.8% (pre) vs. 6.5% (post)).Conclusions: Based on preliminary data the implementation of the BCID2 panel has decreased time to pathogen identification and optimal therapy, but has similar time to effective therapy. Data also shows a 6.5-hour difference in microbiologic clearance time with over 1.5 and 1.8-day difference in ICU and total length of stay. Further investigation into statistical significance of final data set needs to be completed