Antimicrobial Stewardship Program Prompts Increased and Earlier Infectious Diseases Consultation

A recent analysis demonstrated that infectious diseases (ID) specialty intervention was associated with decreased mortality and hospital readmission. These benefits were greatest if involvement occurred within two days of hospital admission. Antimicrobial stewardship programs should augment the services of an ID specialist team and promote formal consultation. Implementation of an antimicrobial stewardship program at the Providence Veterans Affairs Medical Center was associated with an increased number of consults (increase of 72.2%) and decreased time to consult (3.5 days sooner), which might also dramatically improve patient outcomes, including mortality and readmission rates

Assessments of Opportunities to Improve Antibiotic Prescribing in an Emergency Department: A Period Prevalence Survey

Introduction Approximately 30% of all outpatient antimicrobials are inappropriately prescribed. Currently, antimicrobial prescribing patterns in emergency departments (ED) are not well described. Determining inappropriate antimicrobial prescribing patterns and opportunities for interventions by antimicrobial stewardship programs (ASP) are needed. Methods A retrospective chart review was performed among a random sample of non-admitted, adult patients who received an antimicrobial prescription in the ED from January 1 to December 31, 2015. Appropriateness was measured using the Medication Appropriateness Index, and was based on provider adherence to local guidelines. Additional information collected included patient characteristics, initial diagnoses, and other chronic medication use. Results Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense. Conclusion Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention

Impact of a Prospective Audit and Feedback Antimicrobial Stewardship Program at a Veterans Affairs Medical Center: A Six-Point Assessment

Background: Prospective audit and feedback is a core antimicrobial stewardship program (ASP) strategy; however its impact is difficult to measure. Methods: Our quasi-experimental study measured the effect of an ASP on clinical outcomes, antimicrobial use, resistance, costs, patient safety (adverse drug events [ADE] and Clostridium difficile infection [CDI]), and process metrics pre- (9/10–10/11) and post-ASP (9/12–10/13) using propensity adjusted and matched Cox proportional-hazards regression models and interrupted time series (ITS) methods. Results: Among our 2,696 patients, median length of stay was 1 day shorter post-ASP (5, interquartile range [IQR] 3–8 vs. 4, IQR 2–7 days, p Conclusions: Prospective audit and feedback has the potential to improve antimicrobial use and outcomes, and contain bacterial resistance. Our program demonstrated a trend towards decreased length of stay, broad-spectrum antimicrobial use, antimicrobial costs, and adverse events

Cognitive Biases in the Era of COVID-19 : A Case of Clostridium sporogenes Bacteremia in a Patient with Small Bowel Obstruction

Clostridium sporogenes bacteremia in immunocompetent patients is rare with very few reported cases in the literature. We present a case of Clostridium sporogenes bacteremia in an 81-year-old immunocompetent man with small bowel obstruction and hypoxemia during the COVID-19 pandemic. Routine monitoring of prognostic inflammatory markers for COVID-19 created a unique challenge in the management of our patient who developed sepsis with respiratory symptoms. Upon review, bacteremia from Clostridium sporogenes was associated with high mortality rates and could produce similar elevations in the inflammatory markers observed in COVID-19 pneumonia. Further, we reviewed the cognitive biases encountered when monitoring these inflammatory markers during the management of our patient with Clostridium sporogenes bacteremia, who was initially thought to have COVID-19 disease. While our patient ultimately tested negative for COVID-19, early administration of empiric antimicrobial therapy without source control failed to prevent clinical decompensation

Daptomycin-induced eosinophilic pneumonia - a systematic review

Abstract Purpose Eosinophilic pneumonia comprises a group of lung diseases in which eosinophils appear in increased numbers in the lungs and sometimes in the bloodstream. Several case reports link daptomycin use to this phenomenon. Summary We performed a systematic literature review to identify cases of eosinophilic pneumonia associated with daptomycin use. Relevant studies were identified by searching Pubmed/Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Clin-Alert from inception to May 2016, and manual searches of reference lists. All case reports that include information regarding patient age, indication, clinical and objective findings, treatment and outcome were evaluated. Abstracts from conference proceedings as well as case reports not in English were excluded. Descriptive statistics were used to analyze the data. Thirty-five patient-cases were included in the final analysis. Patients most likely to be identified with daptomycin-induced eosinophilic pneumonia were male (83%) and elderly (mean age 65.4 ± 15 years). The dose for daptomycin ranged from 4 to 10 mg/kg/day, but included a large number of patients with renal dysfunction. The average duration of daptomycin therapy upon onset of EP symptoms was 2.8 ± 1.6 weeks. Majority of patients presented with dyspnea (94%), fever (57%) and were also found to have peripheral eosinophilia (77%) and infiltrates/opacities of CT/CXR (86%). Symptom improvement was seen after daptomycin discontinuation (24 h to 1 week). The majority of patients were also prescribed treatment with corticosteroids (66%). Conclusion Clinicians should be aware of daptomycin-induced eosinophilic pneumonia and its symptoms along with its presentation and treatment

Outcomes: Post-Antimicrobial Stewardship Period Compared with Pre- Antimicrobial Stewardship Period.

<p>Outcomes: Post-Antimicrobial Stewardship Period Compared with Pre- Antimicrobial Stewardship Period.</p

Significant Changes in Antimicrobial Use using Interrupted Time Series Analysis.

<p>Significant Changes in Antimicrobial Use using Interrupted Time Series Analysis.</p

Mean Monthly Antimicrobial Use in Days of Therapy per 1000 Patient Days (DOT/1000PD) by Period.

<p>Mean Monthly Antimicrobial Use in Days of Therapy per 1000 Patient Days (DOT/1000PD) by Period.</p

Antimicrobial Stewardship Patient Workup Template.

<p>Antimicrobial Stewardship Patient Workup Template.</p

Antimicrobial Stewardship Interventions and Acceptance Rates.

<p>Data expressed as number of interventions (% accepted). IV = Intravenous; PO = Oral; NA = Intervention no longer appliable, for example patient discharged home, or antibiotic of interest was switched or discontinued. * = Antimicrobial optimization includes any recommendation to improve the drug, dose, or duration of an antimicrobial.</p