2103. Emergency Department (ED) Stewardship: Stratifying ED Sepsis Order Sets by Penicillin (PCN) Allergy Severity

Background: The Surviving Sepsis Campaign Guidelines recommends administration of broad-spectrum antibiotics within 1 hour of sepsis diagnosis; electronic order sets drive antibiotic selection with pre-populated regimens based on the suspected infectious indication. Given the low rate of cephalosporin cross-reactivity in patients with a PCN allergy, we modified our ED sepsis order set (Images 1 and 2) to include cephalosporin options in patients with reported mild-to-moderate PCN reaction histories. This was a single-center, retrospective analysis evaluating the impact of this change on antibiotic prescribing and associated outcomes. Methods: An electronic medical record (EMR) report identified patients ≥18 years of age with a documented PCN allergy that received antibiotics via the ED sepsis order set from December 30, 2012 to September 28, 2013 (pre-intervention) and January 3, 2014 to July 18, 2015 (post-intervention). The primary objective was to compare antibiotic days of therapy (DOT) and length of therapy (LOT) between the pre- and post-groups. The secondary objectives included 30-day readmission and mortality, hospital length of stay (LOS), incidence of C. difficile within 6 months and documented hypersensitivity reactions. Bivariate analyses, with chi-square, Mann–Whitney U, and Poisson means test, were used. Results: A total of 180 patients (90 pre- and 90 post-intervention) were included. Demographics were similar between groups, with the exception of congestive heart failure (CHF) which was more prevalent in the post-intervention group (P = 0.039). Aztreonam, vancomycin, aminoglycoside, and fluoroquinolone DOTs were significantly reduced (P \u3c 0.001) while cephalosporin DOTs significantly increased (P \u3c 0.001) in the post-intervention group. There were no statistical differences in antibiotic LOT, 30-day readmission and mortality, hospital LOS, or incidence of C. difficile infection. For those patients that received cephalosporin antibiotics, there were no hypersensitivity reactions documented in the EMR. Conclusion: Stratifying ED sepsis order sets by PCN allergy history severity is a safe and effective intervention that reduces second-line antibiotics in PCN allergic patients presenting to the ED with suspected sepsis

Urinary Tract Infection Stewardship: A Urinary Antibiogram and Electronic Medical Record Alert Nudging Narrower-Spectrum Antibiotics for Urinary Tract Infections

An antimicrobial stewardship intervention consisting of a urinary antibiogram and an electronic health record best-practice advisory promoted narrower-spectrum antibiotics for uncomplicated urinary tract infections in hospitalized patients. Over 20 months, the intervention significantly reduced ceftriaxone orders by 48% (P \u3c .001) and increased cefazolin use 19 times from baseline (P \u3c .001). Urinary tract infections (UTIs) are the second most common indication for inpatient antibiotics in the United States1, making them a prime target for antimicrobial stewardship programs (ASPs). The 2010 Infectious Diseases Society of America guidelines for acute uncomplicated cystitis recommend narrow-spectrum antibiotics (NSAs)2, yet many hospitalized patients receive broad-spectrum antibiotics (BSAs)1. To reduce BSA use, such as third-generation cephalosporins, and to promote first-generation cephalosporin use for uncomplicated UTIs, we developed a urinary antibiogram and an electronic health record (EHR) best-practice advisory (BPA). We then measured their impact on antibiotic prescriptions for UTIs

Is there a higher prevalence of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE)colonization in patients with antibiotic allergies?

RATIONALE: A penicillin allergy label has been associated with significantly higher rates of MRSA and VRE colonization and correspondingly, poorer clinical outcomes. However, there are limited data examining the association between any antibiotic label and colonization rates. We sought to evaluate for a relationship between patients with an antibiotic allergy and prevalence of MRSA or VRE colonization. METHODS: We retrospectively reviewed all patients with an MRSA surveillance culture between December 15, 2014 and January 31, 2015 or a VRE surveillance culture between January 1, 2013 and January 31, 2015 at our institution. Our primary objective was to evaluate the prevalence of MRSA or VRE colonization among patients with and without antibiotic allergies. Bivariate analysis included chi-square and student t-test to determine statistical significance for categorical and continuous variables, respectively. RESULTS: We included a total of 1053 unique patients screened for MRSA and 290 unique patients screened for VRE. The rate of MRSA and VRE colonization was 6.0% (62/1053) and 32.4% (94/290) in our cohort. Antibiotic allergies were documented in approximately 1 out of 3 patients, 338 (32.1%) for the MRSA group and 94 (32.4%) for VRE group. There was a significant difference in MRSA colonization between patients with and without an antibiotic allergy (45.2% vs. 31.3%, p50.034). In contrast, there was no significant difference in VRE colonization between patients with and without an antibiotic allergy (12% vs. 47%, p50.10). CONCLUSIONS: An antibiotic allergy label was associated with significantly higher rates of MRSA colonization but not with VRE colonization

Review of Clinical Outcomes in Patients Treated with Beta-lactam vs Non-beta-lactam Therapy for AmpC Producing Bacterial Bloodstream Infections

Background AmpC beta-lactamase producing organisms are traditionally treated with carbapenem or fluoroquinolone antibiotics. Recent studies, however, describe similar clinical outcomes in patients that receive cefepime or piperacillin/tazobactam. We sought to assess outcomes in patients with bloodstream infections caused by AmpC-producing organisms that received beta-lactams compared non-beta-lactam therapy. Methods Data was obtained retrospectively from the electronic health record (EHR) from January 2012 to February 2020. The primary objective was 30-day mortality from the day of first positive blood cultures with Enterobacter spp., Citrobacter spp., or Serratia spp. in patients who received non-beta-lactam therapy (carbapenem, fluoroquinolone, trimethoprim/sulfamethoxazole) to those who received beta-lactam therapy (cefepime, piperacillin/tazobactam). Secondary objectives included 30-day recurrence of bacteremia, pathogen isolated, source of bacteremia, hospital length of stay, and duration of antimicrobial therapy. Results A total of 90 patients were included, 50 in the non-beta lactam group and 40 in the beta-lactam group. Demographics were similar between groups. Thirty-day mortality was significantly higher in the beta-lactam group (20% vs 2%, p=0.009). Enterobacter spp. was the most frequently identified pathogen (67%), most commonly isolated from a urinary (31%) or intra-abdominal source (22%). The average duration of antibiotic therapy was significantly higher in the non-beta lactam group (18 vs 12 days, p=0.001). In contrast, there was no significant difference found in hospital length of stay, recurrence of bacteremia, pathogen isolated or source of bacteremia between groups. Conclusion Beta-lactam therapy for the treatment of bloodstream infections caused by Amp-C producing organisms was associated with significantly greater 30-day mortality compared to patients that received non-beta-lactam therapy

Safety of Stopping Antibiotics Prescribed “Just in Case”: Comparison of Mortality, Readmissions and Clostridium difficile in Patients with Accepted Antimicrobial Stewardship Interventions versus Declined

Antibiotics are often prescribed “just in case” when clinical conditions mimic an infection, such as the shortness of breath in heart failure, the erythema of venous stasis or when bacterial culture results are misleading such as asymptomatic bacteriuria (ABU) and C difficile colonization. Through prospective audit and feedback (PAF), antimicrobial stewardship programs (ASP) may guide providers toward appropriate antibiotic use. However, the safety of stopping antibiotics needs to be assessed. We retrospectively reviewed the clinical outcomes of patients with accepted ASP recommendations and compared these to patients in whom the primary team declined ASP recommendations

Safety of Stopping Antibiotics Prescribed “Just in Case”: Comparison of Mortality, Readmissions and Clostridium difficile in Patients with Accepted Antimicrobial Stewardship Interventions versus Declined

Antibiotics are often prescribed “just in case” when clinical conditions mimic an infection, such as the shortness of breath in heart failure, the erythema of venous stasis or when bacterial culture results are misleading such as asymptomatic bacteriuria (ABU) and C difficile colonization. Through prospective audit and feedback (PAF), antimicrobial stewardship programs (ASP) may guide providers toward appropriate antibiotic use. However, the safety of stopping antibiotics needs to be assessed. We retrospectively reviewed the clinical outcomes of patients with accepted ASP recommendations and compared these to patients in whom the primary team declined ASP recommendations

Direct Challenges to Penicillin-Based Antibiotics in the Inpatient Setting

Background: Direct challenge (DC) is an emerging safe and effective alternative to penicillin skin testing (PST) in patients reporting a low-risk reaction history, but limited data exist for the inpatient setting. Objective: To demonstrate the safety and efficacy of DC of penicillin-based antibiotics in the inpatient setting in patients with low-risk, cutaneous-only reaction histories more than 20 years ago. Methods: Adult inpatients reporting penicillin allergy and receiving antibiotics were screened by an infectious disease PharmD for appropriateness for penicillin allergy delabeling. Patients with low-risk, cutaneous-only reaction histories (rash, hives, itching) more than 20 years ago were offered a 3-step DC. Patients with a cutaneous reaction history less than 20 years ago, a history of angioedema, or reactions involving multiple body systems underwent PST followed by a 1-time observed dose of amoxicillin. Results: A total of 372 patients were screened during the study period, with 100 of these patients undergoing further evaluation, 52 with histories appropriate for PST and 48 with histories appropriate for DC. In the PST group, 44 of 52 (84.6%) patients were PST negative. In the DC group, 47 of 48 (97.9%) patients initially tolerated the DC, with 2 of 48 (4.2%) experiencing a delayed reaction. The sole patient with an immediate DC reaction was treated with an antihistamine alone. Beta-lactam antibiotics were subsequently used in 56 of the 100 total patients. Total direct antibiotic savings was $23,375.27. DC was less costly than PST, at$206.18/patient versus $419.63/patient. Conclusions: DC is a safe, effective, and less expensive method for penicillin delabeling in adult inpatients with a low-risk, cutaneous-only reaction history more than 20 years ago