Appropriateness of Vancomycin Use and Associated Outcomes

Background: Several studies have documented increased rates of MRSA associated with adverse patient outcomes. Vancomycin remains the primary treatment of choice and use of vancomycin in hospitalized settings is increasing. Inappropriate vancomycin has been shown to lead to the development of vancomycin resistant organisms. Guidelines developed by IDSA have been used to promote appropriate use of vancomycin. However, inappropriate use of vancomycin remains high and its association with patient outcomes has not been well examined. The objective of this study was to examine appropriateness of vancomycin use and associated outcomes based on IDSA guidelines. Methods: A retrospective observational study of patients ≥18 years old who had received one dose of intravenous vancomycin in January 2019 was conducted at the University of Nebraska Medical Center. Appropriateness of vancomycin use was evaluated with criteria established through IDSA guidelines. Vancomycin use was considered appropriate in serious infections due to beta-lactam resistant gram-positive organisms, treatment of infections in the setting of beta-lactam allergy, surgical prophylaxis in patients allergic to beta-lactam antibiotics and empiric treatment for serious infections such as septic shock, bacteremia and infective endocarditis, healthcare-associated pneumonia, osteomyelitis and septic arthritis and central nervous system infections. De-escalation of vancomycin after 72 hours was considered appropriate when used empirically. Any deviation from criteria was deemed inappropriate. Variables reviewed included age, gender, length of stay, mortality, intensive care unit (ICU) admission, and length of vancomycin use. Data is expressed as percentage for nominal variables and as mean with standard deviation for continuous variables. Age, gender, mortality and ICU admission were further analyzed by chi-square tests. Length of stay and vancomycin use days were analyzed using unpaired t-test. A P-value \u3c 0.05 was considered significant for the study. Results: A total of 595 encounters of vancomycin use were included in the study. Overall, 38.2% of all patients were admitted to the ICU, and hospital mortality was 9.24%. Vancomycin use was shown to be inappropriate in 34.3% of all patient encounters. Slightly higher mortality was noted in the appropriate group, but it was not found to be statistically significant (10.74% in appropriate group vs. 6.37% in inappropriate vancomycin use group; p = 0.10). Mean length of stay in patients between the two groups was not found to be statistically significant (12.60 ± 18.23 days for appropriate group vs. 14.01 ± 21.64 days for inappropriate group; p = 0.40). Significantly higher ICU admission was found for the appropriate group (41.43% in appropriate group vs. 32.35% in the inappropriate group, p = 0.0001). The most common indication for appropriate use of vancomycin was for empiric treatment (47.6%), while surgical prophylaxis in the absence of beta-lactam allergy was the most common indication for the inappropriate vancomycin use group (41.7%). Conclusion: The study reveals that there was inappropriate use in about one-third of all vancomycin use encounters. The study also found some outcomes such as ICU admission to be statistically significant between the two groups. The study identified common indications for inappropriate use to target further interventions.https://digitalcommons.unmc.edu/surp2022/1033/thumbnail.jp

Improving Antimicrobial Stewardship Programs in Small Community Hospitals Through an Assessment and Feedback Model

Small community hospitals often lack expertise and resources for antimicrobial stewardship program implementation. Using an assessment-and-feedback model, Nebraska ASAP performed onsite assessment of antimicrobial stewardship efforts in 5 small community hospitals and provided facility specific feedback on implementation/augmentation of antimicrobial stewardship program. As a result of this model, participating small community hospitals were able to increase the number of antimicrobial stewardship core elements implemented while reducing antibiotic use and incidence of CDI.https://digitalcommons.unmc.edu/asap_pres/1001/thumbnail.jp

Utility of Repeat Testing for COVID-19: Laboratory Stewardship When the Stakes are High

As the coronavirus disease 2019 (COVID-19) continues to circulate, testing strategies are of the utmost importance. Given national shortages of testing supplies, personal protective equipment, and other hospital resources, diagnostic stewardship is necessary to aid in resource management. We report the low utility of serial testing in a low-prevalence setting

Frequently Identified Gaps in Antibiotic Stewardship Programs in Critical Access Hospitals

Background: Nebraska (NE) Infection Control Assessment and Promotion Program (ICAP) is a CDC funded project. ICAP team works in collaboration with NE Department of Health and Human Services (NEDHHS) to assess and improve infection prevention and control programs (IPCP) in various health care settings including resource limited settings like critical access hospitals (CAH). Little is known about the existing gaps in antimicrobial stewardship programs (ASP) of CAH. Hence, we decided to study the current level of ASP activities and factors associated with these activities in CAH. Methods: NE ICAP conducted on-site surveys in 36 CAH from October 2015 to February 2017. ASP activities related to the 7 CDC recommended core elements (CE) including leadership support (LS), accountability, drug expertise (DE), action, tracking, reporting, and education were assessed using a CDC Infection Control Assessment Tool for acute care hospitals. Descriptive analyses evaluated CAH characteristics and frequency of CE implementation. Fisher’s exact, Mann–Whitney, and Kruskal–Wallis tests were used for statistical analyses examining the association of various factors with level of ASP activities. Results: The 36 surveyed CAH had a median of 20 (range 10–25) beds and employed a median of 0.4 (range 0.1–1.6) infection preventionist (IP) full-time equivalent (FTE)/25-bed. Frequency of CE implementation varied among CAH with action and LS as the most (69%) and least (28%) frequently implemented elements, respectively. Close to half (47%) of surveyed CAH had implemented ≥4 CE but only 14% of facilities had all 7 CE. Median bed size and IP FTE/25-bed were similar among CAH with 0–2, 3-5, or ≥6 CE in place. CAH with LS or accountability for ASP implemented higher median numbers of the remaining CE compared with CAH without LS or accountability (5 vs. 2, P \u3c 0.01 and 4 vs. 2, P \u3c 0.01, respectively). Facilities with The presence of LS, accountability and drug expertise were more likely to have all 4 remaining CE implemented than others (56% vs. 8%, P \u3c 0.01). Conclusion: LS, accountability, and DE are important factors for the implementation of the remaining 4 CE in CAH. Although LS was the least frequently implemented CE, when present was associated with implementation of most of the other CE. Acquiring LS will facilitate implementation of additional ASP efforts in CAH.https://digitalcommons.unmc.edu/asap_pres/1000/thumbnail.jp

Use of a beta-lactam graded challenge process for inpatients with self-reported penicillin allergies at an academic medical center

BackgroundThe Antimicrobial Stewardship Program (ASP) at Nebraska Medicine collaborated with a board-certified allergist to develop a penicillin allergy guidance document for treating inpatients with self-reported allergy. This guidance contains an algorithm for evaluating and safely challenging penicillin-allergic patients with beta-lactams without inpatient allergy consults being available.MethodsFollowing multi-disciplinary review, an order set for beta-lactam graded challenges (GC) was implemented in 2018. This contains recommended monitoring and detailed medication orders to challenge patients with various beta-lactam agents. Inpatient orders for GC from 3/2018–6/2022 were retrospectively reviewed to evaluate ordering characteristics, outcomes of the challenge, and whether documentation of the allergy history was updated. All beta-lactam challenges administered to inpatients were included, and descriptive statistics were performed.ResultsOverall, 157 GC were administered; 13 with oral amoxicillin and 144 with intravenous (IV) beta-lactams. Ceftriaxone accounted for the most challenges (43%). All oral challenges were recommended by an Infectious Diseases consult service, as were a majority of IV challenges (60%). Less than one in five were administered in an ICU (19%). Almost all (n = 150, 96%) were tolerated without any adverse event. There was one reaction (1%) of hives and six (4%) involving a rash, none of which had persistent effects. Allergy information was updated in the electronic health record after 92% of the challenges.ConclusionBoth intravenous and oral beta-lactam graded challenges were implemented successfully in a hospital without a regular inpatient allergy consult service. They were well-tolerated, administered primarily in non-ICU settings, and were often ordered by non-specialist services. In patients with a self-reported penicillin allergy, these results demonstrate the utility and safety of a broadly adopted beta-lactam GC process

Evaluation of the Infectious Diseases Society of America’s Core Antimicrobial Stewardship Curriculum for Infectious Diseases Fellows

Background Antimicrobial stewardship (AS) programs are required by Centers for Medicare and Medicaid Services and should ideally have infectious diseases (ID) physician involvement; however, only 50% of ID fellowship programs have formal AS curricula. The Infectious Diseases Society of America (IDSA) formed a workgroup to develop a core AS curriculum for ID fellows. Here we study its impact. Methods ID program directors and fellows in 56 fellowship programs were surveyed regarding the content and effectiveness of their AS training before and after implementation of the IDSA curriculum. Fellows’ knowledge was assessed using multiple-choice questions. Fellows completing their first year of fellowship were surveyed before curriculum implementation (“pre-curriculum”) and compared to first-year fellows who complete the curriculum the following year (“post-curriculum”). Results Forty-nine (88%) program directors and 105 (67%) fellows completed the pre-curriculum surveys; 35 (64%) program directors and 79 (50%) fellows completed the post-curriculum surveys. Prior to IDSA curriculum implementation, only 51% of programs had a “formal” curriculum. After implementation, satisfaction with AS training increased among program directors (16% to 68%) and fellows (51% to 68%). Fellows’ confidence increased in 7/10 AS content areas. Knowledge scores improved from a mean of 4.6 to 5.1 correct answers of 9 questions (P = .028). The major hurdle to curriculum implementation was time, both for formal teaching and for e-learning. Conclusions Effective AS training is a critical component of ID fellowship training. The IDSA Core AS Curriculum can enhance AS training, increase fellow confidence, and improve overall satisfaction of fellows and program directors

Evaluation of cerebrospinal fluid white blood cell count criteria for use of the BioFire® FilmArray® Meningitis/Encephalitis Panel in immunocompromised and nonimmunocompromised patients.

We implemented the BioFire® FilmArray® Meningitis/Encephalitis Panel (MEP) with guidance for use based on patient age, cerebrospinal fluid (CSF) white blood cell (WBC) count and immune system status. MEPs results over 2 years (1/1/2017 to 12/31/18) were reviewed and clinical significance of positive MEP results in patients with CSF WBC ≤ 10 evaluated. Overall, 12% (51/453) of MEPs were positive with 4/184 (2%) positive in nonimmunocompromised (non-IC) with ≤ 10 CSF WBCs. Among positive results in non-IC patient with ≤10 CSF WBCs, none were judged clinically significant. Four of 6 results in immunocompromised patients with ≤10 CSF WBCs were clinically significant. Redundant testing was common and guideline adherence could have safely decreased MEPs use 41% saving \u3e$56,000. Guideline adherence was poor and MEP use can be safely avoided in non-IC adults withWBC, but clinically significant results did occur in IC patients with low CSF WBC. Clinical decision support could reduce unneeded testing and result in significant cost savings