Impact of Comprehensive Education on Antibiotic Duration of Therapy for Community-Acquired Pneumonia in a Community Hospital.

Current guidelines for the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP) recommend 5 days of antimicrobial therapy. Despite these recommendations, the duration of therapy exceeds 5 days for up to 70% of patients, with most superfluous prescribing occurring upon discharge from hospital. Shortening the duration of antibiotic therapy could decrease adverse events, resistance, and costs. To determine whether a pharmacist-initiated modification to the duration of antibiotic therapy prescribed for the treatment of AECOPD or CAP reduced the duration of antibiotic prescriptions. In this prospective, single-centre study of adult inpatients receiving antibiotics for the treatment of AECOPD or CAP between October 2020 and March 2021, pharmacists assigned a 5-day duration to antimicrobials prescribed for these indications. For patients discharged before completion of therapy, the antibiotic start date and intended duration were included on the discharge prescription. Study patients were matched 1:1 with historical controls to compare the total duration of antibiotic therapy with and without the intervention. A total of 100 patients (66 with CAP and 34 with AECOPD) met the inclusion criteria and had their antibiotic treatment duration modified to 5 days. Mean total duration of antibiotic therapy was 5.31 days in the intervention group and 7.11 days in the control group (p < 0.001). Outpatient antibiotic prescribing was 0.86 days in the intervention group and 3.2 days in the control group (p < 0.001). In both groups, the rates of readmission at 30 and 90 days were 19% and 31%, respectively. Pharmacist-initiated modification of antimicrobial therapy resulted in shortening of the duration of therapy by almost 2 days. Including information about treatment duration on the discharge prescription reduced outpatient prescribing without affecting readmission rates.

Background Hospitals have implemented multifaceted approaches to quickly identify CAP, start timely therapy, and reduce hospital readmission, yet there has been minimal focus on providing appropriate duration of therapy. The IDSA CAP guidelines recommend 5 days of antibiotic therapy for patients that are clinically stable and quickly defervesce. However, previous publications suggest duration of therapy for CAP may be unnecessarily prolonged. Methods The objective of this multicenter, quasi-experimental study of hospitalized patients with CAP was to assess the impact of a prospective 6-month stewardship intervention on total duration of antibiotic therapy and associated clinical outcomes. All centers updated institutional CAP guidelines to promote IDSA-concordant durations of therapy and provided education to pharmacists and prescribers. Daily patient-specific prospective audit and feedback was provided by infectious diseases stewardship pharmacists to optimize compliance with guideline recommendations. Results A total of 600 patients were included (307 in the historic control group and 293 in the stewardship intervention group). The stewardship intervention led to significantly increased rates of compliance with IDSA duration of therapy recommendations (5.6% vs. 41.4%, P&amp;lt; &amp;lt; 0.01) and significantly reduced the duration of therapy for CAP (9 vs. 6 days, P &amp;lt; 0.01). Inappropriate days of antibiotic therapy was reduced in the intervention group (4 vs. 1.6 days, P &amp;lt; 0.01), and total avoidance of 720 excessive days of antibiotic therapy. Clinical outcomes, including mortality, length of hospitalization, readmission to hospital with pneumonia, presentation to the ER/clinic with pneumonia within 30 days of discharge, and incidence of C. difficilecolitis, were not different between groups. Conclusion This multicenter evaluation of a prospective stewardship intervention in hospitalized CAP patients reduced the total duration of antibiotic therapy and increased compliance with guideline-concordant duration of therapy without adversely affecting patient outcomes. This project was funded through a competitive stewardship grant provided by Merck &amp; Co. Disclosures A. Huang, Merck: Grant Investigator, Research grant; C. Nguyen, Merck: Grant Investigator, Research grant; J. Grieger, Merck: Grant Investigator, Research grant; S. Revolinski, Merck: Grant Investigator, Research grant; J. Li, Merck: Grant Investigator, Research grant; M. Mack, Merck: Grant Investigator, Research grant; J. N. Wainaina, Merck: Grant Investigator, Research grant; G. Eschenauer, Merck: Grant Investigator, Research grant; T. Patel, Merck: Grant Investigator, Research grant; V. Marshall, Merck: Grant Investigator, Research grant; J. Nagel, Merck: Grant Investigator, Research grant

PurposeAnticoagulant therapy for at least 3–6 months is currently recommended for treatment of venous thromboembolism (VTE) in patients with cancer, but the optimal duration of treatment is unknown. This study examines the association between the duration of anticoagulation treatment and VTE recurrence in cancer patients.MethodsThe Humana claims database was used to identify newly diagnosed cancer patients who had their first VTE diagnosis between January 1, 2013, and May 31, 2015, and initiated injectable or oral anticoagulant therapy. Follow-up was calculated from the index treatment initiation to the end of eligibility or end of data (June 2015). VTE recurrence was defined as a hospitalization with a primary diagnosis of VTE. Cox proportional hazards models were used to evaluate the risk of VTE recurrence by duration of therapy in patients who discontinued therapy.ResultsThe study included 1158 patients. Compared to patients treated for 0 to 3 months, VTE recurrences were significantly lower among patients treated for 3 to 6, or over 6 months. After adjustment for baseline characteristics, patients treated for 3 to 6 months (HR [95%CI], 0.53; 0.37–0.76) and more than 6 months (HR [95%CI], 0.48; 0.34–0.68) were still significantly less likely to have VTE recurrences compared to patients treated for 0 to 3 months (both p < 0.01). Findings were similar using a VTE event definition that included outpatient visits.ConclusionsAmong newly diagnosed cancer patients with VTE, anticoagulant therapy lasting more than 3 months was associated with a lower risk of VTE recurrence.

BackgroundOne of the main roles of the SSM Health WI Regional Antimicrobial Stewardship Program is to create infection treatment pathways based on the Infectious Diseases Society of America (IDSA) practice guidelines. Treatment pathways are used to guide provider prescribing of antimicrobials for disease states such as community-acquired pneumonia (CAP). The objective of this study was to evaluate the safety and effectiveness of a non-severe CAP pharmacist pathway based on the updated IDSA and American Thoracic Society 2019 CAP practice guideline.MethodsA retrospective chart review was performed on all patients placed on the non-severe CAP pharmacist pathway at SSM Health St. Mary’s Hospital in Madison, WI from September 2020 through April 2021. Patients who initially started on the pathway were removed if they met prespecified criteria (Table 1). The primary outcome in this study was 30-day respiratory-related readmission rate. Secondary outcomes included average total length of antibiotic therapy, pharmacist interventions [intravenous (IV) to oral (PO) conversion, antibiotic de-escalation (including discontinuation of azithromycin with negative legionella urinary antigen), duration of therapy], and 30-day all-cause readmission rate. Table 1. Criteria for Removal from the PathwayFigure 1. Pharmacist InterventionsResultsA total of 119 patients were initiated on the non-severe CAP pharmacist pathway, of which 47 patients (40%) completed the pathway and 72 patients (60%) were removed from the pathway. Of the 47 patients who completed the pathway, there were no respiratory-related readmissions with a 30-day all-cause readmission rate of 6.4% (N=3/47). The average total duration of beta-lactam therapy was 6.8 days and the average total duration of macrolide therapy was 1 day due to de-escalation with a negative legionella urinary antigen result. A total of 61 pharmacist-driven interventions were completed [IV to PO conversion (N=15), de-escalation (N=27), and duration of therapy (N=19)]. Table 2. Summary of ResultsConclusionThe findings of this study suggest that implementation of a non-severe CAP pharmacist pathway is safe and effective. No readmissions were related to non-severe CAP management and pharmacists completed guideline-driven interventions related to antimicrobial de-escalation, IV to PO conversion, and duration of therapy. DisclosuresAll Authors: No reported disclosures

BackgroundCommunity-Acquired Pneumonia (CAP) is associated with substantial antibiotic use and potential for overprescribing. Previous studies have demonstrated a reduction in antimicrobial exposure following implementation of provider-driven antimicrobial time-outs (ATOs). ATOs prompt assessment of appropriateness of therapy, clinical response, and duration of therapy. In January 2018, OSF Healthcare System implemented a 48-hour pharmacy-driven ATO in the electronic health record. The purpose of this study was to determine if the implementation of the ATO decreased the duration of antibiotic therapy for CAP at a community hospital.MethodsThis was a retrospective chart review of adults hospitalized with CAP at OSF Saint Anthony Medical Center between May 2016 - October 2017 (pre-implementation; PRE) and April 2018 - September 2019 (post-implementation; POST). The primary outcome was total duration of antibiotic therapy between hospitalization and discharge prescriptions. Secondary outcomes included hospital length of stay (LOS), duration of IV therapy, and rates of treatment failure, relapse, and antibiotic-associated adverse events.ResultsA total of 808 patient charts were reviewed with 155 patients meeting inclusion criteria in both study groups. The mean duration of antibiotic therapy was reduced by 2.14 days (PRE 10.51 days vs. POST 8.37 days; P< 0.001). Duration of IV therapy (3.86% vs. 3.21%; P< 0.001) and 30-day emergency department visit rate (16.13% vs. 3.23%; P< 0.001) were also significantly reduced. Differences in LOS (4.60 days vs. 4.45 days; P=0.279) and 30-day readmission rate (9.03% vs. 4.52%; P=0.114) did not meet statistical significance. Antibiotic-associated diarrhea (28.39% vs. 17.42%; P=0.022) and acute kidney injury (17.42% vs. 6.45%; P=0.003) were significantly reduced while C. difficile infection (2.58% vs. 0.65%; P=0.371) and treatment failure (3.22% vs. 1.94%; P=0.723) only trended downward.ConclusionImplementation of the pharmacy-driven ATO was associated with reduced duration of antibiotic therapy in patients hospitalized with CAP, though total durations still exceeded evidence-based recommendations. The ATO maintained the efficacy of treatment and reduced treatment-associated adverse effects, such as diarrhea and AKI.DisclosuresAll Authors: No reported disclosures

Recent guidelines suggest that duration of antibiotic therapy for hospitalized patients with community-acquired pneumonia (CAP) can be reduced by individualising treatment based on patient's clinical response. However, the degree of application of this principle in clinical practice is unknown. Duration of therapy was analysed in patients identified from the Community-Acquired Pneumonia Organization database and evaluated with respect to severity of the disease on admission and time to clinical stability (TCS). Among the 2,003 patients enrolled, mean duration of total antibiotic therapy was 11 days. Neither the pneumonia severity index (r(2) = 0.005) nor the CRB-65 (r(2) = 0.004) scores were related to total duration of therapy. Duration of intravenous antibiotic therapy was related to TCS (r(2) = 0.198). Conversely, TCS was not related to duration of either oral (r(2) = 0.014) or total (r(2) = 0.02) antibiotic therapy. Neither TCS nor other characteristics were found to be significantly associated with duration of total therapy by logistic regression analysis (r(2)<0.09). The individualised approach suggested by recent guidelines has not been adopted in current clinical practice. Duration of therapy is not influenced by either the severity of disease at the time of hospitalisation or the clinical response to therapy.

Recent guidelines suggest that duration of antibiotic therapy for hospitalized patients with community-acquired pneumonia (CAP) can be reduced by individualising treatment based on patient9s clinical response. However, the degree of...

Background: Recent literature demonstrated a 24-hour reduction in vancomycin duration of therapy (DOT) for skin and soft tissue infections (SSTIs) with a negative methicillin-resistant staphylococcus aureus (MRSA) nasal screening versus a positive nasal screening. Objective of this study was to investigate vancomycin DOT in patients with SSTIs who received MRSA nasal polymerase chain reaction (PCR) screening versus those who did not receive MRSA nasal PCR screening. Methods: A retrospective, multi-center, cohort study was completed in admitted adult patients on vancomycin for SSTI from 01/01/2020 to 09/30/2022. Hospital policy permits any clinician to order a MRSA nasal PCR screening test for various indications, including SSTIs, pneumonia and sepsis. Results: One-hundred-fifty-one patients were included, of which 71 had MRSA nasal PCR screening tests obtained, and 80 did not. The median vancomycin DOT in patients with MRSA nasal PCR screening tests was 19.9 versus 36.7 hours (P = .014) in patients without screening tests. Conclusion: Patients with SSTIs who receive MRSA nasal PCR screening tests have a shortened vancomycin DOT. These results contribute to current data in support of the efficacy and clinical utility of obtaining MRSA nasal PCR screening tests for SSTIs.

Despite a large volume of evidence supporting the use of dual antiplatelet therapy in patients with acute coronary syndrome, there remains major uncertainty regarding the optimal duration of therapy. Clinical...

Urinary tract infections (UTIs) are one of the most common infections encountered in ambulatory care and inpatient settings. Although these infections are common, not all patients are prescribed an appropriate antibiotic or duration of therapy. The primary objective of this analysis was to evaluate the appropriateness of antibiotic selection and duration of therapy for patients in an adult internal medicine clinic diagnosed as having a UTI. We conducted a retrospective chart review (July 1, 2012-June 30, 2013) of adult patients in an internal medicine clinic who were diagnosed as having a UTI. Pediatric and pregnant patients were excluded from the analysis. Data pertaining to the classification of UTI, antibiotic regimen, urine culture, and renal function were collected. All of the data were analyzed to determine whether the prescribing habits at the internal medicine clinic aligned with Infectious Diseases Society of America (IDSA) guidelines for antibiotic selection and duration of therapy for acute uncomplicated cystitis, complicated cystitis, catheter-associated UTI, and pyelonephritis. There were 269 records available for the analysis, with the majority of the cases being uncomplicated and complicated UTIs. Of 128 cases of patients with uncomplicated UTIs and 116 cases of patients with complicated UTIs, 64.1% and 42.2%, respectively, were prescribed appropriate first- or second-line therapy, which aligned with the recommendations of the IDSA. Regarding the individual components of the UTI treatment regimen, antibiotic selection had the highest frequency of appropriateness, with 97.6% of uncomplicated UTI cases and 90.5% of complicated UTI cases having been treated with a recommended antibiotic. In contrast, the treatment duration for uncomplicated and complicated UTIs had the lowest frequency of appropriateness, at 71.9% and 58.6%, respectively. Receiving an adequate antibiotic regimen for a UTI is important to prevent treatment failure and the emergence of resistant organisms. Overall, the studied antibiotic regimens prescribed for various UTIs diagnosed in the clinic did not align with the IDSA recommendations.

Background In an ideal state, the stewardship of antimicrobial agents would happen at the point of order entry. In June 2018, Eskenazi Health implemented a series of clinical decision support tools in the electronic health record (EHR), including required fields on all inpatient antimicrobial orders for indication, type of therapy (empiric or definitive), and duration. When empiric therapy is selected, providers receive a Best Practice Advisory (BPA) at 48 hours to re-evaluate therapy. Additionally, a side bar table was added to all antimicrobials orders that included drug-specific duration of therapy recommendations for common indications. Methods This is a single-center, retrospective, observational chart review that includes adult inpatients prescribed antibiotics for the treatment of CAP or UTI from July 2017 to December 2018. The primary outcome is the overall length of therapy between pre- and post-intervention groups for CAP and UTI. Secondary outcomes include duration of empiric/broad-spectrum therapy, duration of definitive therapy, time to de-escalation, length of hospital stay, C. difficile infections, 30-day readmission, and cost of antimicrobial therapy. Results A total of 541 orders were included for analysis. The composite overall duration of therapy decreased from 7 days to 5 days in the post-intervention group (p&amp;lt; 0.001). For CAP, the duration of therapy (5 days) was not different between groups. For UTI, the duration of therapy decreased from 11 days to 7 days in the post-intervention group (p&amp;lt; 0.001). The duration of empiric therapy decreased from 3 days to 2 days (p&amp;lt; 0.001) and the duration of definitive therapy decreased from 4 days to 3 days (p&amp;lt; 0.001). There was a 1 day longer length of stay for patients in the post-intervention group (p=0.038); however, there was a lower 30-day readmission rate in the post-intervention group (p=0.003). The rate of hospital-acquired C. difficile infections did not differ between groups (p=1.000). It was found that action was taken from the BPA 55.4% of the time after implementation. Conclusion The duration of therapy overall was shortened by 2 days, which was driven by the difference in duration for UTI. Incorporating antimicrobial stewardship principles at the point of order entry can result in fewer days of unnecessary therapy. Disclosures All Authors: No reported disclosures.

BackgroundExcess durations of anti-infective therapy are a common problem that may lead to unintended consequences. Antimicrobial stewardship (AMS) is a growing field that largely focuses on inpatient anti-infective use. For this study, one site was an academic medical center whose AMS uses prospective auditing; the other was a community hospital with pharmacy-driven AMS. Little research has examined durations of anti-infective therapy at hospital discharge.MethodsPatient charts were reviewed and 284 were included in the final analysis. Patients were excluded if discharged on non-oral anti-infectives or only agents for a non-study indication. Patients were included if they were discharged on oral anti-infective therapy for CAP, healthcare-associated pneumonia (HCAP), UTI, cellulitis, and superficial abscess. Evidence-based durations of therapy were utilized to determine the potential inappropriateness of anti-infective therapy. Guidelines from the study period were used. Total duration of therapy was derived from the combination of outpatient therapy plus inpatient therapy beginning with the first day of relevant coverage for the given indication. Descriptive statistics were utilized to compare durations of therapy. Chi-squared tests were utilized to examine differences in expected frequencies. All statistics were performed in SPSS v. 24.ResultsThe average combined duration of therapy was 11.3 days. 190 patients (66.9%) were found to have a potentially inappropriate duration of oral anti-infective therapy at hospital discharge. Only 2 durations were too short. Figure 1 displays the distribution of excess days of therapy. Figure 2 shows the breakdown of potential inappropriateness of duration by diagnosis. Figure 3 displays the percentage of potentially inappropriate cases by site. There were no significant differences in the primary outcome between the sites.ConclusionCAP and cellulitis appear to be areas that are often overtreated. Discharge durations of therapy should be a focus of AMS teams. Many patients receive potentially inappropriate durations of therapy at discharge without any discernible benefit. Further research is needed in this area.DisclosuresAll authors: No reported disclosures.

Antibiotics are often prescribed for hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations. The use of procalcitonin (PCT) in the management of pneumonia has safely reduced antibiotic durations, but limited data on the impact of PCT guidance on the management of COPD exacerbations remain. To determine the impact of PCT guidance on antibiotic utilization for hospitalized adults with exacerbations of COPD. A retrospective, pre-/post-intervention cohort study was conducted to compare the management of patients admitted with COPD exacerbations before and after implementation of PCT guidance. The pre-intervention period was March 1, 2014, through October 31, 2014, and the post-intervention period was March 1, 2015, through October 31, 2015. All patients with hospital admissions during the pre- and post-intervention period with COPD exacerbations were included. Patients with concomitant pneumonia were excluded. Availability of PCT laboratory values in tandem with a PCT guidance algorithm and education. The primary outcome was duration of antibiotic therapy for COPD. Secondary objectives included duration of inpatient length of stay (LOS) and 30-day readmission rates. There were a total of 166 and 139 patients in the pre- and post-intervention cohorts, respectively. There were no differences in mean age (66.2 vs. 65.9; P = 0.82) or use of home oxygenation (34% vs. 39%; P = 0.42) in the pre- and post-intervention groups, respectively. PCT guidance was associated with a reduced number of antibiotic days (5.3 vs. 3.0; p = 0.01) and inpatient LOS (4.1days vs. 2.9days; P = 0.01). Respiratory-related 30-day readmission rates were unaffected (10.8% vs. 9.4%; P = 0.25). Utilizing PCT guidance in the management of COPD exacerbations was associated with a decreased total duration of antibiotic therapy and hospital LOS without negatively impacting hospital readmissions.

BackgroundCommunity acquired pneumonia (CAP) is a significant cause of morbidity and antibiotic overutilization among pediatric patients. The 2011 Infectious Diseases Society of America (IDSA) guidelines recommend a treatment duration of 10 days for pediatric CAP but recognize that shorter courses may be appropriate in certain settings. In February 2022, based on newer literature and extrapolations from the adult population, Michigan Medicine updated its institutional guidelines to recommend an antibiotic duration of 5 days to treat uncomplicated CAP in hospitalized pediatric patients. However, there remains limited evidence to support a shorter duration of therapy for patients admitted to the pediatric intensive care unit (PICU).Baseline characteristics of patients treated for uncomplicated CAP in the PICU at Michigan Medicine from November 2020 to December 2023MethodsThis was a single-center, retrospective cohort study of patients aged 6 months to 17 years old with CAP who were admitted to the PICU at Michigan Medicine from November 2020 to December 2023. Patients with complicated CAP, hospital acquired or ventilator associated pneumonia, cystic fibrosis, severe neutropenia, solid organ or stem cell transplant, tracheostomy dependence, sickle cell disease, or suspicion for fungal infection were excluded from the study. The primary outcome was treatment failure, defined as a composite of readmission, emergency department or outpatient visit, need for antibiotic retreatment, or death attributable to CAP within 30 days of completing antibiotic therapy.Clinical outcomes of patients treated for uncomplicated CAP in the PICU at Michigan Medicine before and after the institutional guideline updateResultsA total of 128 patients met eligibility criteria; 59 (46%) patients were treated before the guideline update and 69 (54%) were treated after the guideline update. The median antibiotic treatment duration was 7.71 days in the pre-guideline update group and 5.58 days in the post-guideline update group (P < 0.001). Three patients in the pre-guideline update group and five patients in the post-guideline update group experienced 30-day treatment failure, which was not a statistically significant difference (P = 0.615). There was no difference in the median hospital length of stay between groups.ConclusionThis study demonstrated that a shorter course of antibiotic therapy did not increase the rate of treatment failure compared to a standard course of therapy for patients admitted to the PICU with uncomplicated CAP.DisclosuresAll Authors: No reported disclosures

Background and ImportanceCommunity-acquired pneumonia (CAP) is still one of the leading causes of death worldwide. In our previous studies, the guideline adherence to national and international CAP guidelines in terms...