Antimicrobial Stewardship Program Pharmacist Research Articles

1257. The Impact of Communication Type on Acceptance Rates of Antimicrobial Stewardship Interventions

Abstract Background While face-to-face communication (ie. “handshake stewardship” (HS)) has been shown to improve antimicrobial stewardship program (ASP) intervention acceptance rates, this strategy is resource intensive. Therefore, systems unable to conduct HS must identify the optimal mode of communication for ASP recommendations. This study evaluated the effects of communication type on ASP intervention acceptance. Methods An infectious disease physician and ASP pharmacist met Monday through Friday to assess appropriateness of select antimicrobials. ASP recommendations were delivered through direct communication via telephone conversations or passive communication via text-page. A text page consisted of a message limited to 240 characters sent directly to the primary team. We performed a retrospective review of all interventions and associated acceptance rates, antimicrobials and antimicrobial indications between January 1st, 2023 to March 31st, 2023. The primary outcome evaluated was ASP intervention acceptance rate. Results Recommendations were delivered through telephone conversations in 267/454 (58.8%) cases compared to 187/454 (41.2%) cases in which recommendations were provided via text-page. We found that direct communication delivered telephonically resulted in a significant increase in ASP intervention acceptance rate compared to passive communication via text page (82.8% vs 73.8%, respectively; p=0.02). This resulted in 884 and 552 days of antimicrobial therapy saved in the telephonic and text-page group, respectively (p=0.64). Significant differences in baseline characteristics included: antimicrobial indications of intraabdominal, respiratory, sepsis and febrile neutropenia; having a broad differential; and an intervention category of de-escalation. Conclusion Direct communication with clinicians (eg. telephonically) improves ASP intervention acceptance rates compared to passive communication styles (eg. text-page). Direct communication with the prescriber encourages shared decision making, increases visibility of ASP, and allows for education to modify prescribing behavior. The success of an ASP relies heavily on provider relationships, which direct communication can further promote. Disclosures All Authors: No reported disclosures

SIGNIFICANT REDUCTION IN CARBAPENEM AND FLUOROQUINOLONE USE WITH IMPLEMENTATION OF MULTIFACETED ANTIBIOTIC STEWARDSHIP PROGRAM (ASP) INTERVENTIONS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: To study the impact of antimicrobial stewardship program (ASP) interventions on carbapenem and fluoroquinolone (FQ) use at our tertiary care center. METHODS: A multifaceted antimicrobial stewardship program (ASP) was implemented in July 2018 at a 160-bed tertiary care center serving the tristate area of Iowa, South Dakota and Nebraska. Carbapenem and FQ use during pre-ASP intervention period (P1: 12/01/2016-6/30/2018) was compared with ASP-intervention period (P2: 07/01/2018-1/31/2020). ASP interventions included: stewardship educational pearls in monthly physician newsletters; educational posters in high-traffic provider areas; suppression of carbapenem results on microbiology susceptibility reports; distributing monthly carbapenem and FQ use data to providers; provider counseling for appropriate ordering; creating carbapenem alternative alert in order-entry software; generating pharmacy decision-support software algorithms to aid in identifying intervention opportunities; removing FQ from HAP/VAP ordersets and carbapenems from order-sets where appropriate; default antibiotic stop dates changed to 7 days in EMR (Epic); adverse effects warning fired as an alert when ordering FQ. Additional ASP pharmacist interventions included procalcitonin protocol allowing pharmacists to reorder follow-up procalcitonin and make recommendations to discontinue therapy where appropriate. RESULTS: Carbapenem use declined significantly from a mean of 64.81 days of therapy (DOT) per 1000 patient days during P1 to 8.91 DOT per 1000 patient days in P2 (p< 0.001). FQ use declined from a mean of 133 DOT per 1000 days in P1 to 46 DOT per 1000 patient days (p< 0.0001) during P2. All hospital units showed a significant decrease in carbapenem and FQ use, with intensive care step-down unit noting 85.7% reduction (p< 0.00001) and intensive care units (ICUs, medical and surgical) noting 52% reduction (p< 0.00001) during P2 compared to P1. During P2, 55% of orders for carbapenems and FQ were found to be appropriate compared to only 39% in P1 (p< 0.0001). Sensitivity profile for Pseudomonas aeruginosa improved from 86% carbapenem sensitivity during P1 to 89% in P2. No Carbapenem-Resistant Enterobacteriaceae isolates were identified during the study period. FQ sensitivity remained stable at 81%. Cost savings of $757 per 1000 patient days were recognized during P2 as a result of reduced carbapenem and FQ use. CONCLUSIONS: A significant decline in total carbapenem and FQ utilization with ICUs showing >50% decline, an increase in proportion of appropriate use as well as cost savings were observed as a result of ASP interventions. CLINICAL IMPLICATIONS: According to the CDC, carbapenems and fluoroquinolones should be key targets for stewardship programs and reducing inappropriate antibiotic use is imperative to preventing emergence of multidrug resistance and potentially improving bacterial antimicrobial susceptibility patterns. With our multifaceted ASP interventions, we demonstrated a significant decrease in the utilization of these two classes of broad-spectrum antibiotics, notably in the intensive care step-down unit and the ICUs. We also noted significant increase in appropriate use; improved carbapenem sensitivity profile for Pseudomonas aeruginosa as well as considerable cost savings. DISCLOSURES: No relevant relationships by Sandeep Gupta, source=Web Response No relevant relationships by Ashlesha Kaushik, source=Web Response No relevant relationships by Michael Padomek, source=Web Response No relevant relationships by Corey Thieman, source=Web Response

187. Significant Decline in Carbapenem Use with Multifaceted Antimicrobial Stewardship Program (ASP) Interventions

BackgroundPer World Health Organization, carbapenems should be key targets for antibiotic stewardship programs.MethodsA multifaceted antimicrobial stewardship program (ASP) was implemented in January 2018 at a 160-bed tertiary care center serving the tristate area of Iowa, South Dakota and Nebraska. Carbapenem use during pre ASP intervention period (P1: 07/01/2016-12/31/2017) was compared with ASP intervention period (P2: 01/01/2018-06/30/2019). ASP interventions included: providing educational pearls in monthly physician newsletter; educational posters in high-traffic provider areas; suppression of carbapenem results on microbiology susceptibility reports; distributing monthly carbapenem use data to providers; provider counseling for appropriate ordering; creating carbapenem alternative alert in order-entry software; generating pharmacy decision-support software algorithms to aid in identifying intervention opportunities; removing carbapenems from order-sets where appropriate. Additional ASP pharmacist interventions: limiting double antibiotic coverage for pseudomonas/anaerobes; de-escalation recommendations.ResultsCarbapenem use declined significantly from a mean of 64.81 days of therapy (DOT) per 1000 patient days during P1 to 8.91 DOT per 1000 patient days in P2 (p< 0.001). All hospital units showed a significant decrease in carbapenem use, with intensive care step-down unit noting 85.7% reduction (p < 0.00001); floors (medicine, pediatric, surgery) with 61.6% reduction (p< 0.00001); and intensive care units with 52% reduction (p< 0.00001) during P2 compared to P1. Defined daily doses per 1000 patient days decreased from 314.9 in P1 to 93.4 in P2 (p< 0.00001). During P2, 58.3% (132/228) of carbapenem orders were found to be appropriate compared to 37.5% (190/506) in P1 (p< 0.00001). Sensitivity profile for Pseudomonas aeruginosa improved from 86% carbapenem sensitivity during P1 to 89% in P2. No Carbapenem Resistant Enterobacteriaceae isolates were identified. Cost savings of $643 per 1000 patient days were recognized in P2 as a result of reduced carbapenem use.ConclusionThere was a significant decline in total carbapenem utilization, an increase in proportion of appropriate use and considerable cost savings as a result of ASP interventions.Disclosures All Authors: No reported disclosures

Outcomes of an ambulatory care pharmacist-led antimicrobial stewardship program within a family medicine resident clinic.

To determine whether an ambulatory care pharmacist (AMCP)-led intervention improved outpatient antibiotic prescribing in a family medicine residency clinic (FMRC) for upper respiratory tract infections (URIs), urinary tract infections (UTIs), and skin and soft-tissue infections (SSTIs). Retrospective, quasi-experimental study comparing guideline-concordant antibiotic prescribing before and after an antimicrobial stewardship program (ASP) intervention. Family medicine residency clinic affiliated with a community teaching hospital. Adult and pediatric patients prescribed antibiotics for URI, UTI, or SSTI between November 1, 2017, and April 31, 2018 (pre-ASP group), or October 1, 2018, and March 31, 2019 (ASP group), were eligible for inclusion. The health-system ASP physician and pharmacist provided live education and pocket cards to FMRC staff with local guidelines as a quick reference. Audit with feedback was delivered every other week by the clinic's AMCP. Guideline-concordance was determined based on the institution's outpatient ASP guidelines. Overall, 525 antibiotic prescriptions were audited (pre-ASP n = 90 and ASP n = 435). Total guideline-concordant antibiotic prescribing at baseline was 38.9% (URI, 53.3%; SSTI, 16.7%; UTI, 46.7%) and improved across all 3 infection types to 57.9% (URI, 61.2%; SSTI, 57.6%; UTI, 53.5%; P = .001). Significant improvements were seen in guideline-concordant antibiotic selection (68.9% vs 80.2%; P = .018), dose (76.7% vs 86.2%; P = .023), and duration of therapy (73.3% vs 86.2%; P = .02). An AMCP-led outpatient ASP intervention significantly improved guideline-concordant antibiotic prescribing for common infections within a FMRC.

Impact of an Antimicrobial Stewardship Program Pharmacist During Microbiology Rounds

The purpose of this study is to describe and evaluate the impact of the participation of an antimicrobial stewardship program (ASP) pharmacist in microbiology rounds at our institution. This single-center retrospective descriptive study included inpatient and ambulatory adults (≥18 years) with a susceptibility request reviewed during microbiology rounds between October 2018 and March 2019. In October 2018, multidisciplinary telephone microbiology rounds were initiated with the medical directors of the clinical microbiology laboratory and ASP pharmacist to review susceptibility requests. Numbers and types of interventions made by an ASP pharmacist and potential benefits were recorded and analyzed. Sixty-seven susceptibility requests were reviewed by an ASP pharmacist, of which 83.6% were inpatient. An ASP pharmacist completed chart reviews for 92.5% of requests and contacted the requester or primary team 74.6% of the time. About half (47.8%) of susceptibility requests were approved, and only 65.2% of requests from an infectious diseases provider were approved (P = .039). The most frequent potential benefits of the intervention included preventing unnecessary susceptibility testing (47.8%), improving clinician understanding (40.3%), and preventing treatment of a culture result deemed as a contaminant (19.4%). ASP pharmacists are uniquely accessible and able to assist with preventing unnecessary susceptibility testing, optimizing antimicrobial therapy, and providing education to other health care professionals.

Incorporating preauthorization into antimicrobial stewardship pharmacist workflow reduces Clostridioides difficile and gastrointestinal panel testing.

To evaluate whether incorporating mandatory prior authorization for Clostridioides difficile testing into antimicrobial stewardship pharmacist workflow could reduce testing in patients with alternative etiologies for diarrhea. Single center, quasi-experimental before-and-after study. Tertiary-care, academic medical center in Ann Arbor, Michigan. Adult and pediatric patients admitted between September 11, 2019 and December 10, 2019 were included if they had an order placed for 1 of the following: (1) C. difficile enzyme immunoassay (EIA) in patients hospitalized >72 hours and received laxatives, oral contrast, or initiated tube feeds within the prior 48 hours, (2) repeat molecular multiplex gastrointestinal pathogen panel (GIPAN) testing, or (3) GIPAN testing in patients hospitalized >72 hours. A best-practice alert prompting prior authorization by the antimicrobial stewardship program (ASP) for EIA or GIPAN testing was implemented. Approval required the provider to page the ASP pharmacist and discuss rationale for testing. The provider could not proceed with the order if ASP approval was not obtained. An average of 2.5 requests per day were received over the 3-month intervention period. The weekly rate of EIA and GIPAN orders per 1,000 patient days decreased significantly from 6.05 ± 0.94 to 4.87 ± 0.78 (IRR, 0.72; 95% CI, 0.56-0.93; P = .010) and from 1.72 ± 0.37 to 0.89 ± 0.29 (IRR, 0.53; 95% CI, 0.37-0.77; P = .001), respectively. We identified an efficient, effective C. difficile and GIPAN diagnostic stewardship approval model.

The impact of rapid diagnostic testing, surveillance software, and clinical pharmacist staffing at a large community hospital in the management of Gram-negative bloodstream infections

Rapid diagnostic testing (RDT) combined with an antimicrobial stewardship program (ASP) has shown improved outcomes in bloodstream infections (BSIs). We assessed the impact of RDT, surveillance software, and ASP pharmacist staffing on time to optimal therapy (TOT) in Gram-negative BSIs. Adults with Gram-negative BSIs were included in this retrospective evaluation across 2 study periods. The preimplementation group (n = 121) had longer TOT than the postimplementation group (n = 120) (59.6 ± 36.2 h versus 29.0 ± 24.2 h, P < 0.001). Escalation (51.1 ± 26.4 h versus 16.9 ± 15.7 h, P < 0.001) and de-escalation (63.1 ± 39.5 h versus 39.2 ± 25.6 h, P < 0.01) of therapy were shorter in the postimplementation group. TOT for patients with multidrug-resistant organisms (MDROs) was shorter in the postimplementation group (61.8 ± 37.2 h versus 21.9 ± 18.8 h, P < 0.001). TOT was shorter during fully staffed clinical pharmacist hours (30.6 ± 58.9 h versus 19.7 ± 31.7 h, p = 0.014). Implementation of RDT and surveillance software with an ASP decreased TOT for Gram-negative BSIs, including MDROs.

Customizing an Electronic Medical Record to Automate the Workflow and Tracking of an Antimicrobial Stewardship Program.

BackgroundDocumenting the actions and effects of an antimicrobial stewardship program (ASP) is essential for quality improvement and support by hospital leadership. Thus, our ASP tallies the number of charts reviewed, types of recommendations, how and to whom they were communicated, whether they were followed, and any effects on antimicrobial days of therapy. Here we describe how we customized the electronic medical record at our institution to facilitate our workflow and data analysis, while highlighting principles that should be adaptable to other ASPs.MethodsThe documentation system involves the creation of a novel and intuitive ASP form in each chart reviewed and 2 mutually exclusive tracking systems: 1 for active forms to facilitate the daily ASP workflow and 1 for finalized forms to generate cumulative reports. The ASP form is created by the ASP pharmacist, edited by the ASP physician, reopened by the pharmacist to assess whether the recommendation was followed and to quantify any antimicrobial days avoided or added, then reviewed and finalized by the ASP physician. Active forms are visible on a real-time “MPage,” whereas all finalized forms are compiled nightly into 65 informative tables and associated graphs.Results and ConclusionsThis system and its underlying principles have automated much of the documentation, facilitated follow-up of interventions, improved the completeness and validity of recorded data and analysis, enabled our ASP to expand its activities, and been associated with decreased antimicrobial usage, drug resistance, and Clostridioides difficile infections.

Evaluation of the Impact of Antimicrobial Stewardship Program (ASP) on Unrestricted Use of Meropenem at an Academic Medical Center

Objective The primary objectives were to evaluate the prescriber acceptance rate of Antimicrobial Stewardship Program (ASP) pharmacist recommendation to de-escalate/discontinue meropenem, and estimate the difference in duration of meropenem therapy. The secondary objective was to determine incidence of adverse events in the two groups. Methods It was a retrospective study. All patients admitted to Gwinnett Medical Center and receiving meropenem from January–November 2015 were included in the study. Exclusion criteria were: patients admitted to intensive care unit, one-time dose, infectious disease consultation, and age &lt;18 years. Electronic medical records were reviewed for data collection. The control group consisted of patients from January–July 2015 when there was no ASP pharmacist. The intervention group consisted of patients from August–November 2015 during which period the ASP pharmacist recommended de-escalation/discontinuation of meropenem based on culture and sensitivity results. Results A total of 41 patients were studied, 21 in the control group and 20 in the intervention group. There was no significant difference in baseline characteristics in the two groups and in terms of prior hospitalization or antibiotic use (within 90 days) and documented or suspected MDRO infection at the time of admission. De-escalation/discontinuation was suggested in 16/20 patients in the intervention group (80%), and intervention was accepted in 68%. The mean duration of therapy was significantly decreased in the intervention group (5.6 days vs. 8.1 days, p =0.0175). Two patients had thrombocytopenia (unrelated to meropenem), and none of the patients had seizure. Conclusion Targeted antibiotic review is an effective ASP strategy, which significantly decreases the duration of meropenem therapy.

1812. Impact of Rapid Identification of Blood Cultures With Antimicrobial Stewardship at Three Community Hospitals Within a Health System

BackgroundThe use of rapid diagnostic tests (RDT) in microbiology decreases time to pathogen identification (ID). When coupled with an Antimicrobial Stewardship Program (ASP), time to optimal antibiotics can be significantly reduced. The purpose of this study was to evaluate the impact of Verigene® Gram-Positive Blood Culture Test (BC-GP) and Gram-Negative Blood Culture Test (BC-GN) implementation with an ASP at three community hospitals within a health system with centralized microbiology services.MethodsA retrospective analysis was conducted to compare time to targeted antibiotics for treatment of bloodstream infections (BSI) before and after implementation of Verigene®. Patients were included with a positive blood culture for organisms detectable by Verigene BC-GP and BC-GN during September 2016 (pre-implementation group) and September 2017 (post-implementation group). Patients were excluded if positive blood culture had more than one organism, patient was actively being treated for an infection unrelated to blood culture or blood culture results were available after patient expired, was discharged or transferred. Targeted antibiotic therapy was defined as antibiotic therapy tailored toward pathogen based on ID and sensitivities. Each ASP pharmacist received Verigene® notifications in real-time. Secondary endpoints were in-hospital mortality, hospital length of stay (LOS), and days of vancomycin therapy.ResultsA total of 93 patients were included in the final analysis with 42 patients in pre- group and 51 in post-group. Patients achieving targeted therapy during their hospital stay was 38 of 42 (90%) in the pre-group and 47 of 51 (92%) in the post-group. Of those who achieved targeted therapy, time to targeted therapy was 78.4 hours vs. 43.1 hours in pre-group vs. post-group, respectively (P < 0.001). No significant difference was detected for in-hospital mortality or hospital LOS. Length of vancomycin therapy was decreased from 85.8 hours to 48.6 hours in post-group (P < 0.001).ConclusionImplementation of RDT in three community hospitals with a centralized microbiology laboratory resulted in a significantly improved time to targeted antibiotics in patients with BSI when combined with ASP pharmacist real-time notification.Disclosures All authors: No reported disclosures.

1937. A Dedicated OPAT Program Reduces Readmission and Complications Rates

BackgroundOutpatient Parenteral Antibiotic Therapy (OPAT) programs provide patients with infections an alternative to prolonged hospitalization. Despite the benefits of decreased hospital lengths of stay (LOS), risks related to central venous catheter (CVC)-related complications and medication toxicities remain. We implemented intensive monitoring with our antimicrobial stewardship program (ASP) aimed at decreasing the frequency of complications and readmissions.MethodsA retrospective study was conducted including all patients discharged from the Birmingham Veterans Affairs (VA) Medical Center on OPAT from January 1, 2014 to December 31, 2014 (Period 1) and January 1, 2015 to December 31, 2016 (Period 2). Prior to January 1, 2015 OPAT was managed by individual infectious diseases physicians. Starting with Period 2, OPAT was monitored by a dedicated ASP physician and pharmacist. Episodes that eclipsed both periods were excluded. Data collection included demographics, antibiotic indication, treatment received, and clinical outcomes (frequency and types of drug-related complications, acute kidney injury [AKI] defined as a rise in serum creatinine requiring a change in antibiotic dosing, CVC complications, hospital readmission, and planned OPAT duration [difference between discharge and planned stop dates]).ResultsPeriod 1 included 120 patients, period 2 included 299 patients. The mean planned OPAT duration was 30.3 days in Period 1vs. 28.3 days in Period 2 (P = 0.21). Demographics and OPAT indications for each period are in Table 1. Fewer patients had complications in Period 2 compared with Period 1 (50 [42%] vs. 77 [26%], P = 0.001). Complications for each period are detailed in Table 2. Readmission rates were lower in Period 2 compared with Period 1 (27.5% of patients vs. 10%, P < 0.0001). Year is significantly negatively associated with complications (P < 0.0001) and hospitalization (P < 0.0001), Figure 3. ConclusionThe establishment of an OPAT-ASP tasked with close monitoring of therapy improved patient outcomes with reductions in the rate of complications and readmissions in our VA population. Our data support the center’s efforts to dedicate centralized resources to improving the outcomes of OPAT patients.Disclosures All authors: No reported disclosures.

A Pilot Study for Antimicrobial Stewardship Post-Discharge: Avoiding Pitfalls at the Transitions of Care

Purpose: Lack of patient follow-up is a major concern during care transitions, and the role of an antimicrobial stewardship program (ASP) in assessing antimicrobial regimens after hospital discharge is not well described. We implemented an expanded ASP to include patients recently discharged from the hospital and measured its impact on inappropriate antimicrobial therapy 72 hours after inpatient culture data were finalized. Methods: A prospective cohort study was conducted at a 583-bed tertiary care center in the Upper Midwest of America. All patients discharged from our facility on antimicrobial therapy with pending culture results between February 3, 2016, and March 2, 2016, were included for review. If a pathogen nonsusceptible to all prescribed antimicrobials was identified post-discharge, a recommendation for therapy modification was communicated to the prescriber. Results: Thirty-eight patients discharged from our hospital on antimicrobial therapy with pending culture results were evaluated for intervention. When final culture susceptibilities were considered, 5 of 38 patients had been prescribed an inappropriate antimicrobial agent. An ASP pharmacist intervened on 4 of 5 patients, resulting in 3 of 5 patients transitioning to appropriate antimicrobial therapy. When compared to a historical cohort, our transitions-of-care ASP yielded a 3.6-fold increase in antimicrobial-related interventions among discharged patients while reducing inappropriate outpatient antimicrobial therapy by 39%. Conclusion: We believe this is the first pharmacist-driven ASP represented in the medical literature which evaluated all available inpatient culture data to serve patients discharged from the hospital. Antimicrobial stewardship for patients in care transitions may provide an opportunity to increase ASP interventions and reduce inappropriate antimicrobial therapy.

A Multi-Faceted Antimicrobial Stewardship Program (ASP) Intervention Using Clinical Pharmacists Reduces Antibiotic Use and Hospital-Acquired Clostridium difficile Infection (HA-CDI)

BackgroundASPs continue to investigate novel ways to improve appropriate antibiotic utilization. The impact of an ASP-led, multi-faceted coaching and real-time feedback model directed towards clinical pharmacists was evaluated.MethodsA single-center, pre-post quasi-experimental study was conducted with a four-month historical control period (11/2016–2/2017) and four-month intervention period (4/2016–7/2016) to reduce the use of ceftriaxone, fluoroquinolones, and clindamycin. Clinical pharmacists were responsible for ensuring the appropriate use of these restricted antimicrobials with limited guidance by the ASP in the historical control period. The intervention was multi-faceted: ASP pharmacists provided daily coaching and feedback on use of targeted agents to the clinical pharmacists, clinical pharmacists made recommendations to optimize therapy, and in-person monthly sessions were held where a dashboard consisting of aggregated utilization data and HA-CDI rates was discussed by the ASP pharmacist. Segmented regression analysis was used to determine the significance of this intervention on the utilization of the antibiotics, measured by days of therapy (DOT) per 1000 patient-days (PD). Rates of HA-CDI were also compared between the groups.ResultsThe use of fluoroquinolones (34.4 vs. 26.2 DOT/1000 PD; Δ -23.9%), ceftriaxone (17.7 vs.. 13.6 DOT/1000 PD; ∆ -23.2%), and clindamycin (18.7 vs.. 13.3 DOT/1000 PD; ∆ -28.9%) decreased during the intervention period. Using segmented regression analysis, a significant decreasing rate of antibiotic use of all three agents was observed during the intervention period (Table). A significant decreasing rate of HA-CDI was also seen (rate ratio (RR): 0.787, 95% CI: 0.743–0.833, P < 0.001).ConclusionA multi-faceted coaching and feedback intervention targeting clinical pharmacists with substantial ASP oversight can significantly reduce inappropriate antibiotic use and HA-CDI in a large hospital.TableSegmented Regression Analysis Drug Effect Rate Ratio 95% CI P-value FluoroquinolonesIntervention*time0.9710.949–0.9950.016CeftriaxoneIntervention*time0.8420.795–0.891<0.001ClindamycinIntervention*time0.9310.904–0.958<0.001Disclosures G. Eschenauer, Merck: Grant Investigator, Research grant; V. D. Marshall, Merck: Grant Investigator, Research grant

An Antimicrobial Stewardship Initiative to Evaluate Penicillin Allergy Labels in Spinal Cord Injury and Long-Term Care Patients

BackgroundInaccurate penicillin (PCN) allergy labels force clinicians to choose less-preferred therapies. Implementation of an inpatient penicillin skin testing (PST) program is one way to assess allergy label validity, but outpatient PST may also play an important role. Within the Miami Veteran Affairs Healthcare System, the Allergy Service and Antimicrobial Stewardship Program (ASP) collaborated to identify and assess PCN allergic patients considered likely to need antibiotics in the future. The purpose of this project is to describe the process and outcomes of this collaboration, targeting Spinal Cord Injury (SCI) and another long-term care patient population.MethodsFrom April 2016 to February 2017, the ASP pharmacist periodically generated a list of patients admitted to the SCI unit or nursing home with an active PCN allergy label. Patients were screened and an electronic consult was sent to an allergist for evaluation. Data for assessment of the intervention were obtained via a continuous quality improvement project overseen by the ASP and Allergy service.ResultsThere were 53 patients identified for ASP pharmacist review. Of these, 24 (45%) were referred to the allergist. To date, 13 patients have been evaluated in the outpatient allergy clinic, 6 referrals cancelled and 5 are pending evaluation. Of the 13 patients evaluated, 11 had their allergy label removed and 2 did not. (One patient declined testing and the other was found to have skin anergy.) Eight of 11 negative patients (73%) received antibiotics after label removal and 5 of these patients (45%) received a β-lactam (totaling 153 days of therapy with 5 intravenous courses for complicated infections).ConclusionAn ASP/Allergy Service collaboration to identify inaccurate penicillin allergy labels in special outpatient populations at risk for requiring antibiotics may have a positive impact on the subsequent rate of the use of first-line antimicrobials.Disclosures All authors: No reported disclosures.

Education and Communication in an Interprofessional Antimicrobial Stewardship Program.

Interprofessional education/interprofessional practice (IPE/IPP) is an essential component in medical education and training. A collaborative interprofessional team environment ensures optimal patient-centered care. To describe the implementation of 2 interprofessional antimicrobial stewardship program (ASP) teams using IPE/IPP and to assess the acceptance rate by the primary medical and surgical teams of ASP recommendations for antimicrobial interventions. A business plan for the ASP was approved at 2 academic medical centers used for the present study. During a 3-year study period, 2 interprofessional ASP teams included an attending physician specializing in infectious disease (ID), an ID physician fellow, an ASP pharmacist, physician residents, medical students, pharmacy residents, and pharmacy students. Educational seminars were presented for all adult-admitting physicians to discuss the need for the ASP and the prospective audit and feedback process. Cases were presented for discussion during ASP/ID rounds and recommendations were agreed upon by the ASP team. A motivational interviewing face-to-face technique was frequently used to convey the ASP team recommendation to the primary medical or surgical team in a noncoercive and educational manner. The ASP team recommendations for ASP interventions were documented in the medical records. The overall acceptance rate of recommendations by the primary medical and surgical teams were greater than 90% (2051 of 2266). The most frequent interventions provided were streamline therapy (601), route of administration change (452), bug-drug mismatch (190), and discontinuation of therapy (179). Route of administration change was also the most frequently accepted intervention (96%). The motivational face-to-face communication technique was particularly useful in conveying ASP team member recommendations to the primary medical or surgical teams. Communicating recommendations as a multidisciplinary team in an educational manner seems to have resulted in to greater acceptance of recommendations.

Incorporating Interprofessional Practice Education and Motivational Interviewing Techniques in Antimicrobial Stewardship Programs at Two Academic Medical Centers

Background Interprofessional practice education (IPE) is an essential component in educating healthcare residents and students in providing optimal patient centered care in a team environment. Antimicrobial Stewardship Program (ASP) teams with similar approaches were implemented at the two academic medical centers associated with our medical school utilizing an IPE approach in 2012. We describe the implementation/process of the ASPs. Methods A business plan for an ASP was approved at each location. An interprofessional ASP team was identified and includes the ID attending physician, ID fellow physician, ASP pharmacist, medical resident physician (MRP), medical student (MS), pharmacy resident (PR) and pharmacy students (PS). ASP educational seminars were presented for all adult admitting physician groups (Surgery, Ob-Gyn, Internal Medicine, Family Medicine) to discuss the need for the ASP and the prospective audit/feedback process. An ASP patient monitoring form for collecting patient information was developed. ASP rounds occur weekdays during ID rounds. Results The ASP pharmacist, PR and/or PS identify patients receiving intravenous antimicrobials and completes the ASP patient monitoring form. Patients are screened for ASP interventions prior to ASP rounds. Patients requiring interventions are presented during ASP rounds for discussion. The ID fellow or ASP pharmacist intervenes with the primary medical team, frequently utilizing motivational interviewing techniques to convey the ASP team recommendation in a non-coercive and educational manner. Antimicrobial education in relationship to clinical problems in patients enhances the educational learning of healthcare providers. Documentation of the ASP team recommendations is completed in the electronic or paper medical record. ASP acceptance rates were > 88% for antimicrobial recommendations since 2012. In addition, 8 ID fellows (82 rotation months), 26 PR, 82 MRP, 64 PS and approximately 32 MS have gained IPE experience in the ASP team. Conclusions The interprofessional ASP team implementation/process has been successful at our institutions. Antimicrobial stewardship and education are emphasized in all interactions of the ASP team. Motivational interviewing may be a useful technique in conveying ASP recommendations.  Business plan presented and approved at each location  Interprofessional ASP Team  Medicine: ID attending physician, ID fellow physician, MRP, MS  Pharmacy: ASP pharmacist, PR, PS  Education seminars  Adult admitting physician groups  Importance of ASP  Prospective audit and feedback process  Documentation procedures  Combined ASP and ID rounds weekdays  ASP patient monitoring form developed BACKGROUND RESULTS Incorporating Interprofessional Practice Education and Motivational Interviewing Techniques In Antimicrobial Stewardship Programs at Two Academic Medical Centers Pamela Foral, Pharm.D., BCPS1-3; Jennifer Anthone, Pharm.D., BCPS4; John Horne, MD2-4; Leo Dobronski, MD2-4; Javaria Syed, M.D.2-4; Christopher Destache, Pharm.D.1,2,4; Renuga Vivekanandan, MD2-4; Laurel Preheim, MD, FIDSA2-4; Gary Gorby, MD, FIDSA2-4; Marvin Bittner, MD, FIDSA, FSHEA2-4 Creighton University School of Pharmacy & Health Professions1, Creighton University School of Medicine2, VA Nebraska Western Iowa Health Care System3, CHI Creighton University Medical Center4, Omaha, NE

Improving the management of candidemia through antimicrobial stewardship interventions

Candidemia is associated with significant morbidity, mortality, and hospital cost. We conducted a quasi-experimental study to evaluate the impact of an Antimicrobial Stewardship Program (ASP) pharmacist's interventions on time to effective antifungal therapy, in-hospital mortality, infection-related length of stay (LOS), and costs in patients with candidemia. Patients in 2008 (pre-intervention, n = 85) were compared to those in 2010 (post-intervention, n = 88). Time to effective therapy was significantly faster (median 13.5 versus 1.3 hours, P = 0.04) and was administered to more patients in the post-intervention group [67 (88%) versus 80 (99%), P = 0.008]. There was no significant difference in in-hospital mortality [16 (19%) versus 26 (30%) patients, P = 0.11], infection-related LOS [10 (7–15.5) versus 11 (7–17) days, P = 0.68], or hospital costs during candidemia [$25,697 (15,645–42,870) versus $31,457 ($16,399–83,649), P = 0.25]. ASP pharmacist interventions standardized and improved the quality of care of patients with candidemia.