Infectious Diseases Pharmacists Research Articles

1127. Validation of an Adult and Pediatric Beta-Lactam Allergy Risk Stratification Tool

Abstract Background Penicillin allergies are commonly reported, yet more than 95% of these patients can tolerate β-lactams. A comprehensive allergy history is essential when determining which patients can safely receive a β-lactam but is rarely obtained. When available, interpretation of the history is often limited by lack of comfort in determining risk of an allergic reaction. Our antimicrobial stewardship and allergy team created a standardized allergy history questionnaire and risk stratification tool. The purpose of this study was to validate this tool by comparing risk levels assigned by various clinicians to that assigned by an allergist. Methods We prospectively identified 50 adult and 50 pediatric patients hospitalized between July 1, 2020 and March 31, 2021 with an allergy to penicillin, amoxicillin, ampicillin, or cephalexin. Patients with severe non-IgE mediated reactions were excluded. All patients (or caregivers) were interviewed by the same pharmacist using the allergy questionnaire. Clinicians from various subspecialties, including an adult and pediatric allergist, an adult and pediatric infectious diseases (ID) physician, an adult and pediatric hospitalist, and an adult and pediatric ID pharmacist, received anonymized completed questionnaires and the risk stratification tool, but were blinded to other clinicians’ responses. The primary endpoint was overall concordance in risk stratification between non-allergists and allergists. Results Overall concordance was 66% (33/50) in adult and 90% (45/50) in pediatric patients (Table 1). Concordance between individual clinicians and the allergist are shown in Figure 1. In adults, anaphylaxis, difficulty breathing, and angioedema were associated with less severe stratification by non-allergists than allergists. No clinicians stratified any pediatric patient into a lower risk category than the allergist. Table 1. Clinician Agreement with Allergist Figure 1. Risk Stratification Severity Compared to Allergist Conclusion Use of a β-lactam allergy risk stratification tool led to agreement with allergist assessment in the majority of patients. Variation in risk assignment was greater in adult patients; however, non-allergist pediatric providers assigned all patients at the same or more severe level as the allergist, indicating safety in this population. Disclosures All Authors: No reported disclosures

101. Impact of an Integrated Tele-Antimicrobial Stewardship Program at a Rural Community Hospital

BackgroundSmall hospitals in the US may lack access to infectious diseases (ID) expertise despite similar rates of antimicrobial use and drug-resistant bacteria as larger hospitals. A tele-antimicrobial stewardship program (TASP) is a force multiplier, expanding access to specialty care, training, and guidance on appropriate resource utilization. Data on the impact of TASPs in community or rural inpatient settings is limited.MethodsWe established a TASP at a 160-bed hospital in Armstrong County, PA (population < 5000) in September 2020. Tele-ID consult services were already being used (Figure 1). A non-local ID pharmacist or ID physician performed prospective audits and provided feedback with 1 local pharmacist on a 30-minute video conference call daily. At TASP implementation, all patients receiving intravenous (IV) fluoroquinolones, metronidazole, and azithromycin were reviewed. Figure 1 shows the additional support following TASP implementation, including addition of ceftriaxone, carbapenems, IV vancomycin, and tocilizumab to daily reviews. A patient monitoring form was developed to track interventions and the local pharmacists were trained in documentation. Table 1 lists other TASP features implemented.Figure 1. TASP Timeline Table 1. TASP Accomplishments ResultsFrom 09/01/2020 to 04/30/2021, 304 stewardship opportunities were identified and 77% of interventions were accepted. Recommending a duration of therapy was accepted most frequently (93.5%) and de-escalation of therapy least frequently (69.6%) (Table 2). Recommending an ID consultation or diagnostic testing was always accepted but only comprised 6.2% of all interventions. Daily calls involved an average of 5 patient reviews. Monthly antimicrobial use declined on average from 673 DOT (days of therapy)/1000 PD (patient days) to 638 DOT/1000 PD (Figure 2). Daily calls were cancelled on 31/166 weekdays (18.7%) due to staffing shortages.Table 2. TASP Interventions (9/2020 - 4/2021) Figure 2. Monthly Antimicrobial Use in Days of Therapy (DOT) per 1000 Patient Days (4/2019 - 5/2021) ConclusionImplementation of TASP in a community hospital resulted in a high percentage of accepted stewardship interventions and lower antimicrobial usage. Success is dependent on robust educational efforts, establishing strong relationships with local providers, and involvement of key stakeholders. Lack of dedicated stewardship time for local pharmacists is a very significant barrier.Disclosures Erin K. McCreary, PharmD, BCPS, BCIDP, AbbVie (Consultant)Cidara (Consultant)Entasis (Consultant)Ferring (Consultant)Infectious Disease Connect, Inc (Other Financial or Material Support, Director of Stewardship Innovation)Merck (Consultant)Shionogi (Consultant)Summit (Consultant) Erin K. McCreary, PharmD, BCPS, BCIDP, AbbVie (Individual(s) Involved: Self): Consultant; Cidara (Individual(s) Involved: Self): Consultant; Entasis (Individual(s) Involved: Self): Consultant; Ferring (Individual(s) Involved: Self): Consultant; Infectious Disease Connect, Inc (Individual(s) Involved: Self): Director of Stewardship Innovation, Other Financial or Material Support; Merck (Individual(s) Involved: Self): Consultant; Shionogi (Individual(s) Involved: Self): Consultant; Summit (Individual(s) Involved: Self): Consultant Tina Khadem, PharmD, Infectious Disease Connect, Inc. (Employee) Nancy Zimmerman, RN, BSN, I’d connect (Employee) John Mellors, MD, Abound Bio, Inc. (Shareholder)Accelevir (Consultant)Co-Crystal Pharma, Inc. (Other Financial or Material Support, Share Options)Gilead Sciences, Inc. (Advisor or Review Panel member, Research Grant or Support)Infectious DIseases Connect (Other Financial or Material Support, Share Options)Janssen (Consultant)Merck (Consultant) Rima Abdel-Massih, MD, Infectious Disease Connect (Employee, Director of Clinical Operations) Rima Abdel-Massih, MD, Infectious Disease Connect (Individual(s) Involved: Self): Chief Medical Officer, Other Financial or Material Support, Other Financial or Material Support, Shareholder J Ryan. Bariola, MD, Infectious Disease Connect (Other Financial or Material Support, salary support)

Hospital Discharge: An Opportune Time for Antimicrobial Stewardship.

Approximately 30% of antimicrobials prescribed in the outpatient setting are unnecessary and up to 50% are inappropriate. Despite this, antimicrobial stewardship (AS) efforts mostly focus on the inpatient setting, and limited data describe AS interventions at hospital discharge. Acknowledging the potential value of discharge AS, we used our existing resources to review discharge oral antimicrobial prescriptions. The primary objective of this retrospective, single-center study was to evaluate the impact of an AS program on discharge oral antimicrobial prescriptions. Discharge oral antimicrobial prescriptions sent to our hospital-operated outpatient pharmacy, reviewed by an infectious diseases (ID) pharmacist, and recorded into our data collection tool from September 1, 2020, to February 28, 2021, were evaluated retrospectively. The primary outcome was to identify the frequency a drug-related problem (DRP) was identified by an ID pharmacist. Secondary outcomes included DRP characterization, percentage of prescriptions with interventions, intervention acceptance rate, and reduction in antimicrobial days dispensed at discharge when interventions to limit treatment duration were accepted. Of the 803 discharge oral antimicrobial prescriptions reviewed, at least 1 DRP was identified in 43.1% (346/803). The most frequently identified DRPs pertained to treatment duration, drug selection, and dose selection. At least 1 intervention was recommended in 42.8% (344/803) of prescriptions. In total, 438 interventions were made and the acceptance rate was 75.6% (331/438). The most common types of interventions included recommendations for a different duration, a different dose or frequency, and antimicrobial discontinuation. When interventions to reduce treatment duration were accepted, the median (interquartile range) number of antimicrobial days decreased from 8 (5-10) days to 4 (0-5.5) days (P < 0.001). An ID pharmacist's review of discharge oral antimicrobial prescriptions sent to our hospital-operated outpatient pharmacy resulted in identification of DRPs and subsequent interventions in a substantial number of prescriptions.

Prospective Study to Reduce Clostridium Difficile Infection in Patients Receiving Autologous Stem Cell Transplantation

Background:Clostridium difficile infection (CDI) is a major complication facing patients undergoing autologous stem cell transplantation (ASCT) and can be associated with increased morbidity and length of stay (LOS). Various institutional and multicenter studies have reported incidence rates in this population ranging from less than 5% to more than 10% in this high-risk population. CDIs are not only problematic for individual patient care, but CDI also negatively impact hospital resource utilization by increasing post-transplant LOS. A prospective quality improvement study was initiated at the University of Virginia (UVA) to decrease CDI.Methods:To decrease CDI rate, a multidisciplinary team comprised of oncology and infectious diseases physicians, pharmacists, and nurses was formed. The group used quality improvement principles to identify and target areas of greatest significance. Retrospective chart review was done of 65 consecutive patient ASCT encounters from June 2016 to July 2017 to establish the baseline cohort. For each of these encounters, extensive patient demographics, clinical, and inpatient event data were collected. Analysis of the data identified 17% CDI rate (n=11) in the 30-day period following ASCT. The aim of study was to decrease the CDI rate by 33%. The team used qualitative and quantitative tools to understand factors contributing to CDI, including: process map and a priority matrix categorizing potential interventions based on impact and ease of implementation. A statistical process control chart (p-chart with 3 sigma limits) depicted rates of CDI in the baseline cohort and intervention groups.Results:The baseline CDI rate was 17%. Three Plan-Do-Study-Act (PDSA) cycles of interventions were implemented; post-intervention data were collected and analyzed. From August 2017 to June 2018, the first PDSA cycle consisted of eliminating ciprofloxacin prophylaxis between T+0 and count recovery (which was standard of care) due to hypothesis that the prophylactic antibiotic itself was leading to increases in CDIs. The first PDSA cycle resulted in an increased CDI rate of 19% (n=12) and worsening of sepsis events. Ciprofloxacin prophylaxis was reinstituted. A second PDSA cycle was executed between July 2018 and January 2020 incorporating ultraviolet (UV) light equipment into existing post-discharge cleaning practices, resulting in a decreased CDI rate of 9% (n=11). A third PDSA cycle was conducted from February 2020 through current (July 2021) and added a 2-step C. diff PCR and toxin assay into testing protocols, leading to a further CDI rate decrease to 7% (n=9). P-chart depicting CDI reduction is shown in Figure 1. A significant difference in CDI incidence was found comparing patients before and after implementation of UV light cleaning practices (p<0.01). Figure 2 is a XMR-chart showing a numerical decrease of hospital LOS from 14.6 to 13.8 days after the 3 PDSA cycles, although this did not reach statistical significance (p=0.055).Conclusions:This prospective study surpassed the goal to reduce CDI by 33% by using quality improvement methods to drive a clinically significant special cause variation reduction in the 30-day CDI incidence after ASCT and a trend towards decreased LOS at UVA. This study not only improved patient care, but likely represents increased patient quality of life and cost savings. Future PDSA cycles are scheduled and may include other cancer patients beyond those receiving ASCT. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Contemporary Perspective on the Treatment of Acinetobacter baumannii Infections: Insights from the Society of Infectious Diseases Pharmacists.

The purpose of this narrative review is to bring together the most recent epidemiologic, preclinical, and clinical findings to offer our perspective on best practices for managing patients with A. baumannii infections with an emphasis on carbapenem-resistant A. baumannii (CRAB). To date, the preferred treatment for CRAB infections has not been defined. Traditional agents with retained in vitro activity (aminoglycosides, polymyxins, and tetracyclines) are limited by suboptimal pharmacokinetic characteristics, emergence of resistance, and/or toxicity. Recently developed and US Food and Drug Administration (FDA)-approved β-lactam/β-lactamase inhibitor agents do not provide enhanced activity against CRAB. On balance, cefiderocol and eravacycline demonstrate potent in vitro activity and are well tolerated, but clinical data for patients with CRAB infections do not yet support widespread use. Given that CRAB has the capacity to infect vulnerable patients and preferred regimens have not been identified, we advocate for combination therapy. Our preferred regimen for critically ill patients infected, or considered to be at high risk for CRAB, includes meropenem, polymyxin B, and ampicillin/sulbactam. Importantly, site of infection, severity of illness, and local epidemiology are essential factors to be considered in selecting combination therapies. Molecular mechanisms of resistance may unveil preferred combinations at individual centers; however, such data are often unavailable to treating clinicians and have not been linked to improved clinical outcomes. Combination strategies may also pose an increased risk for antibiotic toxicity and Clostridioides difficile infection, and should therefore be balanced by understanding patient goals of care and underlying health conditions. Promising therapies that are in clinical development and/or under investigation include durlobactam–sulbactam, cefiderocol combination regimens, and bacteriophage therapy, which may over time eliminate the need for the continued use of polymyxins. Future goals for CRAB management include pathogen-focused treatment paradigms that are based on molecular mechanisms of resistance, local susceptibility rates, and the availability of well-tolerated, effective treatment options.

Minimizing the risk of Clostridium difficile infection as an early complication of autologous stem cell transplantation.

219 Background: Clostridium difficile infection (CDI) is one of the most important affecting patients immunocompromised by autologous stem cell transplantation (ASCT), and can be associated with increased morbidity and length of stay. One precipitating factor for index CDI cases in the ASCT population is heavy antibiotic exposure, which often includes prophylaxis. A retrospective review identified 11 cases of CDI (17%) in the 30-day period following ASCT performed at the University of Virginia Medical Center (UVAMC) between about June 2016 and July 2017. Various institutional and multicenter studies have reported incidence rates in this population ranging from less than 5% to more than 10%. Methods: To decrease CDI rate, a multidisciplinary team comprised of oncology and infectious diseases physicians, pharmacists, and nurses was formed. The group used quality improvement principles to identify and target areas of greatest significance. A first PDSA cycle was conducted between approximately July 2017 and June 2018, during which time administration of standard-of-care ciprofloxacin prophylaxis between T+0 and count recovery was suspended. A second PDSA cycle was executed between approximately May 2018 and July 2019, incorporating UV light equipment into existing post-discharge cleaning practices. Data were analyzed using process control charts with 3-sigma limits for ASCT length-of-stay (LOS) and 30-day post-transplant CDI incidence. Results: Suspension of prophylactic antibiotics did not have a significant effect on CDI incidence in our first PDSA cycle. In our second improvement cycle, most of which elapsed after prophylactic ciprofloxacin had been re-implemented, CDI incidence was almost halved, from 17 to 9%. A numerical decreased in LOS was observed in each subsequent PDSA cycle. Conclusions: Our multidisciplinary team applied quality improvement methods to drive a clinically significant reduction in the 30-day CDI incidence after ASCT at UVAMC. This outcome should be associated with an improved patient experience. Future PDSA cycles are scheduled and may include other cancer patients, beyond those receiving stem cell transplantation.[Table: see text]

Early clinical trial data and real-world assessment of COVID-19 vaccines: Insights from the Society of Infectious Diseases Pharmacists.

As of August 2021, there were three COVID‐19 vaccines available in the United States for the prevention of coronavirus 2019 (COVID‐19). The purpose of this narrative review is to examine the early experience from the Emergency Use Authorization (EUA) of BNT162b2 (Pfizer, Inc./BioNTech), mRNA‐1273 (Moderna, Inc.), and Ad26.COV2.S (Johnson and Johnson/Janssen Global Services, LLC) through July 2021. The EUA data from the clinical trials have largely been corroborated by real‐world effectiveness investigations post‐authorization. These studies indicate that immunity is obtained within 2 weeks post‐vaccination and may endure for 6 months. The immunity conferred by the vaccines may also be effective against SARS‐CoV‐2 variants of concern. Additionally, populations not included in the emergency use authorization studies may also benefit from vaccination. This look back at the initial clinical experience can be used by the global community to inform and develop COVID‐19 vaccine programs.

The role of tazobactam-based combinations for the management of infections due to extended-spectrum β-lactamase-producing Enterobacterales: Insights from the Society of Infectious Diseases Pharmacists.

Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales are a global threat to public health due to their antimicrobial resistance profile and, consequently, their limited available treatment options. Tazobactam is a sulfone β-lactamase inhibitor with in vitro inhibitory activity against common ESBLs in Enterobacterales, including CTX-M. However, the role of tazobactam-based combinations in treating infections caused by ESBL-producing Enterobacterales remains unclear. In the United States, two tazobactam-based combinations are available, piperacillin-tazobactam and ceftolozane-tazobactam. We evaluated and compared the roles of tazobactam-based combinations against ESBL-producing organisms with emphasis on pharmacokinetic/pharmacodynamic exposures in relation to MIC distributions and established breakpoints, clinical outcomes data specific to infection site, and considerations for downstream effects with these agents regarding antimicrobial resistance development. While limited data with ceftolozane-tazobactam are encouraging for its potential role in infections due to ESBL-producing Enterobacterales, further evidence is needed to determine its place in therapy. Conversely, currently available microbiologic, pharmacokinetic, pharmacodynamic, and clinical data do not suggest a role for piperacillin-tazobactam, and we caution clinicians against its usage for these infections.

Variation Among Infectious Diseases Pharmacists for the Treatment of Staphylococcus aureus Bacteremia

Introduction: Staphylococcus aureus bacteremia (SAB) remains complex, in that optimal treatment for patients, including complicated or persistent infection, remains unclear. Two recent surveys have demonstrated practice variations in SAB among infectious diseases (ID) physicians. Objectives: The purpose of this survey was to examine practice variations in SAB among ID pharmacists. Methods: A thirty-five-question survey was electronically distributed to the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (IDPRN) in Fall 2019 to determine differences in SAB management. Data were analyzed utilizing Pearson’s Chi-Square or Fisher’s Exact Test. Results: A total of 106 ID pharmacists responded. Only 28% of pharmacists practiced at hospitals with mandatory ID consultation for SAB. A majority (75%) had rapid diagnostic technology (RDT) for identifying SABSI, but 32% of those facilities with RDT did not notify pharmacy with results. Anti-staphylococcal penicillins were preferred for MSSA blood stream infections (BSI) in patients with central nervous system infection and endocarditis, whereas cefazolin was favored for other MSSA BSI. For persistent MRSA BSI, 34% selected daptomycin alone while 38% elected to combine daptomycin and ceftaroline. Pharmacists at hospitals less than 500 beds were more likely to use daptomycin, while those at larger hospitals were more likely to use daptomycin and ceftaroline for persistent MRSA BSI (P < .05). Conclusions: A survey of ID pharmacists showed variation in the management of SABs, as well as the definition and treatment of persistent SAB. Mandatory ID consultation and RDT use to improve SAB management have not been optimized.

Multisociety statement on coronavirus disease 2019 (COVID-19) vaccination as a condition of employment for healthcare personnel.

This consensus statement by the Society for Healthcare Epidemiology of America (SHEA) and the Society for Post-Acute and Long-Term Care Medicine (AMDA), the Association for Professionals in Epidemiology and Infection Control (APIC), the HIV Medicine Association (HIVMA), the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and the Society of Infectious Diseases Pharmacists (SIDP) recommends that coronavirus disease 2019 (COVID-19) vaccination should be a condition of employment for all healthcare personnel in facilities in the United States. Exemptions from this policy apply to those with medical contraindications to all COVID-19 vaccines available in the United States and other exemptions as specified by federal or state law. The consensus statement also supports COVID-19 vaccination of nonemployees functioning at a healthcare facility (eg, students, contract workers, volunteers, etc).

Diagnostic Stewardship in Lower Respiratory Tract Infections Using Procalcitonin

Background: A team of infectious diseases physicians, infectious diseases pharmacists, clinical laboratorians, and researchers collaborated to assess the management of lower respiratory tract infections (LRTIs). In 1 sample from our institution, 96.1% of pneumonia cases were prescribed antibiotics, compared to 85.0% in a comparison group. A collaborative effort led to the development of a protocol for procalcitonin (PCT)-guided antibiotic prescribing that was approved by several hospital committees, including the Antimicrobial Stewardship Committee and the Healthcare Pharmacy &amp; Therapeutics Committee in December 2020. The aim of this analysis was to develop baseline information on PCT ordering and antibiotic prescribing patterns in LRTIs. Methods: We evaluated all adult inpatients (March–September 2019 and 2020) with a primary diagnosis of LRTI who received at least 1 antibiotic. Two cohorts were established to observe any potential differences in the 2 most recent years prior to adoption of the PCT protocol. Data (eg, demographics, specific diagnosis, length of stay, antimicrobial therapy and duration, PCT labs, etc) were obtained from the UK Center for Clinical and Translational Science, and the study was approved by the local IRB. The primary outcome of interest was antibiotic duration; secondary outcomes of interest were PCT orders, discharge antibiotic prescription, and inpatient length of stay. Results: In total, 432 patients (277 in 2019 and 155 in 2020) were included in this analysis. The average patient age was 61.2 years (SD, ±13.7); 47.7% were female; and 86.1% were white. Most patients were primarily diagnosed with pneumonia (58.8%), followed by COPD with complication (40.5%). In-hospital mortality was 3.5%. The minority of patients had any orders for PCT (29.2%); among them, most had only 1 PCT level measured (84.1%). The median length of hospital stay was 4 days (IQR, 2–6), and the median duration of antibiotic therapy was 4 days (IQR, 3–6). Conclusions: The utilization of PCT in LRTIs occurs in the minority of patient cases at our institution and mostly as a single measurement. The development and implementation of a PCT-guided therapy could help optimize antibiotic usage in patients with LRTIs.Funding: NoDisclosures: None

Antibiotic Stewardship Implementation at Hospitals Without On-Site Infectious Disease Specialists: A Mixed-Methods Study

Background: Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals within the Veterans’ Health Administration (VHA) that lack on-site ID support. Methods: Using a mandatory 2016 VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. For each hospital, antibiotic use (2018–2019) was quantified as days of therapy (DOT) per 1,000 days present, based on NHSN methodology for tracking all antibacterial agents. From July 2019 through April 2020, we conducted semistructured interviews with personnel involved in or affected by ASP activities at 7 qualifying hospitals. All interview transcripts were analyzed using thematic content analysis. Results: Of the 7 acute-care hospitals, 6 (86%) had a long-term care unit; 3 (43%) had an intensive care unit; and 2 (29%) had full-time employment equivalents dedicated to stewardship. Sites averaged 1,075 (SD, ±654) and 148 (SD, ±96) admissions per year in acute-care and long-term care, respectively. At the site-level, mean antibiotic use was 486 DOT (SD, ±98) per 1,000 days-present in acute-care and 207 DOT (SD, ±74) per 1,000 days present in long-term care. We interviewed 42 personnel across the 7 sites. Although sites reported using similar interventions to promote antibiotic stewardship, the shape of these interventions varied. The following 4 common themes were identified: (1) The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. (2) The pharmacist champions were more successful at gaining buy-in for stewardship initiatives when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. (3) Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers to stewardship and improving the acceptance of their stewardship interventions. (4) In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. Conclusions: In this study of 7 hospitals without local ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.Funding: NoDisclosures: None

Prospective Study of an Antifungal Program to Reduce Invasive Fungal Infections in Patients with Acute Myeloid Leukemia Receiving Induction and Re-Induction Chemotherapy

Background: Invasive fungal infections (IFI) can occur up to 40% of patients with hematologic malignancies and are most common in patients with acute myeloid leukemia (AML). National averages within the United States, per Infectious Diseases Society of America (IDSA), range approximately from 8-10% in this high risk population. IFIs are not only problematic for individual patient care, potentially resulting in increased antimicrobial usage and delay of future chemotherapy treatments or stem cell transplant, but IFI also negatively impact hospital resource utilization including increased days in hospital and the intensive care unit (ICU).Methods: In attempt to decrease IFIs in hematologic malignancy patients at the University of Virginia Health System (UVAHS), a multidisciplinary team of oncology and infectious diseases physicians, nurses, and pharmacists was formed to develop an Antifungal Program. Retrospective chart review was done of 79 patient encounters from 7/2011 to 9/2014 to establish our baseline cohort. For each of these encounters, extensive patient demographics, clinical, and inpatient event data were collected. Analysis of our baseline data showed a 19.7% proven or probable IFI rate in patients with acute myeloid leukemia undergoing induction chemotherapy. In concordance with IFI rates published by IDSA, we aimed to decrease the IFI in this patient population at UVAHS to less than 10%. With guidance from the American Society of Clinical Oncology's Quality Training Program, our team utilized multiple qualitative and quantitative tools to further understand factors contributing to an increased rate of IFIs. These tools included a process map and Ishikawa cause-and-effect diagram to depict all the steps from leukemia diagnosis to end of treatment and hospital discharge, a Pareto chart to quantify delays of individual steps, and a priority matrix categorizing potential interventions based on impact and ease of implementation. A statistical process control chart (p-chart) depicted rates of IFI in the baseline cohort and intervention groups.Results: Our baseline proven or probable IFI rate in patients with acute myeloid leukemia was 19.7%. Antifungal prophylaxis was not administered to baseline cohort patients. Per Pareto chart analysis, the team identified the most common problems contributing to IFI: inconsistent definition of IFI, no routine antifungal prophylaxis, and lack of education for the health care team. Two Plan-Do-Study-Act (PDSA) cycles of interventions were implemented; post-intervention data were collected and analyzed. From 9/2014 to 8/2016, the first PDSA cycle consisted of individual attending physicians ordering antifungal prophylaxis on an ad hoc basis; the first PDSA cycle resulted in a decreased IFI rate of 11.7% (n = 77). Though close to project aim of less than 10%, this process was burdensome and not sustainable, as it required individual physicians to remember to add antifungal prophylaxis and did not standardize which antifungal agent was used. During the second PDSA cycle from 8/2016 to 4/2017, a clinical practice guideline standardized the definition of IFI and recommended posaconazole as the prophylactic antifungal of choice. Team champions educated physicians, nurses, and pharmacists on the new standard work. This second PDSA cycle resulted in zero IFIs (n = 18), surpassing the team's goal of improving IFI to less than 10%. P-chart depicting IFI reduction is shown in Figure 1. Additionally, median ICU length of stay improved from 2.5 days to 1.5 days. Overall hospital length of stay decreased from 32.3 days to 29.9 days. As no proven or probable IFI were diagnosed during PDSA Cycle 2, no resistant fungal organisms were noted.Conclusions: This project illustrates the importance of forming a multidisciplinary team, whose collaborative effort developed an Antifungal Program that reduced IFI rates in a statistical significant method. When compared to historical controls, the Antifungal Program decreased both IFI rates and ICU length of stay. To ensure sustainability of the quality improvement study, monthly electronic medical record reports will capture guideline compliance, specifically the use of antifungal agents, and track future IFI. The Antifungal Program is an effective clinical tool to not only improve patient care, but likely represents increased patient quality of life, cost-savings, and decreased length of stay. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Relationships between creatinine increase and mortality rates in patients given vancomycin in 76 hospitals: The increasing role of infectious disease pharmacists.

Vancomycin is a commonly used antimicrobial with the potential for renal toxicity. We evaluated vancomycin duration, changes in renal function after vancomycin initiation ("post-vancomycin" renal function changes), and associated mortality risk among hospitalized patients. We analyzed data from 76 hospitals and excluded patients with a baseline serum creatinine concentration (SCr) of >3.35 mg/dL. We estimated mortality risk relative to vancomycin duration and the magnitude of post-vancomycin SCr change, controlling for demographics, baseline SCr, underlying diseases, clinical acuity, and comorbidities. Among 128,993 adult inpatients treated with vancomycin, 49.0% did not experience SCr elevation. Among the remaining patients, 26.0%, 11.4%, 8.8% and 4.8% experienced increases in post-vancomycin SCr of 1% to 20%, 21% to 40%, 41% to 100%, and greater than 100%, respectively. Compared to mortality risk among patients with a vancomycin therapy duration between 4 and 5 days (the lowest-mortality group), longer vancomycin therapy duration was not independently associated with higher mortality risk after adjusting for confounders. In contrast, there was a graded relationship between post-vancomycin SCr elevation and mortality. Multivariable adjusted mortality odds ratios ranged from 1.60 to 13.66, corresponding to SCr increases of 10% and greater than 200%, respectively. Half of patients given vancomycin did not experience SCr elevation and had the lowest mortality, suggesting that vancomycin can be used safely if renal function is stabilized. In the large study cohort, vancomycin duration itself was not an independent predictor of mortality. Post-vancomycin SCr elevation appeared to be a driver of in-hospital mortality. Even a 10% post-vancomycin SCr increase was associated with an increased mortality risk. This finding stresses the importance of closely monitoring renal function and may support the value of pharmacokinetic dosing.

A national standard that will influence global efforts to protect antibiotics

Though the infectious diseases (ID) pharmacy specialty has been in existence for many years, recent issues have raised the profile of ID pharmacists within the healthcare system. First, antimicrobial resistance rates have reached a crisis point and gained the attention of international organisations.1 Second, and in large part due to antimicrobial resistance, recognition of the suboptimal use of antimicrobial agents has led to the rapid expansion of antimicrobial stewardship programs (ASPs) in many parts of the world.2-4 Finally, the COVID-19 pandemic has highlighted the importance of leadership that understands that practical aspects of antimicrobial pharmacotherapy can rapidly synthesise emerging literature and gain consensus through collaboration to produce local standards. All of these require expertise in antimicrobial therapies, and consequently the need for ID pharmacists has grown. The SHPA Standard of Practice (SOP) in Infectious Diseases for Pharmacy Services sets important national expectations and guidance for pharmacist practitioners wishing to practice ID. We believe that this document espouses the mission of the Society of Infectious Diseases Pharmacists (SIDP), which is to advance infectious diseases pharmacotherapy and lead antimicrobial stewardship to optimise the care of patients with infections. Both of us have served as President of SIDP and we see parallels between this SOP and the mission of SIDP. The SOP highlights the important contributions (in both depth and breadth) to direct patient care by ID pharmacists in varied practice settings including inpatient hospital care, people living with HIV, antimicrobial stewardship, rural and regional health services, community-based parenteral antibiotic therapy and emerging practices in primary care and aged care facilities. The standard also emphasises essential components of ID pharmacy practice beyond front-line patient care and operations: education quality and safety improvement, policy and protocol development, and research. This includes the importance of regional, national, and international collaborations to advance the science and to act as a mechanism that shares knowledge and best practices. The latter is especially pertinent for pharmacists practicing in settings without the benefit of colleagues in the specialty, including ID physicians. Perhaps more important is that this SOP also sets a standard for ID practice to include pharmacist practitioners in key clinical and administrative roles. The latter is not a standalone section but rather woven into all aspects of ID pharmacy practice. The standard also highlights the collaborative nature of infectious diseases practice and specifically mentions the important role of microbiology and infection prevention working together with the ID team to achieve optimal patient care. Highlighting the role of ID pharmacists in hospital leadership throughout the antimicrobial use process is key. Although written for Australia, this SOP has the potential for international impact. Pharmacy practice in other countries may come to mirror best practices described in documents such as this one. At the invitation of the authors, the two of us reviewed and provided input on a draft of this standard with this in mind. They are congruent with positions on pharmacist roles in the leadership of ASPs taken by the Board of Pharmacy Specialties and by SIDP.5-7 The SOP takes a big step forward and sets a standard that acts as a set of goals for pharmacists practicing in ID. These goals will likely change as practices evolve and ID pharmacists find new and innovative ways to improve the care of patients. With these standards as the starting point, ID pharmacists can further the vision of ensuring safe and effective antibiotics for now and the future. The authors have no conflicts of interests to declare.

The best today for a better tomorrow: a standard of practice to both recognise and develop infectious diseases pharmacy

Infectious disease is a multidisciplinary specialty involving infectious diseases physicians, clinical microbiologists, nurses and pharmacists among other specialities. Given that so much of infectious diseases involves antimicrobial drugs, it is obvious that pharmacists are an integral part of the care of patients with infections. Infectious diseases pharmacy has developed as its own specialty over the last 10–15 years with the development of antimicrobial stewardship programs, which are now a requirement of hospital accreditation. For those of us that have the privilege of working with specialist ID pharmacists, there are few days that we would not call upon their expertise for difficult areas – HIV drug interactions, dosing in organ failure and critically ill patients, the more unusual antibiotic interactions, and hospital in the home programs, for example. Australian pharmacists have also contributed immensely to areas outside of direct clinical care. In research, The Australian newspaper named Prof Jason Roberts as the leading national researcher in the fields of both critical care and communicable diseases in 2019.1 Many other examples of the impact of pharmacists are provided in this document. Pharmacists have led the ongoing development of Australian national treatment guidelines, Therapeutic Guidelines, while providing key insights into quality and safety programs at state and national levels, as well as contributing to the National COVID-19 Evidence Task Force, among many other contributions. The SHPA Standard of Practice in Infectious Diseases for Pharmacy Services, published in this issue, crystallises the skills and scope that pharmacists have in the management of infectious diseases, particularly in providing clinical care but also into broader governance systems. These include ensuring the quality use of antimicrobials (through education, antimicrobial stewardship programs, developing and reviewing policies and procedures) and ensuring access through formulary policies. The immediate impact of the Standard is to form the basis for a curriculum for junior pharmacists intending to specialise in this area, or for general pharmacists who may require skills in this area in other settings, such as rural hospitals or community settings. Advanced training for physicians has evolved from an “apprenticeship” model to a more structured educational model. While most currently available post-graduate courses are international, a standardised curriculum should facilitate local training and education initiatives, analogous to accreditation developed for infection prevention and control nurses by the Australasian College of Infection Prevention and Control. Collaborative guidance such as this Standard will help future ID pharmacists to build on existing roles and extend into emerging areas of practice. It should be noted that like the scope of practice of pharmacists more generally, this will continue to evolve and expand over time. The infectious diseases community welcomes this major step in recognising the expertise of infectious diseases pharmacists and their contribution to clinical care and the systems that support healthcare. The author has no conflicts of interest to declare.

Research attempts to fill knowledge gap for vancomycin loading dose practice

It may surprise some pharmacists that the practice of using vancomycin loading doses is not currently supported by robust clinical evidence. A 2020 consensus guideline from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists has graded the current evidence with a B-II, which indicates a recommendation neither for nor against the practice. And while many institutional protocols recommend vancomycin loading doses of 20 mg/kg to 35 mg/kg to prevent treatment failure by rapidly reaching therapeutic concentrations, a new study published in the March 2021 issue of Therapeutic Advances in Infectious Disease suggests it may not matter.

Role of infectious diseases pharmacists in outpatient intravenous and complex oral antimicrobial therapy: Society of Infectious Diseases Pharmacists insights

AbstractOutpatient parenteral antimicrobial therapy (OPAT) is a well‐established mechanism to facilitate patient discharge, lower inpatient admission cost, and decrease the risk of health care–acquired infections. Although there are numerous benefits to patients and health care institutions, OPAT is complex and not without risks. Patients may be discharged on long courses of oral antimicrobials, known as complex outpatient antimicrobial therapy (COpAT), which also requires careful monitoring and oversight. This, coupled with the need for antimicrobial stewardship across the continuum of care, positions pharmacists with infectious diseases (ID) training as crucial leaders in the field of OPAT. The development, implementation, and maintenance of these services requires the careful attention of health care personnel in discharge antimicrobial selection, continuity of care at key care transitions, implementation of optimal care bundles, provision of thorough patient education throughout the OPAT process, coordination with a multidisciplinary team including home infusion and nursing, and monitoring of program metrics to determine successes and opportunities for improvement. Ongoing support for optimal delivery of patient care will be required as OPAT practice, and health care delivery at large, continues to evolve. This involves continued advocacy for collaborative practice development, optimizing payment for nondispensatory OPAT services, and integration of effective telehealth programs. This article summarizes the need for practice expansion of ID pharmacist specialists in OPAT/COpAT management across the care continuum and best practices for establishment of these services.

Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study.

Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA). Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities. The study was conducted across 7 VHA hospitals. In total, 42 hospital personnel were enrolled in the study. The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

Next Generation Sequencing for Microbial Analysis to Select Prophylactic Antibiotic Selection before Urologic Stone Surgery: A Culture Change

Background: This paper aims to determine if the combination of polymerase chain reaction (PCR) and next-generation sequencing (NGS) could identify bacteria in culture-negative urine that would alter prophylaxis management. Methods: We sent approximately 5 - 10 mL of a preoperative urine sample to MicrogenDx for PCR/NGS analysis performed after surgery (blind to the surgeon). The physician prescribed standard of care antibiotic prophylaxis. Cases modeling the hospital course of 3 random patients were reviewed by eight urologists after surgery to determine if NGS results would change their prophylaxis regimen. An infectious disease pharmacist reviewed the cases and provided the “ideal” regimen. Results: Urine cultures identified bacteria in 11% (2/18) of cases. Culture speciation results were consistent with NGS results. NGS detected a dominant bacteria in 56% (10/18) of negative cultures and targetable bacteria in all samples. There was a 15% (3/20) infection rate. In both cases, NGS results suggest inadequate prophylaxis. In response to the case scenarios, 100%, 88%, and 88% of the urologists reported they would change prophylaxis with NGS results. During a case scenario, physicians would tend to overprescribe antibiotics given PCR/NGS data for prophylaxis selection. Conclusion: NGS identifies a targetable bacterium in up to 80% of negative urine cultures before urologic stone surgery. Responses to case scenarios indicate that physicians would change management based on NGS results. Inter-professional (urologic and pharmacy) antibiotic selection with PCR/16S DNA testing may be helpful to improve antibiotic stewardship.