Median Days Of Therapy Research Articles

Hospital-by-hospital carbapenem use in Japan: a nationwide ecological study

The Japanese healthcare system has been based on universal health coverage since 1961. Nationwide antimicrobial use on a hospital-by-hospital basis has not previously been recorded. To determine the nationwide distribution of carbapenem use on a hospital-by-hospital basis and to build predictive models using available hospital data from Japan. An ecological study was conducted using open data released from the Government of Japan. The distribution of days of therapy with carbapenem (per 1000 patient-days) was analysed and predictive models built. The top 1% heavy users by crude distribution and observed-per-predicted ratio distribution were listed and compared. The analysis was conducted in three subcategories stratified by hospital characteristics (tertiary, secondary acute care, and fee-for-service) and among patients in two age groups (16-65 and>65 years). The median days of therapy in the group aged 16-65 years were 7.24 for tertiary hospitals, 3.28 for secondary acute care hospitals, and 1.42 for fee-for-service hospitals. The median days of therapy of the group aged >65 years were 17.28 for tertiary hospitals, 14.43 for secondary acute care hospitals, and 8.21 for fee-for-service hospitals. For multivariable linear regression analyses, each model selected a different combination of covariates from the potential predictors based on hospital characteristics. Because a single predictive model was not appropriate for all hospitals, tailored models are needed to identify hospitals that are heavy users of carbapenem. These findings may serve as a reference to support further research on antibiotic use in healthcare and aid future policies.

Impact of requiring re-authorization of restricted antibiotics on day 3 of therapy.

Pre-authorization of restricted antibiotics is a core component of an antibiotic stewardship programme (ASP). On day 3, information about culture results and clinical status is typically available. Our objective was to compare an ASP that requires initial authorization alone with one requiring initial authorization and re-authorization on day 3 of therapy. A single-centre, retrospective, before and after study was conducted. Randomly selected adults were eligible if receiving a restricted antibiotic for ≥3 days during April to June in 2012 (pre-intervention) and during the same months in 2013 (post-intervention). The target sample size was 166 patients. The intervention required re-authorization of restricted antibiotics that were continuing on day 3. The days of therapy of restricted antibiotic(s), length of hospital stay (LOS) and hospital mortality were compared between pre- and post-intervention periods. The ASP intervention was associated with a decrease in median days of therapy from 5 (4-9) to 4 (3-5) days (P < 0.001) for all restricted agents, from 5 (3-6) to 3 (3-5) days for broad-spectrum Gram-negative agents (P < 0.001) and from 6.5 (6-7) to 3 (3-4.5) days for oral vancomycin. The proportion of subjects receiving restricted agents for >4 days decreased from 57.8% to 30.1% (P < 0.001). LOS decreased from 8 (5-17) to 6 (5-9) days (P = 0.005) without a significant change in hospital mortality. Requiring re-authorization of restricted antibiotics on day 3 of therapy in addition to initial authorization was associated with reduction in overall consumption of restricted antibiotics and LOS without adversely affecting hospital mortality.

Impact of Procalcitonin-Guided Antibiotic Management on Antibiotic Exposure and Outcomes: Real-world Evidence.

BackgroundDelayed pathogen identification and nonspecific clinical findings make definitive decisions regarding antibiotics challenging. The stimuli of bacterial toxins and inflammation make procalcitonin (PCT) unique in its ability to differentiate bacterial infection from other causes of inflammation, and thus it is useful for antibiotic management. The objective of our study was to evaluate the impact of a PCT algorithm (PCT-A) on current practice.MethodsA single-center, retrospective cohort study was conducted to evaluate the impact of adding PCT-A to stewardship practices. Data from 4 years prior to and after PCT-A implementation were compared in critical and acute care patients of all ages receiving parenteral antibiotics for a DRG coded for infection. A baseline PCT was obtained on admission in patients with suspected bacterial infection. Serial PCT measurements were repeated daily to evaluate effectiveness of therapy. Outcomes of interest were antibiotic exposure, hospital mortality, 30-day readmission, Clostridium difficile infection (CDI), and adverse drug events during hospitalization.ResultsA total of 985 patients (pre-PCT-A group) were compared with 1167 patients (post-PCT-A group). Antimicrobial stewardship alone (pre-PCT-A) resulted in a median days of therapy (DOT) of 17 (interquartile range [IQR], 8.5–22.5) vs 9.0 (IQR, 6.5–12) in the post-PCT-A group (P < .0001). Secondary outcomes were also significantly reduced in the post-PCT-A group.ConclusionThe addition of PCT in a facility with an established stewardship program resulted in a significant reduction in antibiotic exposure and adverse outcomes. PCT may improve antibiotic management when diagnostic clarity and resolution of infection are lacking.

The Impact of Biofire Filmarray Respiratory Panel on Antibiotic Usage in the Emergency Department at an Academic Medical Center

BackgroundBiofire respiratory panel is a multiplex PCR test designed to detect 17 pathogens within 1 hour. It has greater sensitivity, specificity, and number of pathogens detected compared with older testing methods. The aim of this research was to evaluate the impact of Biofire respiratory panel on antibiotic usage in the emergency department (ED) of an academic medical center.MethodsThis was an observational chart review. Patients with positive RSV or influenza rapid antigen test or PCR test, and patients with a positive Biofire test were included. RSV or influenza tests were reviewed from July to December 2015, and Biofire tests were reviewed from July to December 2016. The primary outcome was to evaluate the duration of antibiotic therapy in patients with viral respiratory infections diagnosed with RSV and influenza rapid antigen and PCR testing compared with Biofire viral respiratory panel. Secondary outcomes included virus type, antibiotic prescription rates on discharge, number of addmissions, procalcitonin levels, and oseltamivir usage.ResultsIn 2016, 67% (105/155) of biofire tests were positive. The most common pathogen was rhinovirus and enterovirus (42%). Of the positive results, 23/105 (22%) received antibiotics with 6 patients having antibiotics discontinued within 72 hours. Another 6 patients had bacterial coinfections. A total of 18/105 (17%) received antibiotic prescriptions on discharge. Median days of therapy (DOT) in hospital was 1 day and median DOT for prescriptions was 8.5 days. There were 5 procalcitonin tests and no oseltamivir usage. Overall 38/105 (36%) patients were admitted to inpatient. In 2015, 3% (20/1313) of RSV (14) and influenza (6) rapid antigen and PCR tests were positive. A total of 5/20 (25%) patients received antibiotics, with 3/20 (15%) patients receiving a prescription for outpatient antibiotics. Median DOT in the hospital was 3 days and median DOT for prescriptions was 10 days. There were 2 procalcitonin tests and 2 cases used oseltamivir. Overall 19 patients were admitted.ConclusionAntibiotics are witheld in the majority of patients with positive Biofire testing. Most patients were treated with supportive care measures only. Biofire continues to be a useful tool to identify candidates for antibiotic avoidance in the ED at our institution.Disclosures All authors: No reported disclosures.

Impact of Procalcitonin (PCT)-Guided Antibiotic Management on Antibiotic Exposure and Outcomes: Real World Evidence

BackgroundAntibiotic overuse and misuse, the main causes of antibiotic resistance, often result from lack of diagnostic clarity. Delayed pathogen identification paired with nonspecific clinical findings may leave clinicians with insufficient evidence to make definitive decisions regarding the need for antibiotics. The dual stimulus of bacterial toxins and inflammation make Procalcitonin (PCT) unique in its ability to differentiate bacterial infection from other causes of inflammation and thus useful for antibiotic management. The objective of our study was to evaluate the impact of a PCT-guided algorithm (PCT-A) on current practice.MethodsA single-center, retrospective cohort study was conducted to evaluate the impact of adding PCT-A to current stewardship practices. Patient data from four years prior to and four years after PCT-A implementation was compared in critical and acute care patients of all ages receiving parenteral antibiotics for a DRG coded for infection. A baseline PCT was obtained at the time of admission in all patients with suspected or proven bacterial infection. Serial PCT measurements were repeated at 24 hour intervals to evaluate effectiveness of therapy. Outcomes of interest were antibiotic exposure, mortality, 30-day readmission, C. difficile infection (CDI) and adverse drug events (ADE).Results985 patients in the pre PCT-A group were compared with 1167 patients in the post PCT-A group. Antimicrobial stewardship alone in the pre PCT-A group resulted in a median Days of Therapy (DOT) of 17.0 (IQR 8.5–22.5) vs. 9.0 (IQR 6.5–12.0) in the post PCT-A group (between-group difference -8.0 DOT, P < 0.0001). Mortality, readmission, CDI and ADEs were also significantly reduced (-51%, -37%,-60%, -41% respectively) in the post PCT-A group.ConclusionThe addition of PCT to clinical judgment and antibiotic management practices in a facility with an established stewardship program resulted in a significant reduction in antibiotic exposure and adverse outcome. PCT may improve antibiotic management in situations where diagnostic clarity and resolution of infection are lacking.Disclosures M. Broyles, Roche Diagnostics: Scientific Advisor, Consulting fee and Educational grant; Thermo Fisher Scientific: Scientific Advisor, Consulting fee and Educational grant; bioMerieux: Scientific Advisor, Speaker honorarium

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

BackgroundAntibiotics are often prescribed “just in case” when clinical conditions mimic an infection, such as the shortness of breath in heart failure, the erythema of venous stasis or when bacterial culture results are misleading such as asymptomatic bacteriuria (ABU) and C difficile colonization. Through prospective audit and feedback (PAF), antimicrobial stewardship programs (ASP) may guide providers toward appropriate antibiotic use. However, the safety of stopping antibiotics needs to be assessed. We retrospectively reviewed the clinical outcomes of patients with accepted ASP recommendations and compared these to patients in whom the primary team declined ASP recommendations.MethodsThe ASP database was used to identify patients receiving written PAF to stop antibiotics prescribed for noninfectious conditions from January 1, 2016 to December 31, 2016. The primary objective was to compare antibiotic days of therapy (DOT), total length of therapy (LOT), hospital length of stay (LOS), 30-day mortality, and the incidence of C. difficile within 6 months of the ASP intervention, occurring among patients whose primary treating team accepted vs. rejected the ASP recommendation. We compared the two groups using Chi-square and student t-test to determine statistical significance for categorical and continuous variables, respectively.ResultsThere were 232 ASP recommendations to stop antibiotics for noninfectious conditions: 150 (65%) interventions were accepted. Baseline demographic characteristics, comorbidities, intensive care admission and surgery during that hospitalization were similar between the two groups. The most common noninfectious conditions were ABU (55%), followed by respiratory (19%) and intra-abdominal (17%). The median antibiotic DOT and LOT were significantly reduced in the accepted group, 3 (3–5) vs. 8 (5–12.25) days (P < 0.001) and 3 (2–4) vs. 7 (5–10) days (P < 0.001), respectively. There were no statistical differences in 30-day mortality, 30-day readmission, and C.difficilewithin 6 months.ConclusionOur institutional ASP’s PAF to stop antibiotics for noninfectious conditions led to a significant reduction in antimicrobial exposure without negatively affecting mortality or hospital outcomes.Disclosures All authors: No reported disclosures.

Impact of piperacillin-tazobactam shortage on meropenem use: implications for antimicrobial stewardship programs

Drug shortages pose a clear detriment to antimicrobial stewardship (AS) efforts. Our objective was to evaluate the effect of a piperacillin-tazobactam shortage on meropenem use, related costs, and associated changes in AS activity. A quasi-experimental quality improvement review compared adult patients receiving meropenem ≥72h three months pre-shortage and three months during the shortage. 320 patients were included (pre-shortage: 103; shortage: 217). Baseline characteristics were similar, but the length of stay was slightly longer in pre-shortage [19 (11–32) days] versus shortage [16 (11–32) days] (p=0.094). In pre-shortage and shortage, median days of therapy and estimated meropenem cost were 7 (5–11) and 7 (5–10) and $309.93 ($173.60–$507.03) and $255.30 ($204.24–$424.31), respectively (p=0.411 and p=0.050). Frequency of ID consultation was similar (16.8% in pre- and 25.3% in shortage, p=0.091). AS interventions increased during the shortage period (99 in pre-shortage and 205 in shortage). De-escalation occurred in 19.4% versus 32.7% of the patients in pre-shortage and shortage (p=0.014). The piperacillin-tazobactam shortage was associated with a 111% increase in meropenem prescriptions despite active AS, but was not associated with changes in mortality, length of therapy, or meropenem costs. AS should be aware that shortages may require proactive countermeasures to avoid inappropriate antimicrobial use during shortage periods.

A multidimensional antimicrobial stewardship intervention targeting aztreonam use in patients with a reported penicillin allergy.

Local antimicrobial susceptibility patterns should be considered for antimicrobial therapy decisions. Antibiogram data can guide beta-lactam antibiotic use in the presence of a penicillin allergy, particularly when allergic cross-reactivity among antibiotic agents is unlikely. To evaluate the effect of a multidimensional antimicrobial stewardship intervention to improve antibiogram-driven antibiotic selection for patients with a reported penicillin allergy receiving aztreonam. This historically controlled, quasi-experimental study compared historical aztreonam use with prospective antibiotic selection following a pharmacist-led intervention in patients with a penicillin allergy. The impact of this intervention on aztreonam use, antimicrobial selection, patient allergy profile updates, length of stay, in-hospital mortality, and antibiotic cost savings was assessed. A significant reduction in median days of aztreonam therapy (4.0 vs. 2.0; p = 0.0001) and median days of therapy per 1000 patient days (14.5 vs. 9.3; p = 0.0001) was found in the intervention group. A pharmacist-led antimicrobial stewardship intervention facilitated antibiogram-driven antibiotic therapy while reducing aztreonam use in patients without an anaphylactic penicillin allergy. Further trials are needed to assess the utility of similar antimicrobial stewardship interventions for patients with penicillin allergy.