Prophylaxis Rates Research Articles

250. An Assessment of the Penicillin Allergy Label in Patients Undergoing Orthopedic Procedures at a VA Medical Center

BackgroundApproximately 10% of the population is labeled as penicillin (PCN) allergic, while only 1% of these individuals have a true IgE mediated allergy. This label influences the prescription of the most appropriate antibiotic and ultimately leads to antimicrobial resistance, hospital readmission, increased length of hospital stays, use of critical care beds, and greater healthcare costs. Post-surgical complications in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) are also increased when patients receive an alternative antibiotic due to PCN allergy. MethodsA retrospective chart review identified patients who underwent a TKA or THA during the 2018-2020 calendar years at the Washington DC VA Medical Center. Multiple operations at different times on the same patient were regarded as separate events. The primary outcome was patients who were evaluable for penicillin allergy de-labeling and the secondary outcome was perioperative antibiotic choice.ResultsPatients in both groups were predominantly male, Black, and over the age of 60. Of a total of 317 procedures performed, we identified 28 procedures in which patients carried a PCN allergy label (PAL) and received a β-lactam alternative antibiotic for surgical prophylaxis. No patients in the PAL group received cefazolin for prophylaxis, compared to 87% of the non-PAL group who were appropriately given cefazolin. In the group carrying the PAL, 62% of patients received vancomycin and 29% of patients received clindamycin for pre-operative prophylaxis. Only one of these patients had a formal allergy consult note, but the PCN allergy was not addressed during that visit. Fewer patients (4%) required ICU admission during their hospitalization in the non-PAL group versus 10% of patients in the PAL group. Table 1. Patient Demographics and Procedure Detail ConclusionThe use of alternative antibiotics in pre-procedural prophylaxis can contribute to adverse events associated with high-risk broader spectrum antimicrobials as well as increased costs associated with antimicrobials such as vancomycin. Our facility began implementation of a penicillin de-labeling program in 2018 via skin testing and direct oral challenge in collaboration with colleagues from Allergy and Immunology. Removal of PAL in this population can increase rates of appropriate prophylaxis. Disclosures All Authors: No reported disclosures

137. Impact of Antimicrobial Stewardship Interventions on Post-Elective Caesarean Antibiotic Prophylaxis and Surgical Site Infections

BackgroundAntimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. Post-operative antibiotics are generally not necessary, especially those without surgical site infections risk factors (e.g. obesity). Few studies have described the impact of ASP interventions on patient outcomes especially in unique populations such as obstetrics. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use and patient outcomes including SSI rates.MethodsThis pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was actively discouraged in those without SSI risk factors. This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 7 months (phase 2). Phase 3 (next 6 months) constituted speaking to the operating consultant. The primary outcome was post-operative oral antibiotics prescription rates. Secondary outcomes included rates of 30-day post-operative SSI.ResultsA total of 1751 women was reviewed. Appropriateness of pre-operative antibiotic prophylaxis was 98% in our institution. There were 244 women pre-intervention, 274 in post-intervention phase 1, 658 in phase 2 and 575 in phase 3. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), which reduced significantly post-intervention to 54% (148) in phase 1, 50% (331) in phase 2 and 39% (226) in phase 3 (p< 0.001). There was no significant difference in patients who developed post-operative SSI pre-post intervention (0.8%, 2 of 242 vs. 1.9%, 28 of 1479, p=0.420) and among who received post-operative oral antibiotics compared to those without (1.9%, 17 of 905 vs. 1.5%, 13 of 846, p=0.582).ConclusionASP interventions can reduce post-eLSCS antibiotic prophylaxis rates without adversely impacting patient safety.Disclosures All Authors: No reported disclosures

Pneumocystis Jirovecii Infection in Autologous Hematopoietic Stem Cell Transplant Recipients

BackgroundInfections remain a common cause of morbidity and mortality following hematopoietic stem cell transplant (HSCT). Pneumocystis jiroveci pneumonia (PJP) is an opportunistic infection that can occur in HSCT patients, although the association is best demonstrated in allogeneic HSCT, occurring less commonly in autologous HSCT. However, reports on PJP incidence, timing of infection, and outcomes among autologous HSCT cohorts are limited. Furthermore, while current guidelines recommend 3-6 months of prophylaxis against PJP following autologous HSCT, the optimal duration and even necessity of prophylaxis is not well established.Patients and MethodsWe performed a retrospective analysis of all consecutive patients who had autologous HSCT at the University of Michigan Blood and Marrow Transplantation program over a 20-year period from 1/1/2000 through 12/31/2019. The cohort consisted of a total of 2082 patients, 1221 male (58.6%), with median age 56 (range 10 months - 77 years, 91.2% ≥ 18 years). Records were searched for use of PJP prophylaxis over 6-month and 2-year follow-up periods post-HCT to determine rates of prophylaxis and choice of agent. Cases of polymerase-chain reaction (PCR)-confirmed PJP occurring within two years of HSCT were identified. The timing, clinical and laboratory features at diagnosis, use of concurrent immunosuppression, treatment, and outcomes were determined.ResultsOf the 2082 patients undergoing autologous HCT, 704 patients (33.8%) received PJP prophylaxis in the first 6 months following transplant. Prophylaxis rates varied over time, ranging from 14.6% to 80.0% when calculated by year of transplant (Figure 1). Trimethoprim-sulfamethoxazole (TMP-SMX) was the most used prophylaxis agent (70.3%), followed by inhaled pentamidine (31.8%), with intravenous pentamidine (8.1%), dapsone (7.1%), and atovaquone (2.6%) being used less frequently.There were 9 cases of PJP identified in our cohort, with an incidence of 0.43%. There were 6 males, with median age of 50 (range 34 - 69). Cases occurred a median of 126 days following HSCT (range 65 - 496), with 4 cases occurring after 6 months. None of the patients were on PJP prophylaxis at the time of diagnosis, and only 2 patients had received prophylaxis at any point after transplant. In 8 of 9 cases, patients were receiving concurrent pharmacologic immunosuppression in the form of steroids or maintenance brentuximab (Table 1).All patients presented with symptoms compatible with PJP, most often with fevers, dyspnea, and cough. Diagnosis was made by PCR from bronchoalveolar lavage specimen in 8 cases, and from sputum sample in 1 case. All patients were lymphopenic at the time of diagnosis, with median absolute lymphocyte count of 400 cells/µL (range 200 - 1100). Patients were most often treated with TMP-SMX. Three patients required transfer to the intensive care unit and 2 were intubated. Ultimately, 2 patients died from PJP infection; the remaining 7 recovered (Table 2).ConclusionOur analysis reveals that among a large cohort, incidence of PJP following autologous HSCT is low. This was the case even with relatively modest rates of PJP prophylaxis in the first 6 months following transplant. Most cases of PJP occurred in patients receiving additional immunosuppression and often occurred late following transplant. [Display omitted] DisclosuresPianko: Karyopharm: Honoraria.

Association of Ikir-Mismatching and Donor Akirs with Better Outcomes in Haploidentical Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia

Objectives: Natural killer (NK) cells are the first donor-derived lymphocytes to be reconstituted after transplantation and play a critical role in improving transplantation outcomes. Their surface receptor, killer cell immunoglobulin like receptor (KIR), can trigger the alloreactivity of NK cells and have been shown to be protective for acute and chronic graft-versus-host disease (aGVHD, cGVHD) while retaining graft-versus-leukemia (GVL) effect. However, different results have been reported about KIR matching models and KIR alleles based on patient, donor and transplant characteristics, resulting in significant controversy about the best donor selection strategy. Here, we investigated the potential influence of KIR matching and KIR alleles on GVHD prophylaxis, overall survival (OS) and relapse rate (RR) of haploidentical hematopoietic stem cell transplantation (haplo-HSCT) in acute myeloid leukemia (AML) patients. Methods：Data from 79 patients with AML treated with haplo-HSCT between May 2015 and May 2021 in the transplantation unit of the Fujian Medical University Union Hospital were retrospectively analyzed. The cohort included 49 male patients (62.0%) and 30 female (38.0%), with a median age of 25 years (1-68 years). KIR genotyping was performed by the PCR-SSO method. The amplicons were quantified on the Luminex 200 flow analyzer and analyzed using the Quick-Type for Lifecodes software for generating KIR data. HLA-A and -B alleles were typed by polymerase chain reaction using sequence-specific primers (PCR-SSP) (TBG, Taipei, Taiwan). HLA-C genotyping was determined by reverse hybridization with sequence specific oligonucleotides probes (rSSO) Line probe assay. Cox proportional hazards model and Kaplan-Meier survival curves were used for analysis. Results：At the time of transplantation, 49 cases (62.0%) were at CR1, while 30 (38.0%) were not. aGVHD occurred in 16 patients (20.3%) and recurrence arose in 10 patients (12.7%), 4 (5.1%) cases cGVHD was observed. After adjusting for age, disease-risk, disease-status, HLA-match, donor gender, conditioning regimen intensity and type of post-grafting GVHD prophylaxis, Cox regression analysis revealed that both KIR ligand-ligand mismatching (KLM) and KIR receptor-ligand matching (RLM) was associated with an decreased risk of aGVHD and relapse compared to KIR ligand-ligand matching and receptor-ligand matching group, respectively (aGVHD: KLM: p=0.047, RLM: p＜0.001; RR: KLM: p=0.049, RLM: p=0.017). Furthermore, RLM shows more accurate in prediction of relapse and aGVHD compared with KLM in both aGVHD and relapse. (aGHVD: p=0.009; RR: p=0.039). After taking activating KIR (aKIR) into consideration to compensate the defect of only inhibitory KIR (iKIR) dominant model, we found that patients with more donor activating KIRs can reach the lower incidence of aGVHD and relapse, and the benefit can gradually increase parallel with the increase in donor activating KIRs. (aGVHD：p=0.019；RR：p=0.037). Patients with both receptor-ligand mismatch and the most donor aKIRs can reach the lowest relapse, lowest incidence of aGVHD and best overall survival (OS). Conclusions: KIR-mismatch, both KLM and RLM significantly reduced the risk of aGVHD and relapse after halpo-HSCT in AML patients and RLM show more superiority in the prediction of HSCT outcome. The synergistic effects of receptor-ligand mismatch and more donor aKIRs can provide a better clinically applicable donor selection strategy to improve haplo-HSCT outcome in AML patients. DisclosuresHu: Astellas Pharma, Inc.: Research Funding.

Real-World Bleeding Outcomes, Weekly Factor Consumption Doses, Annualized Factor Costs in Severe-Type Patients with Hemophilia a (PwHA) before and after Switching to Extended Half-Life rFVIII-Fc Prophylaxis

Introduction: Stand half-life (SHL) rFVIII had been used in patients with hemophilia A (PwHA) for episodic treatment (ET) and prophylaxis therapy (PT) for years. Extended half-life (EHL) rFVIII had been available since 2014, also available in Taiwan since 2018, and resulted in markedly increased willingness for PT because it reduced injection burden. We aimed to investigate the real-world bleeding outcomes, weekly factor doses, and factor costs of severe-type PwHA with pre-switch SHL rFVIII and post-switch EHL rFVIIIFc prophylaxis in Taiwan, and made a pre-switch and post-switch comparison.Methods and Materials: There were totally 51 non-inhibitor, severe-type PwHA, with complete bleeding records before and after switching from SHL rFVIII to EHL rFVIII-Fc, enrolled from two hemophilia centers during Nov, 2018－July, 2019. Most of them had various degree of one to more major joints arthropathy, except children. The medical charts were retrospective reviewed and data were collected, including body features and factor regimen, etc. Patients' annualized bleeding/joint-bleeding rate (ABR/AJBR), weekly doses (WD), annualized factor costs (AFC) were obtained from the chart records of pre-switch 12 months and post-switch at least more-than 6-month until July, 2019. Data from scheduled operation or hospitalization due to trauma or accidence were excluded.Results: There were 8 boys and 43 adults, the median age of all PwHA when switching was 35.6 years (10.5-62). Before switching, these 51 PTP treated with SHL rFVIII who received ET (ET group), irregular prophylaxis (IP group), and regular prophylaxis (RP group) were 19 (37.3%), 7 (13.7%), and 25 (49%), respectively. Bleeding records of 51 PTP treated with SHL rFVIII were traced back with 11.8±0.9 months. After switching to rFVIII-Fc, 3 PwHA receiving ET were excluded, and bleeding records of 48 received RP were obtained with 14.7±4.6 months. Pre-switch and post-switch prophylaxis rate were 62.7% (32/51) and 94.1% (48/51), respectively. For comparison of pre-switch and post-switch outcomes: Median ABR was reduced from 48, 12, and 4 to 1.15, 1.9, and 1.5 for ET, IP, and RP group, respectively. Median AJBR was reduced from 32, 11, and 4 to 0.95, 0.7, and 1.2 for ET, IP, and RP group, respectively. Median WD was increased from 38.4, 52.9, and 63.6 IU/kg/wk to 84.6, 84.5, and 84.9 IU/kg/wk for ET, IP, and RP group, respectively. Median AFC was increased from 4,141,800, 4,064,000 and 5,129,700 NTD to 7,042,325, 5,835,450, and 5,762,810 NTD for ET, IP, and RP group, respectively. Comparing pre-switch and post-switch outcomes of children and adults who received pre-switch and post-switch prophylaxis, median ABR was reduced from 3 and 5 to 1.35 and 1.85 for children and adults, respectively. Median AJBR was reduced from 3 and 4 to 1.35 and 1.15 for children and adults, respectively. Median WD was increased from 58.8 and 58.3 IU/kg/wk to 87.85 and 83.85 IU/kg/wk for children and adults, respectively. Median AFC was increased from 4,104,225 and 5,879,025 NTD to 4,419,800 and 6,024,916 NTD for children and adults, respectively. For all PwHA, zero ABR accounted for 5.9% (3/51) with pre-switch SHL rFVIII treatment and for 20.8% (10/48) with post-switch rFVIII-Fc prophylaxis. Zero AJBR accounted for 9.8% (5/51) with SHL rFVIII treatment and for 33.3% (16/48) with rFVIII-Fc prophylaxis. For PwHA with pre- and post-switch prophylaxis, zero ABR accounted for 12.5% (1/8) and 8.3% (2/24), respectively, for children and adults on SHL rFVIII prophylaxis and 25% (2/8) and 25% (6/24) respectively, for children and adults on rFVIII-Fc prophylaxis. Zero AJBR accounted for 12.5% (1/8) and 16.7% (4/24), respectively, for children and adults on SHL rFVIII prophylaxis and 25% (2/8) and 37.5% (9/24) respectively, for children and adults on rFVIII-Fc prophylaxis.Conclusion: In real-world setting, for pre-switch ET group, switch to rFVIII-Fc prophylaxis made both mean ABR and AJBR reduced >95%, and mean WD increased >50%. For pre-switch IP group, switch to rFVIII-Fc prophylaxis made both mean ABR and AJBR reduced >80%, and mean WD increased >35%. For pre-switch RP group, switch to rFVIII-Fc prophylaxis made both mean ABR and AJBR also reduced >45%, and mean WD increased >20%. The proportions in zero ABR and zero AJBR as post-switch rFVIII-Fc prophylaxis were increased. No matter in ET, IP, or RP group, after switching to RP with rFVIII-Fc, improvement for bleeding outcomes was quite evident. DisclosuresNo relevant conflicts of interest to declare.

Risk Assessing Medical Inpatients for Hospital-Acquired Venous Thrombosis: The Medical Inpatients Thrombosis and Hemostasis (MITH) Study

Introduction: Multiple regulatory agencies and professional societies recommend risk assessment of hospitalized medical patients for hospital-acquired (HA) venous thromboembolism (VTE) and provision of pharmacologic prophylaxis to those at risk. Extant risk assessment models (RAMs) include risk factors not knowable or difficult to assess at admission and often do not include risk factors reflecting illness acuity (such as laboratory studies and vital signs at admission). We developed a RAM for HA-VTE that reports absolute VTE risk, as opposed to arbitrary risk categories, using only objective risk factors measured within the first 24 hours of admission.Methods: The study setting was a combined academic and community 540-bed teaching hospital in northwest Vermont (The University of Vermont Medical Center). Using validated electronic health record (EHR) derived phenotypes (computable phenotypes), we captured all medical admissions between 2010-2019 and examined patient demographics, past medical history, and presenting vital and laboratory measures as potential risk factors for HA-VTE. As risk assessment should happen within 24 hours of admission, we only assessed risk factors knowable within this timeframe. Individuals with VTE at admission were excluded. Key outcome and risk factor definitions were validated using chart review. Bayesian logistic regression with a least absolute shrinkage and selection operator (LASSO) prior probability distribution was used to select risk factors for the model. Variables with a t-statistic ≥1.5 or ≤-1.5 were included in the final model. Full or prophylactic anticoagulation use was adjusted for in the final model. Model performance was assessed using bootstrap resampling to estimate area under the receiver operating characteristic (AUC) curve and calibration slope with 95% confidence interval (CI).Results: There were 62,468 medical admissions in the study period with 219 HA-VTE events. Chart review demonstrated the positive predictive value of our HA-VTE computable phenotype to be 84% and the negative predictive value 99%. Mean age was 65 years and 51% were male. Comorbid conditions were common in this hospitalized population, including active cancer (29%), congestive heart failure (25%), diabetes (27%), hypertension (59%), and prior myocardial infarction (13%). Seven risk factors met the criteria for inclusion in the final model: prior history of VTE (OR 2.7; 95% CI 1.8, 3.8), red cell distribution width ≥14.7% (OR 1.6; 95% CI 1.2, 2.2), creatinine ≥2.0 mg/dL or on dialysis (OR 2.0; 95% CI 1.4, 2.8), serum sodium <136 MEq/L (OR 1.5; 95% CI 1.1, 2.1), active cancer (OR 1.4; 95% CI 1.1, 2.0), malnutrition based on prior reported weight loss (OR 2.1; 95% CI 1.3, 3.3), and low hemoglobin (<13.6 g/dL in men, <12.1 g/dL in women; OR 1.5; 95% CI 1.0, 2.1). The unadjusted AUC of the RAM was 0.73 with an unadjusted calibration slope 1.09 (Figure 1). The optimism-adjusted AUC was 0.68 (95% CI 0.64, 0.71) and the optimism-adjusted calibration slope was 0.87 (95% CI: 0.72, 1.03).Discussion: We developed and internally validated a RAM for HA-VTE during medical hospitalization which incorporates simple, objective risk factors knowable within the first 24 hours of admission. Unlike most prior RAMs, this model also incorporates risk factors reflecting illness severity such as laboratory results. The RAM has good fit and calibration and will be moved forward to external validation. Future applications include incorporating the RAM into hospital admission workflows and assessing VTE prophylaxis rates and the incidence of HA-VTE and HA-bleeding. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Rationale and design of a prospective, multicenter, randomized controlled trial of postoperative venous thromboembolism prophylaxis in Chinese adult patients with inguinal hernia (CHAT-3 trial).

Venous thromboembolism (VTE) is one of the most common causes of preventable harm for patients in hospitals. Nearly half of all VTE events was estimated to occur after surgical procedure. The Caprini risk score is the most extensively used risk assessment tool in predicting postoperative VTE, which is too complicate for surgeons to use properly in their clinical practice. The CHAT-3 trial will be a prospective, multicenter, randomized, parallel-group trial, which is designed to identify patients at moderate or high risk of VTE after inguinal hernia surgery using the previously established three-factor model, and to use low molecular weight heparin (LMWH) for VTE prevention, in comparison to the current routine assessment and practice used in those patients. Totally, 1,008 patients planned to undergo inguinal hernia surgery will be enrolled, with cluster randomization at 1:1 ratio into intervention arm and control arm. The primary outcomes are the accordance of perioperative VTE prophylaxis based on current guidelines and the rate of pharmacological prophylaxis for VTE. The secondary outcomes are the occurrences of perioperative VTE, major bleeding, mortality of patients after inguinal hernia surgery, and trend of D-dimer during the follow-up period. This study will create evidence that whether the administration based on a simple model is of efficacy and safety for VTE prophylaxis among Chinese patients underwent inguinal hernia surgery. The CHAT-3 trial (Trial registration number: ChiCTR2000033769).

Prophylaxis against pneumocystis pneumonia in rheumatoid arthritis patients treated with b/tsDMARDs: insights from 3787 cases in the FIRST registry.

ObjectivesThe use of biologic and targeted synthetic (b/ts) DMARDs in the treatment of RA is increasing. Therefore, prevention of b/tsDMARDs-induced infection is important. Here we describe a prophylaxis protocol for preventing pneumocystis pneumonia (PCP) in RA patients treated with b/tsDMARDs.MethodsThe study subjects were 3787 RA patients from the FIRST registry. They were divided into cohort 1 (n = 807, requiring prophylaxis against PCP based on physicians’ assessment at the point of new treatment with or switch to b/tsDMARDs) and cohort 2 (n = 2980, receiving strategic PCP prophylaxis). The incidence and risk factors for PCP were investigated.ResultsTwenty-six PCP cases were observed throughout the study. After the introduction of strategic PCP prophylaxis, PCP incidence diminished from 0.51/100 person-years (PYs) to 0.21/100 PYs (risk ratio = 0.42). Sulfamethoxazole and trimethoprim in combination (SMX–TMP) showed greater efficacy in the prevention of PCP than pentamidine inhalation (P <0.0001). The prophylaxis rate increased chronologically despite the falls in the average SMX–TMP dose and in the incidence of PCP. Subanalysis of the data for 929 patients from both groups who did not receive prophylaxis showed that old age, high BMI, coexisting lung diseases, low lymphocyte count, and low serum IgG levels increased the risk of PCP development. Development of PCP could be predicted (using an equation based on these variables) in patients not treated with glucocorticoids [area under the curve (AUC) = 0.910)], but less accurately in those on glucocorticoids (AUC = 0.746).ConclusionsOur study clarified the risk factors for PCP in RA patients on b/tsDMARDs treatment and highlighted and defined the criteria for effective prophylaxis against PCP.

Rationalising antibiotic use after low-risk vaginal deliveries in a hospital setting in India

BackgroundIn 2017, a postoperative multidrug resistant case of urinary tract infection made obstetricians at Sitaram Bhartia Institute of Science and Research introspect the antibiotic usage in labouring mothers. Random case...

Implementation of a risk-stratified approach to prevent postoperative nausea and vomiting in an institution with high baseline rates of prophylaxis.

Background and Aims:Although a risk-adjusted approach to preventing postoperative nausea and vomiting (PONV) is generally recommended, the successful implementation of such practice without mandated protocols remains elusive. To date, such a strategy has never been adapted to curb high baseline rates of prophylaxis.Material and Methods:We conducted an observational study on a cohort of patients undergoing elective surgery before and after the implementation of a quality improvement initiative including a risk-stratified approach to prevent PONV. The primary outcome was the number of prophylactic interventions administered. Secondary outcome included the repetition of ineffective medications and the need for rescue medication in the post-anesthesia care unit (PACU).Results:A total of 636 patients were included; 325 patients during the control period and 311 after the intervention. The educational program failed to reduce the amount of prophylactic antiemetics administered (2.0 vs. 2.6, P < 0.001) and the repeat administration of ineffective medications for rescue (16% vs. 20%, P = 0.15). More patients in the intervention group required rescue medication compared to the control group (16.9% vs. 9.7%; P = 0.04).Conclusion:Implementation of best practices to combat PONV remains elusive. Our results indicate that difficulties in changing provider behavior also apply to institutions with high prophylactic antiemetic administration rates.

Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic (VTE-PACC): a Systems-Based, Personalized, Multidisciplinary Program to Increase Venous Thromboembolism (VTE) Risk Assessment, Education and Anticoagulant Prophylaxis in Cancer Outpatients Initiating Therapy

Introduction : Anticoagulant prophylaxis reduces VTE rates by ~50% in selected oncology patients. Among cancer patients starting chemotherapy, 2014 ASCO Guidelines recommend VTE risk assessment, VTE education, and administration of pharmacologic prophylaxis in selected patients. While validated VTE risk stratification tools are available, <10% of oncologists use a risk assessment tool in practice. Further, evidence-based and practical guidance for how to implement VTE prevention guidelines in cancer outpatients is lacking.Hypothesis : Implementation of a systems-based multidisciplinary program that utilizes the electronic health record (EHR) and offers personalized VTE prophylaxis recommendations by consulting hematologists would increase VTE risk assessment, increase VTE education rates, and increase the rate of VTE prophylaxis in high risk patients initiating outpatient chemotherapy.Methods: At a tertiary university cancer center, based on a quality improvement framework with an iterative design to refine the intervention over time, VTE-PACC is a multidisciplinary thrombo-oncology program developed and implemented by nurses, oncologists, pharmacists and hematologists. We identified high risk patients, provided standardized VTE education, and tailored prophylaxis for adult cancer outpatients initiating chemotherapy. Patients receiving hormonal therapy or with brain cancer were not included in the program. An assessment of VTE risk using the Khorana and Protecht scores via the EHR was built into clinical process flow and all patients were provided education on VTE symptoms and risk reduction. Patients with a high predicted VTE risk during treatment (defined as ≥3 points on the Khorana or Protecht score) were offered a hematology consultation to consider VTE prophylaxis. Results of the consultation including individualized drug and dosing recommendations were communicated to the treating oncologist.Results : Between October 1, 2015 and July 1, 2017 (comprising a 6 month implementation phase and subsequent 15 months post implementation), 850 patients were evaluated. VTE risk assessment and education rates increased from less than 5% to 84.3% (range 65.8- 97.6% per month) during the implementation phase. Improvement in EHR documentation processes and clinical work flow resulted in a further increase to 94.9% over the subsequent 15 months. In the post-implementation phase, 153 patients (23.7%) were identified as high risk of VTE based on the Khorana or Protecht scores and offered referral to hematology. The largest patient derived factor for referral acceptance was consultative visits coincident with receiving therapy or an oncology visit. Of these high risk patients, 86% received prophylactic anticoagulation therapy (49% DOAC (direct oral anticoagulant), 32% low molecular weight heparin, 17% unfractionated heparin and 2% warfarin).Conclusion: The VTE-PACC intervention used a multidisciplinary EHR based approach to improve VTE risk assessment and education rates in cancer outpatients initiating therapy. The great majority of high risk patients also received prophylactic anticoagulation. As large trials on the benefits and risks of pharmacologic prophylaxis are completed, methods applied here may readily translate these findings into practice. DisclosuresNo relevant conflicts of interest to declare.

Pneumocystis Jiroveci Pneunomia Prophylaxis during Maintenance Therapy with Hyper-CVAD Regimens for Adult Acute Lymphoblastic Leukemia

BACKGROUNDPneumocystis jiroveci pneumonia (PCP) can be a deadly opportunistic infection in immunocompromised patients. Patients with acute lymphoblastic leukemia (ALL) are at risk for PCP due to their underlying disease, use of high doses of corticosteroids and receipt of lymphocyte-depleting chemotherapy. It is recommended that patients receive PCP prophylaxis during treatment for ALL. Trimethoprim/sulfamethoxazole (TMP/SMZ) is a common agent utilized but some practitioners are concerned about myelosuppression induced by TMP/SMZ. HyperCVAD regimens are the standard treatment strategy for ALL patients at our institution. Historically, PCP prophylaxis with TMP/SMZ was delayed until the beginning of maintenance therapy. This retrospective analysis evaluated PCP prophylaxis and incidence in ALL patients receiving maintenance therapy on a HyperCVAD regimen. Any influence of PCP prophylaxis on clinical outcomes was also evaluated. METHODSNewly diagnosed adult (≥ 18 yo) patients with ALL or lymphoblastic lymphoma who received at least one cycle of maintenance therapy on a HyperCVAD regimen between April 2000 to December 2016 were reviewed. Interim chart reviews were performed to identify the use of PCP prophylaxis and definite or suspected cases of PCP, as well as to document maintenance therapy doses or change in patient status, until the completion of maintenance therapy. Suspected PCP cases (missing microbiological documentation of Pneumocystis) were defined as those patients receiving PCP active therapy based on clinical presentation and imaging. RESULTSDuring the study period, 363 frontline ALL patients received at least one cycle of HyperCVAD maintenance therapy. 346 (198 males and 148 females) patients had sufficient documentation. Of these 346 patients, 145 never received PCP prophylaxis, 67 received i ntermittent PCP prophylaxis, and 134 received uninterrupted PCP prophylaxis throughout maintenance therapy. Only 3 cases of PCP (0.9%) were identified, one confirmed and 2 suspected. All cases occurred within the first 6 months of maintenance therapy and in patients never receiving PCP prophylaxis. The majority of patients receiving prophylaxis were on TMP/SMZ (97%); the most common regimen was 160 mg of the TMP component (1 DS tablet) twice daily two days per week. PCP prophylaxis rates have decreased over time - 55% of patients received uninterrupted PCP prophylaxis if initiated ALL maintenance therapy in 2000-2005 versus 10% of patients received uninterrupted maintenance if initiated ALL maintenance therapy in 2010-2016 (p=<0.001). Philadelphia-positive patients (106/346, 31%) received TKI-based maintenance therapy (TKI, corticosteroid, vincristine). Philadelphia-positive patients were less likely to receive uninterrupted PCP prophylaxis (p<0.0001). Doses of TKI were not statistically different between PCP prophylaxis groups. Philadelphia-negative patients received maintenance therapy containing mercaptopurine and methotrexate (plus corticosteroid, vincristine). Doses of mercaptopurine and methotrexate were not statistically different between PCP prophylaxis groups (p=0.75, p=0.4 respectively). ANC values were analyzed over time and were not significantly different between PCP prophylaxis groups (p=0.36 for never versus uninterrupted PCP prophylaxis). ALC values were also evaluated and were significantly lower in the uninterrupted PCP prophylaxis group at baseline, maintenance year 1 and maintenance year 2 (p=0.0464, p=0.0002, p=0.0001 respectively). Relapse rate, PFS and OS did not differ between the never, intermittent and uninterrupted PCP prophylaxis groups. CONCLUSIONSThe rate of PCP was low in this group of adult patients with newly diagnosed ALL undergoing maintenance therapy as part of a HyperCVAD regimen. All PCP cases occurred in patients not receiving PCP prophylaxis. TMP/SMZ prophylaxis had no significant effect on doses of ALL maintenance therapy provided as well as PFS and OS. TMP/SMZ remains a safe, effective choice for PCP prophylaxis in adult ALL patients. Given the low incidence of PCP in this population, future studies are warranted to identify risk factors that allow selection of patients who would benefit the most from PCP prophylaxis. DisclosuresJabbour:Bristol-Myers Squibb: Consultancy.

A Description of the Type, Frequency and Severity of Infections Among Sixteen Patients Treated for T-Cell Lymphoma

BackgroundInfections are an important cause of morbidity and mortality in T-cell lymphomas. Factors contributing to increased risk of infection include the nature of the underlying disease, as well as treatment-associated immunosuppression. Currently there are few reports describing the types of infections, including preventable infections, in this cohort of patients. The aim of the study was to identify the type, frequency and severity of infection in patients with T-cell lymphoma undergoing treatment.MethodsA case series was performed on all patients with T-cell lymphoma over a 5-year period from 2011 to 2016 at a tertiary Australian hospital. Information was collected from medical record review regarding patient demographics, lymphoma treatment and outcomes, and infectious outcomes. Severe infections were recorded, defined as infection requiring hospitalization.ResultsSixteen patients were identified with a diagnosis of T-cell lymphoma who received treatment at our institution. There were 42 discrete episodes of severe infections in total. Severe infections occurred in 81% of patients, with over 40% having more than one infection. The median length of hospital stay was 13 days, 33% required intensive care admission and 14% of infectious episodes resulted in death. Only 50% of infectious episodes were microbiologically proven, with the most common etiology being bacterial. The most commonly isolated organism overall was Staphylococcus aureus, with the most common source of infection being skin and soft tissue. There was one case of cytomegalovirus (CMV) infection and five cases (12%) of invasive fungal infection. The highest rates of infection occurred during progressive disease. Rates of prophylaxis were highest with antiviral agents, and comparatively lower with antibacterial and antifungal agents.ConclusionInfections are frequent, opportunistic and severe in patients with T-cell lymphoma. Our data suggests that fungal prophylaxis may be indicated with T-cell lymphoma.

Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis.

Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers. Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated. Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis. The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study. Clinical decision rule evaluated in a single population, level III.

Real‐world outcomes with recombinant factor IX Fc fusion protein (rFIXFc) prophylaxis: Longitudinal follow‐up in a national adult cohort

In 2017, all people with severe haemophilia B (PWSHB) in Ireland switched from standard half-life (SHL) recombinant FIX (rFIX) to rFIX Fc fusion protein (rFIXFc) prophylaxis. To evaluate prophylaxis regimens, bleeding rates and factor usage for two years of rFIXFc prophylaxis in a real-world setting. Data collected retrospectively from electronic diaries and medical records of PWSHB for a two-year period on rFIXFc prophylaxis were compared with paired baseline data on SHL rFIX treatment. 28 PWSHB (≥18years) were enrolled, and at switchover 79% were receiving prophylaxis and 21% episodic treatment with SHL rFIX. At 24months following switchover, all remained on rFIXFc prophylaxis with reduced infusion frequency; median dose per infusion once weekly (55IU/kg, 20/28), every 10days (63IU/kg, 2/28) or every 14days (98IU/kg, 6/28). Median annualised bleed rate improved significantly on rFIXFc prophylaxis (2.0 versus 3.3 on SHL FIX) (p=0.01). Median FIX trough level with once-weekly infusions was 0.09IU/ml (0.06-0.14IU/ml). Management of bleeding episodes was similar with rFIXFc and SHL rFIX; one infusion was sufficient to treat 74% and 77% of bleeds, respectively, with similar total median treatment per bleeding episode. Factor consumption reduced by 28% with rFIXFc prophylaxis (57IU/kg/week, range 40-86IU/kg/week) compared with SHL rFIX (79IU/kg/week, range 44-210IU/kg/week) (p=0.002). This study provides important insights into real-world experience of switching to rFIXFc prophylaxis in an adult population, demonstrating high rates of prophylaxis, with reduced infusion frequency, bleeding and FIX consumption.

Review of the Appropriateness of Surgical Antimicrobial Prophylaxis

Aim: This review aims to describe the appropriateness of surgical antimicrobial prophylaxis during the last decade.&#x0D; Methodology: The review included a searching web of science for articles focused on “the appropriateness of surgical antimicrobial prophylaxis”. The searching process was conducted on 29 Nov 2020 and included original articles so the review articles were excluded.&#x0D; Results: The review included 57 articles; 38 articles were published after 2015 and the rest before 2015. Most of the articles that were included in the review showed a high rate of inappropriate surgical prophylaxis and showed inappropriate duration and time of the antibiotics used.&#x0D; Conclusion: It can be concluded that the rate of surgical prophylaxis inappropriateness was high and the main cause for this result was inappropriate timing and duration. Numerous interventions including educational interventions such as one-time seminars and online e-learning modules are needed to improve the adherence to the guidelines.

Compliance with American College of Chest Physicians (ACCP) recommendations for thromboembolic prophylaxis in the intensive care unit: a level I trauma center experience

BackgroundRecommendations are for nearly universal venous thromboembolism (VTE) prophylaxis in critically ill hospitalized patients because of their well-recognized risks. In those intensive care units (ICUs) where patient care is more uniformly directed, it may be expected that VTE prophylaxis would more closely follow this standard over units that are less uniform, such as open-model ICUs.MethodsThis was a retrospective cohort study on all patients aged 18+ admitted to an open ICU between 6/1/2017 and 5/31/2018. Patients were excluded if they had instructions to receive comfort measures only or required therapeutic anticoagulant administration. Prophylaxis administration practices, including administration of mechanical and/or pharmacologic prophylaxis and delayed (≥48 h post-ICU admission) initiation of pharmacologic prophylaxis, were compared between patients admitted to the ICU by the trauma service versus other departments. Root causes for opting out of pharmacological prophylaxis were documented and compared between the two study groups.ResultsOne-hundred two study participants were admitted by the trauma service, and 98 were from a non-trauma service. Mechanical (98% trauma vs. 99% non-trauma, P = 0.99) and pharmacologic (54% vs. 44%, P = 0.16) prophylaxis rates were similar between the two admission groups. The median time from ICU admission to pharmacologic prophylaxis initiation was 53 h for the trauma service and 10 h for the non–trauma services (P ≤ 0.01). In regression analyses, trauma-service admission (odds ratio (OR) = 2.88, 95% confidence interval (CI) 1.21–6.83) and increasing ICU length of stay (OR = 1.13, 95% CI 1.05–1.21) were independently associated with pharmacologic prophylaxis use. Trauma-service admission (OR = 8.30, 95% CI 2.18–31.56) and increasing hospital length of stay (OR = 1.15, 95% CI 1.03–1.28) were independently associated with delayed prophylaxis initiation.ConclusionsOverall, the receipt of VTE prophylaxis of any type was close to 100%, due to the nearly universal use of mechanical compression devices among ICU patients in this study. However, when examining pharmacologic prophylaxis specifically, the rate was considerably lower than is currently recommended: 54% among the trauma services and 44% among non-trauma services.

The negative aftermath of prostate biopsy: prophylaxis, complications and antimicrobial stewardship: results of the global prevalence study of infections in urology 2010\u20132019

PurposeTo evaluate and report the complications, and to analyse antimicrobial stewardship aspects following prostate biopsies (P-Bx) based on the data from a 9-year global study.MethodsThe primary outcome was to compare complications after P-Bx between patients of two cohorts: 2010–2014 and 2016–2019. Primary outcomes included symptoms of lower and severe/systemic urinary tract infection (LUTIS and SUTIS, respectively), and positive urine culture. Readmission to hospital after P-Bx, need for additional antimicrobial therapy, consumption of different antimicrobial agents for prophylaxis and therapy were evaluated. Students t test and chi-square test were used for comparative analyses.ResultsOutcome data were available for 1615 men. Fluoroquinolones-based prophylaxis rate increased from 72.0% in 2010–2014 to 78.6% in 2015–2019. Overall rates of complications increased from 6 to 11.7% including an increase in symptomatic complications from 4.7 to 10.2%, mainly due to an increase in LUTIS. Rates of patients seeking additional medical help in primary care after P-Bx increased from 7.4 to 14.4%; cases requiring post P-Bx antibiotic treatment increased from 6.1 to 9.7%, most of which received fluoroquinolones. Transperineal P-Bx was significantly associated with LUTIS. Following transrectal P-Bx, 2.8% developed febrile infections and 4.0% required hospitalisation. Two men (0.12%) died after transrectal P-Bx due to sepsis.ConclusionsThe rates of complications after P-Bx tended to increase in time, as well as rates of patients seeking additional medical help in the post-P-Bx period. To reduce the risk of infectious complications and to comply with the principles of antibiotic stewardship, clinicians should switch to the transperineal biopsy route.

Improving rates of venous thromboembolism prophylaxis in multiple myeloma patients on immunomodulatory drugs through a pharmacy-based system.

Immunomodulatory drugs used to treat multiple myeloma carry an increased risk of venous thromboembolic (VTE) disease. Previously published guidelines outline consensus opinion on how to mitigate this risk. We collected baseline data to analyze how these strategies are utilized at our single institution and sought to improve the rates of anticoagulation for high-risk patients. This was done through a quality improvement project that added pharmacy/haematology oversight to the VTE risk assessment. Thirty-nine patients newly started on IMiDs were assessed for VTE risk. This information was passed on to the myeloma provider for consideration. Twenty-two patients were classified as high risk for VTE. Of the high-risk patients, 14 (64%) were placed on an anticoagulant for thromboprophylaxis. Eleven (79%) of the 14 used direct oral anticoagulants (DOACs). Eight high-risk patients did not receive an anticoagulant for thromboprophylaxis; 4 of these developed VTE. No patients on anticoagulation developed a VTE. This strategy had rare minor bleeding complications. This quality action verifies guideline-based thromboprophylaxis in multiple myeloma and supports the benefit of pharmacy oversight in improving VTE rates. The use of DOACs in myeloma should be further explored.

A cross-sectional, multicenter, observational study to assess the prophylaxis of venous thromboembolism in Lebanese and Jordanian hospitals

BackgroundThere is a growing body of evidence showing substantial underuse of appropriate venous thromboembolism (VTE) prophylaxis in patients at risk. In the present study, our goal was to assess the current practices in the use rate of VTE prophylaxis among hospitalized patients in Jordan and Lebanon.MethodsA cross-sectional, multicenter, observational study was conducted on 40 centers across Lebanon and Jordan. We included patients who were admitted to the participating hospitals for the treatment of a serious medical or surgical illness. The patients’ records were screened for the fulfillment of inclusion/exclusion criteria during a single assessment visit. The proportion of medical and surgical patients who were at risk of VTE and the thrombo-prophylactic measures employed by physicians for these patients were assessed according to the American College of Chest Physicians (ACCP 2016) guidelines.ResultsThe present study included 704 patients (400 from Jordan and 304 from Lebanon) with a mean age of 54.9 ± 17.5 years. Almost 59% of the patients received prophylaxis treatment in form of pharmacological anticoagulant prophylaxis and/or mechanical prophylaxis. Low molecular weight heparin was the most commonly used anticoagulant for VTE prophylaxis in 366 out of the total 704 (51.9%) patients in the analysis cohort. Two hundred and sixteen patients (52, 95% confidence interval [47.1–56.9%]) received appropriate prophylactic agents out of 415 patients who were eligible for prophylaxis according to the ACCP 2016 guidelines. On the other hand, 199 (72.1, 95% confidence interval [66.4–77.3%) patients received prophylaxis out of 276 ineligible patients. The rate of compliance to guidelines showed wide variations according to the type of hospital, specialty, and the patients’ age. The multivariate logistic regression analysis showed that only age was a significant predictor of appropriate VTE prophylaxis (odds ratio [OR] 1.05, P < 0.001).ConclusionThe rates of the appropriate use of VTE prophylaxis are low in Lebanon and Jordan. There is a lack of compliance to guidelines for VTE prophylaxis use for hospitalized patients in both countries.