Antimicrobial Stewardship Programs: Comparison of a Program with Infectious Diseases Pharmacist Support to a Program with a Geographic Pharmacist Staffing Model

Background:

Stewardship of antimicrobial agents is an essential function of hospital pharmacies. The ideal pharmacist staffing model for antimicrobial stewardship programs is not known.

Objective:

To inform staffing decisions for antimicrobial stewardship teams, we aimed to compare an antimicrobial stewardship program with a dedicated Infectious Diseases (ID) pharmacist (Dedicated ID Pharmacist Hospital) to a program relying on ward pharmacists for stewardship activities (Geographic Model Hospital).

Methods:

We reviewed a randomly selected sample of 290 cases of inpatient parenteral antibiotic use. The electronic medical record was reviewed for compliance with indicators of appropriate antimicrobial stewardship.

Results:

At the hospital staffed by a dedicated ID pharmacist, 96.8% of patients received initial antimicrobial therapy that adhered to local treatment guidelines compared to 87% of patients at the hospital that assigned antimicrobial stewardship duties to ward pharmacists (P < .002). Therapy was modified within 24 hours of availability of laboratory data in 86.7% of cases at the Dedicated ID Pharmacist Hospital versus 72.6% of cases at the Geographic Model Hospital (P < .03). When a patient’s illness was determined not to be caused by a bacterial infection, antibiotics were discontinued in 78.0% of cases at the Dedicated ID Pharmacist Hospital and in 33.3% of cases at the Geographic Model Hospital (P < .0002).

Conclusion:

An antimicrobial stewardship program with a dedicated ID pharmacist was associated with greater adherence to recommended antimicrobial therapy practices when compared to a stewardship program that relied on ward pharmacists.     

Antimicrobial Stewardship in a Community Hospital: Attacking the More Difficult Problems

Background:

Antibiotic stewardship has been proposed as an important way to reduce or prevent antibiotic resistance. In 2001, a community hospital implemented an antimicrobial management program. It was successful in reducing antimicrobial utilization and expenditure. In 2011, with the implementation of a data-mining tool, the program was expanded and its focus transitioned from control of antimicrobial use to guiding judicious antimicrobial prescribing.

Objective:

To test the hypothesis that adding a data-mining tool to an existing antimicrobial stewardship program will further increase appropriate use of antimicrobials.

Design:

Interventional study with historical comparison.

Methods:

Rules and alerts were built into the data-mining tool to aid in identifying inappropriate antibiotic utilization. Decentralized pharmacists acted on alerts for intravenous (IV) to oral conversion, perioperative antibiotic duration, and restricted antimicrobials. An Infectious Diseases (ID) Pharmacist and ID Physician/Hospital Epidemiologist focused on all other identified alert types such as antibiotic de-escalation, bug-drug mismatch, and double coverage. Electronic chart notes and phone calls to physicians were utilized to make recommendations.

Results:

During 2012, 2,003 antimicrobial interventions were made with a 90% acceptance rate. Targeted broad-spectrum antimicrobial use decreased by 15% in 2012 compared to 2010, which represented cost savings of $1,621,730. There were no statistically significant changes in antimicrobial resistance, and no adverse patient outcomes were noted.

Conclusions:

The addition of a data-mining tool to an antimicrobial stewardship program can further decrease inappropriate use of antimicrobials, provide a greater reduction in overall antimicrobial use, and provide increased cost savings without negatively affecting patient outcomes.Key Words: antimicrobial stewardship, data-mining tool, patient outcome metrics, process metrics, recommendationsAntibiotic stewardship has been proposed as an important way to reduce antibiotic resistance and preserve the limited armamentarium of antibiotics. In many hospitals, antibiotic stewardship programs were implemented in response to an outbreak caused by multidrug-resistant (MDR) organisms. In 2001, Texas Health Presbyterian Hospital of Dallas implemented a Comprehensive Antimicrobial Management Program (CAMP) in the absence of an outbreak of MDR infections. It was conceived as a quality improvement project to address the growing concerns of antibiotic misuse.¹ Inappropriate antibiotic prescribing is a major concern as rates of health care-associated infections and antimicrobial resistance continue to rise. It has been estimated that up to 50% of antimicrobial use is inappropriate.² Prior to September 2011, interventions by CAMP were limited to conversion from intravenous (IV) to oral administration for highly bioavailable antimicrobials; discontinuation of perioperative antimicrobial prophylaxis at 24 hours for clean and clean-contaminated surgical procedures; and restriction of use of antibiotics that have a high risk for adverse events, have a high potential to promote resistance, or are expensive. Inappropriate utilization was not analyzed due to limited resources.This program was successful in reducing antibiotic expenditures and was associated with modest improvements in antibiotic susceptibility.¹ However, it was largely noninterventional for monitoring antibiotic choice; it relied on physicians to voluntarily comply with policies on “restricted antibiotics.” After publication of the 2007 Infectious Disease Society of America (IDSA) practice guideline on antibiotic stewardship, it became clear that a more interventional program with rapid feedback was needed to ensure optimal use of antibiotics.³ With the advent of data-mining programs (eg, Sentri7, TheraDoc, SafetySurveillor) that interface with electronic health records (EHRs), it became possible to survey, in real-time, multiple different antibiotics, culture results, and clinical diagnoses. In Sentri7, the Infectious Disease (ID) Pharmacist has the administrative capability to create rules without the need for external or hospital information technology (IT) support. Currently, our EHR cannot data mine clinical microbiology information, and any additional rule build would require IT programming. Kullar and colleagues describe several other limitations with their EHR (EPIC).⁴     

A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success

Background:

Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. “Antimicrobial stewardship” is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs.

Objective:

To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians’ attitudes toward and behaviours related to antimicrobial prescribing.

Methods:

In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013.

Results:

The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards’ credibility and their ability to influence the uptake of effective antimicrobial use.

Conclusions:

Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.     

Taking an Antibiotic Time-out: Utilization and Usability of a Self-Stewardship Time-out Program for Renewal of Vancomycin and Piperacillin-Tazobactam

Background:

Antibiotic time-outs can promote critical thinking and greater attention to reviewing indications for continuation.

Objective:

We pilot tested an antibiotic time-out program at a tertiary care teaching hospital where vancomycin and piperacillin-tazobactam continuation past day 3 had previously required infectious diseases service approval.

Methods:

The time-out program consisted of 3 components: (1) an electronic antimicrobial dashboard that aggregated infection-relevant clinical data; (2) a templated note in the electronic medical record that included a structured review of antibiotic indications and that provided automatic approval of continuation of therapy when indicated; and (3) an educational and social marketing campaign.

Results:

In the first 6 months of program implementation, vancomycin was discontinued by day 5 in 93/145 (64%) courses where a time-out was performed on day 4 versus in 96/199 (48%) 1 year prior (P = .04). Seven vancomycin continuations via template (5% of time-outs) were guideline-discordant by retrospective chart review versus none 1 year prior (P = .002). Piperacillin-tazobactam was discontinued by day 5 in 70/105 (67%) courses versus 58/93 (62%) 1 year prior (P = .55); 9 continuations (9% of time-outs) were guideline-discordant versus two 1 year prior (P = .06). A usability survey completed by 32 physicians demonstrated modest satisfaction with the overall program, antimicrobial dashboard, and renewal templates.

Conclusions:

By providing practitioners with clinical informatics support and guidance, the intervention increased provider confidence in making decisions to de-escalate antimicrobial therapy in ambiguous circumstances wherein they previously sought authorization for continuation from an antimicrobial steward.     

Pharmacy Management of Postoperative Blood Glucose in Open Heart Surgery Patients: Evaluation of an Intravenous to Subcutaneous Insulin Protocol

Purpose:

To develop and implement a protocol to improve blood glucose (BG) control during transition from intravenous (IV) to subcutaneous (SC) insulin, increase compliance with Surgical Care Improvement Project (SCIP) measures, and decrease sternal wound infections post open heart surgery (OHS).

Methods:

An IV to SC protocol was developed and implemented. A retrospective chart review of patients who underwent OHS was conducted from January 2, 2009 to September 30, 2010 (pre protocol) and from October 1, 2010 to December 31, 2011 (post protocol). Data collected included age, sex, history of diabetes mellitus (DM), BG values, hypoglycemia incidence, length of stay, and incidence of sternal wound infections.

Results:

A total of 243 patients were included in the study. Compliance with SCIP postoperative day 1 and 2 BG goals was similar pre and post protocol (P = .24 and .248). One sternal wound infection occurred after protocol implementation, whereas 6 occurred pre protocol (P = .046). Change in BG when transitioning from IV to SC insulin was similar between the groups, however there were significantly fewer hypoglycemia episodes post protocol (P < .001).

Conclusion:

Though differences were not found in compliance with SCIP postoperative day 1 and 2 measures, fewer sternal wound infections and hypoglycemic episodes were reported, indicating that the pharmacy protocol may have a positive impact on patient outcomes.Key Words: hyperglycemia, hypoglycemia, postoperative complications, surgical wound infectionInsulin resistance and elevated blood glucose (BG) levels are commonly seen in hospitalized patients irrespective of a history of diabetes mellitus (DM).¹ These issues arise in almost all critically ill patients, especially those who have undergone open heart surgery (OHS), coronary artery bypass graft (CABG), and/or valve replacement (VR). Hyperglycemia and insulin resistance increase morbidity, specifically the incidence of sternal wound infections, and mortality.^1–3 Hyperglycemia and increased insulin resistance may be due to many factors, but they are highly associated with the release of inflammatory substances, such as cytokines, and stress hormones, such as cortisol.⁴ To help reduce morbidity and mortality, guidelines and recommendations regarding BG goals have been put forth by the Society of Thoracic Surgeons (STS) and the Surgical Care Improvement Project (SCIP). Though these guidelines and recommendations have similar objectives, their BG goals differ slightly. The STS recommends maintaining BG levels <180 mg/dL throughout the entire hospitalization (pre, peri, and post operative), whereas SCIP focuses on meeting a BG goal of <200 mg/dL at 6:00 a.m. on postoperative day (POD) 1 and 2.^1,5At St. Elizabeth’s Hospital (SEH), a 500-bed facility located in Belleville, Illinois, an increase in sternal wound infections was seen within the OHS patient population during the spring months of 2010 compared to previous months. After an analysis of other factors affecting infection rates such as preoperative antibiotic administration, surgeon, surgical technicians, and operating rooms showed no association with the increase in sternal wound infections, pharmacy was consulted to evaluate postoperative BG control. An initial pilot study of 7 patients was conducted in June 2010 to evaluate current BG control throughout the identified patients’ entire stay. The data collected showed that patients post OHS were meeting the POD 1 goal of <200 mg/dL, but in many cases they were not meeting the POD 2 goal (43%). Additionally, the data collected from this small sample identified conversion from intravenous (IV) to subcutaneous (SC) insulin as a major area needing improvement. To help meet SCIP measures and potentially reduce the incidence of sternal wound infections, the pharmacy implemented a new IV to SC insulin protocol.     

Vomiting of oral medications by pediatric patients: survey of medication redosing practices

Background:

At the time of this study, the authors’ pediatric tertiary care hospital had no policy to guide actions when a child vomited after ingesting oral medication, and limited information was available in the literature.

Objectives:

To characterize this clinical problem at the study hospital, to identify current practices related to redosing of medications at the study hospital, and to collect guidelines and opinions of health care professionals at other pediatric hospitals on this topic.

Methods:

Two online surveys were conducted, each over a 1-month period in late 2010, to identify current practices and opinions of pediatric health care professionals about redosing of medications after vomiting. E-mail distribution lists and health care forums were used to recruit participants.

Results:

Of the 76 responses from the study hospital, 65 were suitable for analysis. Many respondents reported encountering vomiting after administration of oral medications on a weekly (25 [38%]) or monthly (24 [37%]) basis. Most of the respondents reported that they would follow a general rule to redose if vomiting occurred within 30 min (39 [60%]) or 15 min (21 [32%]) after initial ingestion. When respondents were asked to rate the importance of 8 factors potentially affecting the decision to redose, more than half indicated that time after dose ingestion (59 [91%]), medication type (45 [69%]), patient status (39 [60%]), and visibility of medication in the vomitus (36 [55%]) were very important. Of the 53 respondents to the survey of health care professionals at other institutions, 16 (30%) indicated that their pediatric hospital or ward had a guideline on redosing in cases of vomiting after administration of oral medications. Most respondents (12/13 [92%]) stated that the guideline took into account the interval between initial ingestion and vomiting.

Conclusions:

The problem of vomiting after administration of an oral medication was prevalent at the study hospital, and guidelines were scarce at other pediatric institutions. Health care professionals at the study hospital and other institutions listed the time between ingestion and vomiting as the most important factor in the decision to redose the medication.     

Urinary Tract Infections: Leading Initiatives in Selecting Empiric Outpatient Treatment (UTILISE)

Background

Overuse of fluoroquinolone antibiotics is associated with outbreaks of methicillin-resistant Staphylococcus aureus and of Clostridium difficile–associated diarrhea and increasing resistance in gram-negative organisms. Over the past decade, resistance of Escherichia coli to ciprofloxacin has increased in the Regina Qu’Appelle Health Region. In August 2011, an exploratory audit of the Regina General Hospital (RGH) emergency department showed that 20% of new antibiotic orders were for fluoroquinolones, and 60% of these new fluoroquinolone orders were for ciprofloxacin. It was postulated that ciprofloxacin was predominantly prescribed for outpatients with urinary tract infection.

Objective:

To develop, implement, and evaluate a best-practice algorithm for the empiric treatment of uncomplicated urinary tract infection in the RGH emergency department, as part of an educational initiative for emergency physicians.

Methods:

A literature review was conducted and local antibiogram data were analyzed to establish a best-practice algorithm for treatment of uncomplicated urinary tract infection in outpatients seen in the emergency department. A chart review was conducted from January to March 2011 to establish a baseline of empiric antibiotic use. An educational strategy targeting emergency physicians described changes in antibiotic resistance patterns in the health region, principles of antimicrobial stewardship, drivers of resistance, and the results of a literature review of best practice for urinary tract infection in outpatients. A post-intervention audit was conducted from January to March 2012 to determine changes in practice.

Results:

Comparison of results from the post-intervention audit with baseline data showed that adherence to best practice increased significantly, from 41% (39/96) before the intervention to 66% (50/76) after the intervention (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.51–5.25; p < 0.001). There was also a significant change in overall antibiotic selection (OR 0.25, 95% CI 0.11–0.58; p < 0.001). Further analysis suggested that this significant change was driven by a decrease in use of ciprofloxacin, from 32% (31/96) to 11% (8/76).

Conclusion:

Creation of a best-practice algorithm and education focused on emergency physicians significantly increased adherence to best practice and optimized antibiotic prescribing for outpatients with uncomplicated urinary tract infection by limiting overuse of fluoroquinolones, primarily ciprofloxacin.     

Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study)

Background:

Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality.

Objectives:

The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care–associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used.

Methods:

An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared.

Results:

Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care–associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group.

Conclusion:

An audit and feedback intervention related to hospitalists’ prescribing for pneumonia increased adherence to local best practice.     

Antibiotic Prescribing Practices for Catheter Urine Culture Results

Background:

The literature suggests that positive results of catheter urine cultures frequently lead to unnecessary antimicrobial prescribing, which therefore represents an important target for stewardship.

Objective:

To assess the appropriateness of antibiotic prescribing in response to the results of urine cultures from patients with indwelling urinary catheters.

Methods:

This retrospective study was conducted at a tertiary care centre and involved adults with indwelling urinary catheters from whom urine specimens were obtained for culture. Patients with positive or negative culture results were identified from microbiology laboratory reports. The medical records of consecutive patients were screened to select a sample of 80 inpatients (40 per group). Abstracted patient histories were independently evaluated by an expert panel of 3 infectious diseases consultants blinded to the decisions of prescribers and of fellow panelists. The primary end point was concordance of each patient’s treatment decision (with respect to the indication) between the expert panel (based on majority agreement, i.e., at least 2 of the 3 expert panelists) and the prescriber. The secondary end points were unnecessary days of therapy and selected outcomes over a predefined period after urine was obtained for culture.

Results:

A total of 591 charts were screened to generate the targeted number of patients. Baseline demographic characteristics were comparable for the 2 groups, except antibiotic exposure before urine collection was significantly more frequent for the group with negative culture results. The treatment decision was concordant in 40% (16/40) of the patients with a positive culture result and 85% (34/40) of those with a negative culture result (p < 0.001). The most common reason for discordance was administration of antibiotics when not indicated (23 of 24 patients with a positive result and 5 of 6 patients with a negative result), which accounted for 165 and 32 unnecessary days of therapy per 1000 inpatient-days, respectively (p < 0.001). Adverse effects occurred in 2 of the 23 patients with a positive result who received antibiotics that were not indicated.

Conclusions:

Appropriateness of antibiotic prescribing, as measured by concordance of decisions between the expert panel and prescribers, was more common among patients with negative urine culture results than among those with positive results. However, there is an opportunity to improve prescribing for both groups through antimicrobial stewardship initiatives. Unnecessary days of therapy and adverse effects were more common in patients with a positive culture result.     

Impact of a Cost Visibility Tool in the Electronic Medical Record on Antibiotic Prescribing in an Academic Medical Center

Background:

Studies evaluating the impact of passive cost visibility tools on antibiotic prescribing are lacking.

Objective:

The objective of this study was to evaluate whether the implementation of a passive antibiotic cost visibility tool would impact antibiotic prescribing and decrease antibiotic spending.

Methods:

An efficiency and effectiveness initiative (EEI) was implemented in October 2012. To support the EEI, an antibiotic cost visibility tool was created in June 2013 displaying the relative cost of antibiotics. Using an observational study of interrupted time series design, 3 time frames were studied: pre EEI, post EEI, and post cost visibility tool implementation. The primary outcome was antibiotic cost per 1,000 patient days. Secondary outcomes included case mix index (CMI)–adjusted antibiotic cost per 1,000 patient days and utilization of the cost visibility tool.

Results:

Initiation of the EEI was associated with a $4,675 decrease in antibiotic cost per 1,000 patient days (P = .003), and costs continued to decrease in the months following EEI (P = .009). After implementation of the cost visibility tool, costs remained stable (P = .844). Despite CMI increasing over time, adjustment for CMI had no impact on the directionality or statistical significance of the results.

Conclusion:

Our study demonstrated a significant and sustained decrease in antibiotic cost per 1,000 patient days when focused medication cost reduction efforts were implemented, but passive cost visibility tool implementation was not associated with additional cost reduction. Antibiotic cost visibility tools may be of most benefit when prior medication cost reduction efforts are lacking or when an active intervention is incorporated.     

Decentralized Automated Dispensing Devices: Systematic Review of Clinical and Economic Impacts in Hospitals

Background:

Technologies have been developed over the past 20 years to automate the stages of drug distribution in hospitals, including ordering, dispensing, delivery, and administration of medications, in attempts to decrease medication error rates. Decentralized automated dispensing devices (ADDs) represent one such technology that is being adopted by hospitals across Canada, but the touted benefits, in terms of improved patient safety and cost savings, are increasingly being questioned.

Objective:

To summarize and evaluate the existing literature reporting the clinical and economic impacts of using decentralized ADDs in hospitals.

Data Sources:

A literature search was conducted in MEDLINE, Embase, and all evidence-based medicine databases for the years 1992 to 2012 to identify English-language articles reporting on the use of ADDs in hospital wards.

Study Selection and Data Extraction:

All randomized controlled trials, observational studies, before-and-after studies, time series analyses, cost-effectiveness and cost–benefit analyses, and review articles were considered for inclusion. Studies evaluating pharmacy-based ADDs, such as bar code–based medication dispensing carousels, automated dispensing shelves, and combinations of various dispensing modalities, were excluded.

Data Synthesis:

Of 175 studies initially identified, 8 were retained for evidence synthesis. It appears that ADDs were effective in reducing medication storage errors and the time that nurses spent taking inventory of narcotics and controlled substances. There was no definitive evidence that using ADDs increased the time that nurses or pharmacists spent with patients, reduced medication errors resulting in patient harm, or reduced costs in Canadian hospitals. However, pharmacy technicians spent more time stocking the machines.

Conclusion:

ADDs have limited potential to decrease medication errors and increase efficiencies, but their impact is highly institution-specific, and use of this technology requires proper integration into an institution’s medication distribution process. Before deploying this technology, it is recommended that Canadian hospitals carefully examine their current systems and the benefits they hope to gain with the changes.     

A point prevalence survey of antibiotic prescriptions: benchmarking and patterns of use

AIM

The aim of the study was to assess current patterns of antibiotic prescribing and the impact of a hospital antibiotic policy on these practices.

METHODS

The study involved collecting information regarding hospitalized patients utilizing the ESAC audit tool.

RESULTS

In the study site hospital, the use of the restricted agents was low whilst the use of the non-restricted agents was high. Compliance with the hospital antibiotic guidelines was 70%.

DISCUSSION

The findings identified monitoring non-restricted antibiotics and compliance with guidelines as targets for quality improvements in our hospital. Point prevalence surveys may offer a simple method of monitoring antibiotic policies, thus, informing antibiotic stewardship.     

Risk Factors for and Outcomes of Bacteremia Caused by Extended-Spectrum ?-Lactamase–Producing Escherichia coli and Klebsiella Species at a Canadian Tertiary Care Hospital

Background:

Antimicrobial resistance due to production of extended-spectrum ß-lactamases by Escherichia coli and Klebsiella species (ESBL-EK) is concerning. Previous studies have shown that bacteremia due to ESBL-producing organisms is associated with increases in length of stay and/or mortality rate. Rates of infection by ESBL-EK vary worldwide, and regional differences in the prevalence of risk factors are likely. Few Canadian studies assessing risk factors for ESBL-EK infections or the outcomes of empiric therapy have been published.

Objectives:

To determine risk factors for and patient outcomes associated with ESBL-EK bacteremia. The appropriateness of empiric antibiotic therapy and the effect of inappropriate empiric therapy on these outcomes were also examined.

Methods:

In a retrospective, 1:1 case–control study conducted in a tertiary care hospital between 2005 and 2010, data for 40 patients with ESBL-EK bacteremia were compared with data for 40 patients who had non-ESBL-EK bacteremia.

Results:

Of all variables tested, only antibiotic use within the previous 3 months was found to be an independent risk factor for acquisition of ESBL-EK bacteremia (odds ratio 5.2, 95% confidence interval 1.6–16.9). A greater proportion of patients with non-ESBL-EK bacteremia received appropriate empiric therapy (88% [35/40] versus 15% [6/40], p < 0.001). Time to appropriate therapy was longer for those with ESBL-EK bacteremia (2.42 days versus 0.17 day, p < 0.001). Patient outcomes, including length of stay in hospital, admission to the intensive care unit (ICU), length of stay in the ICU (if applicable), and in-hospital mortality were not affected by the presence of ESBL-EK or the appropriateness of empiric therapy.

Conclusions:

Previous antibiotic use was a significant, independent risk factor for acquiring ESBL-EK. Thus, prior antibiotic use is an important consideration in the selection of empiric antibiotic therapy and should increase the concern for resistant pathogens.     

Time to Administration of Antibiotics among Inpatients with Severe Sepsis or Septic Shock

Background

Current evidence suggests that administration of appropriate antibiotic therapy within 1 h after the onset of hypotension significantly improves mortality rates among patients with severe sepsis and septic shock.

Objectives:

To determine the interval from recognition of severe sepsis or septic shock in inpatients to initial administration of antibiotic and to assess institutional compliance with the Surviving Sepsis Campaign’s recommendation for early antibiotic therapy.

Methods:

A 6-month retrospective chart analysis was conducted to determine the interval from documented onset of hypotension to initial administration of antibiotic for patients with severe sepsis or septic shock. Patients who were admitted to a general medicine ward, a surgery ward, or the intensive care unit (ICU) of a 475-bed university-affiliated hospital and who met the criteria for severe sepsis or septic shock were eligible for inclusion. Patients who received antibiotics before meeting the criteria for severe sepsis or septic shock were excluded.

Results:

Charts for 100 patients with severe sepsis or septic shock were reviewed. The mean age was 69.0 years (standard deviation 18.7 years), and 56% were men. The median interval from onset of severe sepsis or septic shock to administration of antibiotic was 4.00 h (interquartile range [IQR] 1.80–6.45 h). The median interval from the time a physician ordered an antibiotic to administration of the drug was 1.28 h (IQR 0.57–3.05 h). The interval between ordering and administration differed significantly for patients on the wards (5.67 h), those with onset in the ICU (4.00 h), and those with onset in the emergency department (3.28 h) (p = 0.039). The overall survival rate was 56%.

Conclusion:

At the study hospital, the interval from onset of severe sepsis or septic shock to initial administration of antibiotic to inpatients exceeded the 1-h period recommended by the Surviving Sepsis Campaign. These results will be used as a baseline for future quality assurance and improvement initiatives aimed at minimizing the time to antibiotic administration for this group of patients, who are at high risk of death.     

Impact of noncompliance with alendronate and risedronate on the incidence of nonvertebral osteoporotic fractures in elderly women

AIMS

To evaluate the association between noncompliance with alendronate and risedronate and the risk of nonvertebral osteoporotic fracture in community-dwelling elderly women.

METHODS

A nested case–control study was conducted using the Quebec administrative health databases. To be included in the cohort, women needed to be aged ≥ 68 years and to have initiated treatment with alendronate or risedronate between 1 January 2002 and 31 March 2005. Cases consisted of all women with an incident nonvertebral osteoporotic fracture occurring ≥ 1 year after initiation of therapy. Each case was matched with up to 20 controls using incidence density sampling, according to age (± 1 year) and follow-up duration. A woman was noncompliant if she had a medication possession ratio (MPR) <80% for total follow-up duration. Rate ratios (RR) for fracture were estimated through conditional logistic regression analysis, adjusting for potential confounders.

RESULTS

Among the 30 259 women included in the cohort, 1036 nonvertebral fracture cases were identified and were matched to 20 069 controls. Compared with women with a MPR ≥ 80%, those with a MPR < 80% had a greater risk of nonvertebral fracture [adjusted RR 1.27, 95% confidence interval (CI) 1.12, 1.44]. Considering hip fracture only, the multivariate model yielded similar results, (adjusted RR 1.28, 95% CI 1.02, 1.61).

CONCLUSIONS

Among community-dwelling elderly women, noncompliance with alendronate or risedronate is associated with an increased risk of nonvertebral fracture.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• Compliance with alendronate and risedronate is suboptimal.
• Few studies have specifically evaluated the impact of noncompliance with alendronate or risedronate on the incidence of osteoporotic fractures in community-dwelling elderly women.

WHAT THIS STUDY ADDS

• Among community-dwelling elderly women, noncompliance [defined as medication possession ratio (MPR) < 80%] with alendronate or risedronate was associated with a 27% increased risk of nonvertebral fracture [rate ratio (RR) 1.27, 95% confidence interval (CI) 1.12, 1.44].
• This study is the first to assess the impact of noncompliance with bisphosphonates in a subgroup of women aged > 80 years.
• Among women aged > 80 years, MPR < 80% was associated with a 48% greater risk of sustaining a nonvertebral fracture (RR 1.48, 95% CI 1.19, 1.85), compared with women with a MPR ≥ 80%.

     

Identifying missed opportunities to curtail antimicrobial therapy for presumed ventilator-associated pneumonia using the clinical pulmonary infection score

Background:

Early discontinuation of antimicrobial therapy for ventilator-associated pneumonia can reduce the emergence of antimicrobial resistance, the occurrence of adverse drug events, and the cost of therapy. Evidence suggests that discontinuation of therapy by day 3 may be appropriate for patients with a clinical pulmonary infection score of 6 or less at baseline and on day 3.

Objectives:

To determine the proportion of patients eligible for antimicrobial discontinuation on day 3 and day 7 of therapy and to determine the proportion of eligible patients for whom antimicrobials were discontinued within these timeframes.

Methods:

A 6-month observational study was conducted from October 3, 2005, to March 31, 2006, in a 27-bed medical–surgical tertiary care intensive care unit. Clinical pharmacists attended daily rounds and prospectively identified patients for inclusion in the study. A study pharmacist retrospectively calculated clinical pulmonary infection scores. Other data were obtained from the quality-improvement database and patient health records for the intensive care unit.

Results:

Ninety-two patients were treated for ventilator-associated pneumonia during the study period, of whom 49 were included in the analysis. At day 3, 17 (35%) of the 49 patients were eligible for early discontinuation of antimicrobial therapy, but therapy was discontinued for only 2 (12%) of these 17 patients. At day 7, 10 (32%) of 31 patients were eligible for antimicrobial discontinuation, but therapy was discontinued for only 1 (10%) of these 10 patients.

Conclusions:

A significant opportunity exists at the authors’ institution to develop and implement an antimicrobial discontinuation policy that uses the clinical pulmonary infection score to guide antimicrobial use for patients with ventilator-associated pneumonia.