Abstract Background In accordance with the American Thoracic Society (ATS) guidelines for community-acquired pneumonia (CAP), ceftriaxone plus a macrolide is commonly used as first-line for inpatient treatment of non-severe CAP(Metlay, 2019). In a community hospital, a CAP protocol was implemented to grant pharmacists the capability to discontinue antibiotics, including ceftriaxone, after 5 days of treatment in hospitalized patients that have reached clinical stability. On the other hand, extended treatment duration of ceftriaxone can lead to increased resistance, Clostridium difficile infections, adverse effects and cost (Guo 2017, Thomas 2002). The objective of this study is to compare patient outcomes between patients using ≤5 days (recommended duration) and >5 days (extended duration) of ceftriaxone. Methods This study is a retrospective chart review in a community hospital, from Nov 1, 2022 to April 30, 2023. Adult patients treated with ceftriaxone for ≥ 3 days for CAP were included. Patients treated for non-pulmonary infections and/or co-infections were excluded. The primary outcome of this study is 30-day mortality; secondary outcomes include length of stay, and Clostridium difficile infection within 90 days. Outcomes were analyzed with Chi-square/Fischer’s exact test, normality test, student t-test, and Mann-Whitney U test using Prism Version 10. IRB Number: 2024-167 AHGL Results The 30-day all-cause mortality was 7.1% for the ≤5 days group (N = 379) and 7.8% for the >5 days group (N = 166) was not statistically significant (p = 0.77). Length of stay median with interquartile range (IQR) was 6 (IQR 4-9) for the ≤5 days group and 8 (IQR 6-11) for the >5 days group (p < 0.01). The Clostridium difficile infection prevalence of 0.5% in the ≤5 days group and 0% in the >5 days group was too low to make any relevant analysis. Conclusion This study comparing patient outcomes between ≤5 days and >5 days durations of ceftriaxone for community-acquired pneumonia (CAP) revealed no significant difference in 30-day all-cause mortality rates but a significantly shorter hospital stays in ≤5 days group, which suggests that shorter ceftriaxone durations as per protocol can potentially optimize patient care by reducing hospital stays without compromising mortality outcome. Disclosures All Authors: No reported disclosures
Abstract Background Over 90% of children with reported penicillin allergy can tolerate penicillin without incident. Developing effective and safe strategies to remove inappropriate penicillin allergies has the potential to improve care; however, guidance on how to identify, test, and delabel patients is limited. Methods In April 2019, Children’s Hospital Colorado (CHCO) implemented a penicillin allergy clinical pathway (CP) alongside a risk assessment tool to stratify patients based on allergic history (Figure 1). Patients at “no increased risk” were educated and delabeled without testing. Low risk patients were offered an oral amoxicillin drug challenge with close observation. A single, non-graded, treatment dose of amoxicillin (45 mg/kg, max dose 1000mg) was used for low risk patients, and no preceding allergic skin testing was performed. Patients with no signs or symptoms of allergic response 60 minutes after amoxicillin administration were delabeled. Children delabeled of penicillin allergies on the CHCO hospital medicine service were compared between the pre-CP (1/1/17-3/31/19) and post-CP (4/1/19-3/31/20) cohorts. Figure 1. Penicillin Allergy Risk Assessment Results Pre-CP, 683/10624 (6.4%) patients reported a penicillin allergy and 18/683 (2.6%) were delabeled by discharge. Post-CP, 345/6559 (5.3%) patients reported a penicillin allergy and 47/345 (13.6%) were delabeled by discharge (P-value < 0.0001, Figure 2). Among the 47 post-CP patients, 11 were delabeled by history alone, 19 underwent oral amoxicillin drug challenge per CP, and 17 received a different treatment dose penicillin per treatment team. Only one penicillin-exposed patients had a reaction. This patient developed a delayed, non-progressive rash and had penicillin allergy restored to their chart. No patient required emergency medical intervention, and none were “relabeled” penicillin allergic in the 6 months following discharge. Figure 2. Monthly Rate of Penicillin Allergic Patients Delabeled by Discharge Conclusion A drug challenge using a single non-graded dose of oral amoxicillin is a safe and effective strategy to delabel low risk children of inappropriate penicillin allergies when implemented alongside a risk assessment tool. Further studies are needed to evaluate the long-term benefits of delabeling inappropriate penicillin allergies and to continue monitoring for adverse events. Disclosures All Authors: No reported disclosures
Multisystem inflammatory disorder in children (MIS-C) is a recently identified rare disease process seen in some children after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. As a new disease entity, there have been efforts to clarify the diagnostic criteria for MIS-C to most accurately identify patients with this disease, while differentiating them from those with severe acute coronavirus disease 2019 (COVID-19). In this study, the researchers aimed to compare the clinical characteristics and outcomes of children and adolescents with MIS-C and those with severe COVID-19 to better distinguish between these disease states.In this case series, 1116 patients were included who were ≤21 years of age hospitalized between March and October 2020 from 66 hospitals across 31 states. A total of 539 of these patients had MIS-C, and 577 patients had severe acute COVID-19. The Centers for Disease Control and Prevention definition for MIS-C was used in this study, which includes children <21 years old, fevers >38°C for >24 hours, clinically severe illness of ≥2 organs (multisystem involvement), no other plausible diagnosis, and evidence of current or recent SARS-CoV-2 infection or recent exposure. Severe acute COVID-19 was defined by clinical consensus criteria, including a positive reverse-transcriptase polymerase chain reaction test for SARS-CoV-2 and severe involvement of ≥1 organ systems.Patient surveillance data in the Overcoming COVID-19 network registry for hospitalized patients <12 years old with MIS-C and severe acute COVID-19 were included in the analysis. Sex, race, ethnicity, comorbid conditions, presenting signs and symptoms, laboratory values within 48 hours of admission, severe complications, and clinical outcomes were compared between the 2 groups in the registry. Multivariable regression was used to compute adjusted risk ratios of factors associated with COVID-19 versus those associated with MIS-C.Compared with patients with severe COVID-19, patients with MIS-C were more likely to be 6 to 12 years of age and of non-Hispanic Black race. Patients with MIS-C also had a higher neutrophil to lymphocyte ratio, higher C-reactive protein, and lower platelet count, when compared with those with severe COVID-19. Clinical syndromes, including cardiorespiratory involvement, cardiovascular without respiratory involvement, and mucocutaneous without cardiorespiratory involvement, were more likely in the MIS-C group, compared with the severe COVID-19 group. Both groups had similar rates of severe respiratory involvement without cardiovascular involvement and death rates during hospitalization. In patients with MIS-C who received echocardiograms, 34% of them had depressed left ventricular ejection fraction (LVEF); however, 91% had returned to a normal LVEF by 30 days, and 99% of those evaluated had a normal LVEF by 90 days. A total of 13% of patients with MIS-C who were evaluated for coronary aneurysms had aneurysms identified; 79% of those aneurysms resolved by 30 days, and 100% resolved by 90 days.There are patterns of clinical presentation in MIS-C and severe COVID-19 in a large cohort that can help differentiate these 2 disease processes and inform appropriate treatment. The cardiac involvement seen in MIS-C has a high likelihood of resolving over time.MIS-C and severe acute COVID-19 are currently understood to be discrete disease entities but often have overlapping clinical features, making it difficult to differentiate the 2 in some instances. Given that MIS-C is newly identified, in this study, the authors sought to clarify the defining features that discriminates between these 2 disease states. In this large case series, the authors were able to find differentiating factors including age, race, and clinical presentations. Mucocutaneous findings were more likely seen in MIS-C and may be a defining feature that is easy for the clinician to identify to support a diagnosis of MIS-C. Finally, laboratory values suggesting an inflammatory state such as elevated C-reactive protein and an increased neutrophil to lymphocyte ratio can help clinicians differentiate MIS-C from severe COVID-19.
Penicillin allergy is reported in up to 10% of the general population; however, >90% of patients reporting an allergy are tolerant. Patients labeled as penicillin allergic have longer hospital stays, increased exposure to suboptimal antibiotics, and an increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. The primary aim with our quality improvement initiative was to increase penicillin allergy delabeling to at least 10% among all hospitalized pediatric patients reporting a penicillin allergy with efforts directed toward patients determined to be low risk for true allergic reaction.Our quality improvement project included several interventions: the development of a multidisciplinary clinical care pathway to identify eligible patients, workflow optimization to support delabeling, an educational intervention, and participation in our institution's quality improvement incentive program. Our interventions were targeted to facilitate appropriate delabeling by the primary hospital medicine team. Statistical process control charts were used to assess the impact of this intervention pre- and postpathway implementation.After implementation of the clinical pathway, the percentage of patients admitted to hospital medicine delabeled of their penicillin allergy by discharge increased to 11.7%. More than one-half of those delabeled (51.2%) received a penicillin-based antimicrobial at time of discharge. There have been no adverse events or allergic reactions requiring emergency medication administration since pathway implementation.Our quality improvement initiative successfully increased the rate of penicillin allergy delabeling among low-risk hospitalized pediatric patients, allowing for increased use of optimal antibiotics.
