The incidence and virulence of Clostridium difficile infection (CDI) has recently increased. National CDI treatment guidelines stratify patients based on clinical symptoms and recommend treatment based on severity of illness. In 2009, Advocate Lutheran General Hospital (Park Ridge, Illinois) adopted guidelines with treatment algorithms identical to the national guidelines. The purpose of this study was to determine whether patients were being treated in accordance with the CDI guidelines and whether adherence impacted patient outcomes.This was a retrospective, descriptive study. Subjects were identified by CDI-associated ICD-9 codes from July 1, 2009 to June 30, 2011 and stratified by disease severity. Guideline adherence was assessed based on initial treatment selection, and subjects were then further categorized as undertreated (UT), overtreated (OT), or appropriately treated (AT). Secondary endpoints included need for therapy escalation, clinical cure, recurrence rates, 90-day all-cause mortality, proton pump inhibitor (PPI), and antimicrobial use.Two hundred fifty subjects totaling 324 encounters were analyzed. Overall guideline adherence was 42.9%. Adherence rates by CDI severity were mild-moderate, 53.9%; severe, 39.0%; and severe-complicated, 17.9% (P < .001). Of all the subjects, 42.9% were AT, 30.9% were OT, and 26.2% were UT. Clinical outcomes between UT versus AT subjects were as follows: therapy escalation required, 34.1% versus 27.5% (P = .289); clinical cure, 41.2% versus 55.7% (P = .033); mortality, 24.7% versus 10.1% (P = .003); and recurrence, 44.7% versus 24.8% (P < .02). Clinical outcomes between AT versus OT subjects were as follows: therapy escalation required 27.5% versus 14.4% (P < .02); clinical cure, 55.7% versus 66.7% (P = .089); mortality, 10.1% versus 7.8% (P = .553); recurrence, 24.8% versus 27.8% (P = .871).The majority of subjects were not treated according to CDI guidelines, particularly those with severe and severe-complicated disease. UT subjects had worse clinical outcomes and OT subjects failed to show significant improvements in clinical outcomes compared to AT subjects. Emphasis should be placed on CDI guideline adherence as this may be associated with improved outcomes.
More than half of all medications are inappropriately prescribed, dispensed, or sold and only 50% of patients take their medications correctly. Oftentimes, unwanted or expired medications are saved for later use, stored indefinitely, or disposed via the sink, toilet, or garbage.To determine how residents in Cook County, Illinois, use, store, and dispose of their medications to assess the possible impact of these medications on health care and the environment.Researchers at the University of Illinois conducted a survey of Cook County residents over a 13-week period. Residents were surveyed regarding their use, storage, and disposal of prescription and nonprescription medications.From 3954 telephone numbers generated through random-digit dialing, 445 telephone interviews were completed. Eighty-one and a half percent of respondents had prescription medications and 92.4% had nonprescription medications in their homes. On average, respondents possessed 4.4 distinct prescription and 5.5 distinct nonprescription medications. Despite possessing a number of medications, approximately 30% of respondents stated that they took no medication on a regular basis; 59% of respondents reported disposing medications in the household gar bage and 31% flushed them down the toilet or sink. Over 80% of respondents stated that they had never received information about proper medication disposal. Thirty-seven percent reported having leftover unexpired medications from a previous illness. Of these, 63% stopped taking their medications because they believed that they no longer needed them or because they felt better. Thirty-two percent of respondents expected to have leftover prescription medications within the next 6 months.Almost all respondents had excess and leftover medications in their homes. This may be a result of both overprescribing and poor medication adherence. In addition to the potential human health risk of nonadherence, disposal of excess medication raises concerns about their environmental impact and safety.
Abstract Background The Clinical and Laboratory Standards Institute (CLSI) lowered the minimum inhibitory concentration (MIC) breakpoints of various β-lactam antimicrobials eliminating the need for confirmatory testing of extended-spectrum β-lactamase (ESBL) organisms. Our institution adopted the new CLSI breakpoints in June 2015. This multi-site study assessed the impact of laboratory cessation of ESBL reporting on the MIC distribution of commonly used antimicrobials and clinical outcomes. Methods This retrospective study included adult inpatients with positive blood cultures for Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or Proteus mirabilis from June 2012 to June 2018. Patients were included in the pre-implementation group if they had an ESBL-positive blood culture from June 2012 to May 2015 and in the post-implementation group if they had a ceftriaxone-resistant organism from June 2015 to June 2018. Patients who died or transitioned to hospice within 48 hours of blood culture identification or before final susceptibilities were excluded. The primary outcome was MIC distribution of ceftriaxone, ceftazidime, cefepime, piperacillin/tazobactam, fluoroquinolones, and carbapenems. Secondary outcomes were antimicrobial prescribing patterns, 30-day all-cause mortality, 30-day re-infection rate, and time to microbiological clearance. Results A total of 249 patients were included (n = 40, pre-implementation; n = 209, post-implementation). Pitt Bacteremia Scores were significantly higher in the pre-implementation group (3.59 ± 2.85 vs. 2.21 ± 2.06; P = 0.0004). The median MIC distribution for each antimicrobial stayed within one dilution throughout the study timeframe. Carbapenem use decreased in the post-implementation group [n = 35 (87%) vs. n = 131 (63%)]. No significant differences were noted for other secondary outcomes: 30-day all-cause mortality (15% vs. 10%; P = 0.40), 30-day re-infection rate (2.5% vs. 4.3%; P = 1), and time to microbiological clearance (2.28 ± 1.2 vs. 2.41 ± 1.76 days; P = 0.72). Conclusion Adoption of lowered CLSI breakpoints did not impact MIC distribution of select antimicrobials for Enterobacteriaceae; however, it has affected antimicrobial prescribing patterns. Disclosures All authors: No reported disclosures.
The methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) has a negative predictive value of 95.2–99.2% for MRSA pneumonia. Negative MRSA nasal PCR results can be used as an effective tool to discontinue unnecessary empiric vancomycin therapy. This single-center, pre–post quasi experimental pilot study evaluated the impact of a pharmacist-led MRSA nasal PCR screening protocol on vancomycin days of therapy (DOT) in patients with pneumonia. All adult patients with IV vancomycin ordered for pneumonia admitted to nonintensive care units were included. Patients who received nasal mupirocin, transitioned to hospice during admission, or had another indication requiring vancomycin were excluded. Pharmacists ordered an MRSA nasal PCR, per protocol, upon order verification. Negative results were used to recommend vancomycin discontinuation when appropriate. Prospective data were compared with a random retrospective cohort during a similar time frame the previous year. The primary outcome was vancomycin DOT before and after protocol implementation. Secondary outcomes included length of stay, quantity of vancomycin levels obtained, in-hospital mortality, acute kidney injury incidence, adherence to the protocol, and need for antimicrobial escalation. A total of 130 patients were included (n = 65, pre-intervention; n = 65, post-intervention). No statistically significant differences were observed in the demographics between the two groups. The median reduction in vancomycin DOT was 1.4 days [2.9 days (IQR 1.8–4.1) vs. 1.5 days (IQR 0.7–2.3); P < 0.001]. The percentage of IV vancomycin ordered for pneumonia was reduced by 5.2% (19.6% vs. 14.4%; P = 0.036). The protocol also resulted in a decreased median number of serum vancomycin levels (P < 0.001). No statistically significant differences were observed in the secondary outcomes, and there were no adverse clinical outcomes. Protocol adherence was 67.9% overall. Implementation of a pharmacist-led MRSA surveillance protocol significantly reduced vancomycin days of therapy, reduced serum vancomycin levels, and had no unintended adverse consequences for respiratory tract infections. Results from this pilot project will be used to expand this protocol systemwide. All authors: No reported disclosures.
Traditional antibiograms use local resistance patterns and susceptibility data to guide empiric antimicrobial therapy selection. However, antibiograms are rarely unit-specific and do not account for patient-specific risk factors. The objective was to develop an Emergency Department (ED)-specific antibiogram and evaluate the impact of risk factors on antimicrobial susceptibility. This retrospective, single-center descriptive study used culture and susceptibility data from January 1 to December 31, 2016 to create an ED-specific antibiogram for the most commonly isolated organisms. Susceptibilities were then compared with the hospital antibiogram. All ED isolates were further stratified by the following risk factors: age, disposition from ED, previous antimicrobial use and/or hospitalization within 30 days, and presenting location. Descriptive statistics, Pearson Chi-Square/Fisher’s Exact Tests, and logistic regression were performed. A two-tailed p-value of <0.05 was considered statistically significant. A total of 2158 isolates from the ED were included: Escherichia coli (EC) (n = 1244), Klebsiella pneumoniae (KP) (n = 232), Proteus mirabilis (PM) (n = 131), Pseudomonas aeruginosa (PA) (n = 103), Staphylococcus aureus (SA) (n = 303), and Enterococcus faecalis (EF) (n = 145). The majority of patients were <65 years old (n = 1088) and presented from the community (n = 1800) with no antimicrobial exposure (n = 1628) nor hospitalization (n = 1895) within 30 days. There were no statistically significant differences between the ED and hospital antibiogram (n = 5739) for KP, PM, PA, SA, and EF. The hospital antibiogram overestimated EC resistance rates for cefazolin (20% vs. 15.6%, P = 0.049), ceftriaxone (9.6% vs. 6.4%, P < 0.033), and ciprofloxacin (23.7% vs. 15.4%, P < 0.006). There were significantly more risk factors present in patients discharged from the ED vs. those admitted (P < 0.0001). Healthcare facility residence had the greatest impact on susceptibility, especially EC (81.8% vs. 34.9%, P < 0.0001) and PM (75.3% vs. 33%, P < 0.0001) ciprofloxacin susceptibility. Development of an ED-specific antibiogram can aid physicians in prescribing appropriate empiric therapy when risk factors are included. All authors: No reported disclosures.
The incidence and virulence of Clostridium difficile infection (CDI) has recently increased. National CDI treatment guidelines stratify patients based on clinical symptoms and recommend treatment based on severity of illness. In 2009, Advocate Lutheran General Hospital (Park Ridge, Illinois) adopted guidelines with treatment algorithms identical to the national guidelines. The purpose of this study was to determine whether patients were being treated in accordance with the CDI guidelines and whether adherence impacted patient outcomes.This was a retrospective, descriptive study. Subjects were identified by CDI-associated ICD-9 codes from July 1, 2009 to June 30, 2011 and stratified by disease severity. Guideline adherence was assessed based on initial treatment selection, and subjects were then further categorized as undertreated (UT), overtreated (OT), or appropriately treated (AT). Secondary endpoints included need for therapy escalation, clinical cure, recurrence rates, 90-day all-cause mortality, proton pump inhibitor (PPI), and antimicrobial use.Two hundred fifty subjects totaling 324 encounters were analyzed. Overall guideline adherence was 42.9%. Adherence rates by CDI severity were mild-moderate, 53.9%; severe, 39.0%; and severe-complicated, 17.9% (P < .001). Of all the subjects, 42.9% were AT, 30.9% were OT, and 26.2% were UT. Clinical outcomes between UT versus AT subjects were as follows: therapy escalation required, 34.1% versus 27.5% (P = .289); clinical cure, 41.2% versus 55.7% (P = .033); mortality, 24.7% versus 10.1% (P = .003); and recurrence, 44.7% versus 24.8% (P < .02). Clinical outcomes between AT versus OT subjects were as follows: therapy escalation required 27.5% versus 14.4% (P < .02); clinical cure, 55.7% versus 66.7% (P = .089); mortality, 10.1% versus 7.8% (P = .553); recurrence, 24.8% versus 27.8% (P = .871).The majority of subjects were not treated according to CDI guidelines, particularly those with severe and severe-complicated disease. UT subjects had worse clinical outcomes and OT subjects failed to show significant improvements in clinical outcomes compared to AT subjects. Emphasis should be placed on CDI guideline adherence as this may be associated with improved outcomes.
