Faculty Bibliography

PURPOSE:A critical shortage of small-volume parenteral solutions in late 2017 led hospitals to develop strategies to ensure availability for critical patients, including administration of antibiotics as intravenous push (IVP). Minimal literature has been published to date that assesses the safety of administration of beta-lactams via this route. Therefore, the purpose of this study was to evaluate the safety of IVP administration of select beta-lactam antibiotics. METHODS:We performed a retrospective review of IVP administrations of aztreonam, ceftriaxone, cefepime, and meropenem at two campuses of the New York University Langone Health system after October 2017. Patients receiving surgical prophylaxis or more than one IVP antibiotic simultaneously were excluded. The primary endpoint was adverse events (ADE) following IVP administration of antibiotics. RESULTS:We evaluated 1000 patients who received IVP aztreonam (n = 43), ceftriaxone (n = 544), cefepime (n = 368) or meropenem (n = 45). There were 10 (1%) ADE observed, 5 of which were allergic reactions. Four ADE were neurotoxicity related to IVP cefepime. Based on the Naranjo score, 1 adverse event was "probably" and 3 were "possibly" related to cefepime IVP administration. Lastly, only 1 report of phlebitis was observed with the use of IVP ceftriaxone. CONCLUSIONS:The use of IVP as an alternative to intravenous piggyback (IVPB) during times of drug shortage for select beta-lactam antibiotics appears to be safe, and ADE are similar to those previously described for IVPB administration. Future studies evaluating clinical outcomes between IVP and IVPB administration may be of benefit.

Background. Appropriate periprocedural antibiotic prophylaxis is critical to optimize in order to reduce excessive antibiotics exposure for patients and to minimize the risk for procedure-related infection. Wrong antibiotic or excess antibiotics increase the risk for development of antimicrobial resistance, Clostridium difficile infection, adverse side effects. Incorrect or missed antibiotic can put the patient at risk for an infection. Methods. Interventions included education of vascular and interventional radiology (IR) consult RN and physicians regarding updated institutional antimicrobial prophylaxis guidelines for vascular and IR procedures, creation of a consulting template that incorporated ongoing antibiotics. Review of recent cultures was incorporated into workflow and consult evaluation. Handoff between the IR RN and IR attendings was expanded to include a review of antimicrobials. Results. All IR cases were reviewed for antibiotic administration for 3 months preand post-intervention. In the pre-intervention timeframe, 23 of 290 procedures (7.9%) were associated with inappropriate antibiotic administration, further delineated as 6 cases where no antibiotics were given, 7 cases of inappropriate antibiotics administered, and 10 cases where extraneous antibiotics were administered. Of the 39 total procedures where antibiotics were indicated, 17 (43.6%) were associated with antibiotic errors. In the post-intervention period, only 9 of 309 total procedures (10.3%) were associated with inappropriate antibiotic administration: missed antibiotics in 3 cases, inappropriate antibiotics in 4 cases, and unnecessary antibiotics in 2 cases. Of the 32 cases where antibiotics were indicated, only 7 (21.9%) were associated with antibiotic errors. Conclusion. Incorporating current antibiotics and review of culture data in a preoperative review and template for patients who need a surgical procedure helps guide appropriate antibiotic decision-making and greatly decreases administration of unnecessary antibiotics

Oritavancin (Orbactiv): a new-generation lipoglycopeptide for the treatment of acute bacterial skin and skin structure infections.

Purpose: Leveraging pharmacy personnel resources for the purpose of antimicrobial stewardship program (ASP) operations presents a challenging task. We describe our experience integrating all pharmacists into an ASP, and evaluate the impact on ASP interventions, antimicrobial utilization, rate of selected hospital-onset infections and readmission. Summary: During a study period (January 1 to December 31, 2015), a total of 14 552 ASP-related pharmacy interventions were performed (ASP clinical pharmacotherapy specialists [CPS] n = 4025; non-ASP CPS n = 4888; hospital pharmacists n = 5639). Sixty percent of interventions by ASP CPS were initiated utilizing the dedicated ASP phone, and 40% through prospective audit and feedback. Non-ASP CPS performed interventions during bedside rounds (dose adjustment 23%, initiate new or alternative anti-infective 21%, discontinue antibiotic(s) 12%, therapeutic drug monitoring 11%, de-escalation 4%), whereas hospital pharmacists participated at the point of verification (dose adjustment 75%, restricted antibiotic verification 15%, and reporting major drug-drug interactions 4%). The acceptance rate of interventions by providers and clinicians was >90% for all groups. Annual aggregate antimicrobial use decreased by 6.4 days of therapy/1000 patient-days (DOT/1000 PD; P = 1.0). Ceftriaxone use increased by 8.4 DOT/1000 PD (P = .029) without a significant compensatory increase in the use of antipseudomonal agents. Sustained low rates of hospital-onset Clostridium difficile (CDI) and carbapenem-resistant Enterobacteriaceae (CRE) infections were observed in 2015 compared with the prior year (1.1 and 1.2 cases/1000 PD, 0.2 and 0.1 cases/1000 PD, respectively). Thirty-day readmission rate decreased by 0.6% (P = .019). Conclusions: Integration of all pharmacists into ASP activities based on the level of patient care and responsibilities is an effective strategy to expand clinical services provided by ASP.