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Implementing an Inpatient Pediatric Prospective Audit and Feedback Antimicrobial Stewardship Program Within a Larger Medical Center

Lighter-Fisher, Jennifer; Desai, Sonya; Stachel, Anna; Pham, Vinh Philip; Klejmont, Liana; Dubrovskaya, Yanina
BACKGROUND: Pediatric antimicrobial stewardship programs (ASPs) within larger institutions have unique opportunities to develop programs specialized to the needs of the pediatric program. In January 2013, our institution established a formalized pediatric ASP utilizing the prospective audit and feedback process. In an effort to standardize therapy and improve quality of care, members of the ASP developed evidence-based guidelines for management of common inpatient pediatric infections. ASP members met periodically with faculty and house staff to discuss guidelines and ways to improve prescribing. METHODS: Provider adherence with clinical inpatient practice guidelines, frequency of interventions suggested by ASP, and acceptance of interventions by providers were elements used to measure process change. We measured outcome data by analyzing antimicrobial utilization (defined as days of therapy) and length of therapy. RESULTS: Over a period of 2 years, institutional ASP guidelines were applicable to nearly half (44%) of all antimicrobial orders. Interventions were performed on 30% of all antimicrobial orders, of which 89% were accepted. Total antimicrobial days of therapy and length of therapy decreased significantly when comparing pre- and post-ASP. Overall, the susceptibility profiles of common bacterial pathogens to antibiotics remained stable. CONCLUSIONS: Pediatric ASPs within larger institutions have opportunities to create programs specific to the needs of the population they serve. We observed high rates of adherence by providers and a subsequent reduction in antibiotic utilization when implementing an audit feedback-based process.
PMID: 28814444
ISSN: 2154-1663
CID: 2670742

Promoting judicious antibiotic use: Results of an outpatient-based randomized EMR-generated intervention study [Meeting Abstract]

Stachel, A; Szerencsy, A; Pulgarin, C; Fucito, N; Pham, V
Background. According to the CDC, up to 50% of antibiotic (abx) prescriptions are not needed or inappropriate-often used too long or too broadly. Repercussions include multidrug resistance, adverse reactions, and increased incidence and mortality from Clostridium difficile. A JAMA study demonstrated that IDSA guidelines can influence abx prescribing patterns positively for genitourinary infections. In this electronic age, interventions include providing direct access to guidelines through a Best Practice Alert (BPA) embedded within electronic medical records (EMR). This assists clinicians when recommending abx. The study's goal was to improve compliance with guidelines when treating uncomplicated UTIs at outpatient sites by using targeted education and Clinical Decision Support (CDS). Methods. Outpatient sites were randomized with matching into two groups: BPA intervention group (IG) (71 sites; 4,555 visits) or control group (CG) (56 sites; 2,078 visits). The BPA listed the appropriate abx regimens according to guidelines. A second modification presented all providers with a list of abx options including dosage and frequency. The effects of two CDS interventions were assessed for one year. Results. Results indicate the IG improved in BPA abx compliance over the CG. Figure 1 shows compliance with BPA recommended antibiotics among the IG increased from 17% to 23% during Q1 2014-Q2 2017 compared with a 0% increase in the CG (P <.0001). However, overall IDSA recommended compliance did not significantly increase: IG -2% vs CG 1% (P = .26). UTI patients of providers who saw the BPA alert were 1.9 times (CI: 1.7, 2.3) times more likely to receive recommended abx compared with the CG. Conclusion. This randomized control study provides promising data that the use of CDS, specifically BPAs embedded within EMRs, can be used effectively to assist and encourage compliance with guidelines. Next steps include: continuing to educate providers on best practices, consider including more abx options in BPA to reduce errors in prescribing and improve overall compliance, and implementing similar CDS interventions for upper respiratory infections and other infections. (Figure Presented)
EMBASE:628003365
ISSN: 2328-8957
CID: 3931572

Meropenem extended infusion (EI) vs. (vs) standard infusion (SI) in critically ill patients: Evaluation of outcomes [Meeting Abstract]

Ahmed, N; Jen, S -P P; Altshuler, D; Papadopoulos, J; Pham, V; Dubrovskaya, Y
Background. Due to altered pharmacokinetics/pharmacodynamics in critically ill patients, administration of beta-lactams as EI provides better target attainment in therapeutic drug monitoring studies. To optimize meropenem (MER) dosing in patients with severe sepsis or septic shock, our antimicrobial stewardship program implemented a MER EI protocol in an 18-bed medical intensive care unit (MICU) in March 2014. Methods. We conducted a retrospective evaluation to compare outcomes in MICU patients with severe sepsis and septic shock who received MER for >=72h administered as EI 1 g over 3 h Q8H with a total daily dose (TDD) 3g (1/2015-1/2017) vs. SI 500 mg over 30 minutes Q6H with TDD 2 g (1/2012-1/2014). ICU mortality and clinical response (CR) were evaluated as endpoints. CR was defined by improvement in signs and symptoms of infection. Results. Of 667 patients who received MER, 148 were included (EI n = 52, SI n = 96). Age, weight, comorbidities (malignancy 31 vs. 33%, P = 0.8; chronic liver disease [CLD] 15 vs. 23%, P = 0.4), severity of illness (median mAPACHE II 18 vs. 19, P = 0.6; SOFA 5 vs. 6, P = 0.5) and vasopressors' use (75 vs. 79%, P = 0.5) were comparable between EI and SI groups. Serum creatinine (SCr) was lower in EI group (median 1.1 vs. 1.4 SI, P = 0.05). Gram-negative (GN) pathogens (MIC<=0.25 mg/mL, 94%) were identified in 44% of patients in EI vs. 38% in SI group, P = 0.5. MER TDD was higher in EI group (3 vs. 1.5g SI, P < 0.01) with no difference in use of combination therapy (64 vs. 46%, P = 0.06). ICU mortality (median time to death 9 days) was lower (19 vs. 37%, P = 0.047) and CR was higher (83 vs. 46%, P = 0.038) in EI vs. SI group. Total pressor days on MER were shorter (2 vs. 3 days, P < 0.01) and white blood cell normalization rate was higher (87% vs. 51%, P < 0.01) in EI vs. SI group, whereas there was no difference in days of mechanical ventilation, duration of MER therapy and ICU stay. After adjusting for SCr, severity of illness scores, combination therapy and SI group in a multivariate model, CLD (OR 3.3, 95% CI 1.36-7.77, P = 0.008) and lower MER TDD (OR 1.8, 95% CI 1.09-2.98, P = 0.02) were independent predictors of ICU mortality. Conclusion. In this cohort of MICU patients with severe sepsis or septic shock and low MIC of GN pathogens, there was improved mortality and CR in MER EI group. Our finding of potential benefit of higher MER TDD in these patients warrants further exploration in a prospective study
EMBASE:628004417
ISSN: 2328-8957
CID: 3931582

Eight years of antimicrobial stewardship program (ASP) at a large academic medical center: Antibiotic utilization, hospital-onset clostridium difficile infection (HO-CDI) and resistance trends [Meeting Abstract]

Dubrovskaya, Y; Stachel, A; Inglima, K; Siegfried, J; Jen, S -P P; Pham, V; Aguero-Rosenfield, M; Phillips, M
Background. Antibiotic (ABX) use and outcome measures (rate of HO-CDI, local antimicrobial resistance) are recommended ASP metrics. These metrics can be used for internal benchmarking to assess ASP performance within an institution over time. Methods. An adult ASP at our 750-bed academic medical center was implemented in 2008. ASP interventions include prospective audit and feedback, prior authorization with fuoroquinolone (FLQ) restriction as an ASP target and implementation of facility-specifc guidelines for common infections. Newer ASP initiatives were Cepheid/Xpert for blood cultures with Gram-positive cocci in pairs and clusters with daily real-time ASP interventions (11/2014), oral vancomycin secondary prophylaxis for patients with prior CDI (4/2014) and optimization of beta-lactam (BL) dosing (pip-eracillin-tazobactam [PTZ] extended infusion hospital-wide 4/2013; cefepime [CEF] 4/2015 and meropenem 7/2015 protocols). ABX use is measured in days of therapy per 1000 patient-days (DOT/1000 PD) and length of therapy/admission when ABX were administered (LOT/ADM). NHSN defnition is used for HO-CDI. For resistance trends the first unique isolate/patient/year regardless of source or susceptibility profle was included. Statistical analysis of trends during 8-years period 2009-2016 was performed by Poisson (SAS). Results. Major shifs in ABX use include decrease in FLQ use (-17%, P < 0.01) with compensatory increase in cefriaxone (CTX, +12%, P < 0.01), antipseudomonal BL (+3%, P < 0.01) and no change in carbapenem (+0.6%, P=0.5) as well as an increase in nafcillin and oxacillin (+7%, P < 0.01) use. There was a decrease in aggregate LOT/ADM (-4%, P < 0.01) with no change in DOT/1000 PD. We observed a decrease in HO-CDI rate (-17%, P < 0.01). Major resistance trends include reduction in Enterobacteriaceae spp. and Pseudomonas aeruginosa isolates nonsusceptible (NS) to FLQ (-4%, P < 0.01;-10%, P < 0.01, respectively) with increase in Enterobacteriaceae spp. NS to cefriaxone, (+3%, P < 0.01). A decrease in P. aeruginosa NS to PTZ (-11%, P < 0.01) and no change for CEF was reported. There was no Difference in Enterobacteriaceae spp. NS to PTZ or CEF. Conclusion. Overall, reported trends aligned with ASP initiatives. Increased CTX NS is of concern and warrants an ASP-led strategy to decrease CTX use
EMBASE:628119697
ISSN: 2328-8957
CID: 3943702

Reducing Postsurgical Wound Complications: A Critical Review

Delmore, Barbara; Cohen, Joshua Mitchell; O'Neill, Daniel; Chu, Andy; Pham, Vinh; Chiu, Ernest
GENERAL PURPOSE: To provide information on risk factors for surgical site infections (SSIs) and actions to mitigate that risk. TARGET AUDIENCE: This continuing education activity is intended for surgeons, surgical teams, physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify modifiable risk factors associated with the development of SSIs.2. Select steps to mitigate the risks for and morbidity from SSIs. ABSTRACT: Given the current reimbursement structure, the avoidance of a surgical site infection (SSI) is crucial. Although many risk factors are associated with the formation of an SSI, a proactive and interprofessional approach can help modify some factors. Postoperative strategies also can be applied to help prevent an SSI. If an SSI becomes a chronic wound, there are recommended guidelines and strategies that can foster healing.
PMID: 28520605
ISSN: 1538-8654
CID: 2562932

Hepatitis C in the correctional-community continuum of care: Poor baseline linkage rates and early improvement with care coordination [Meeting Abstract]

Akiyama, M; MacDonald, R; Jordan, A; Laraque, F; Columbus, D; Maurantonio, M; Schwartz, J; Pham, V; Carmody, E
Background. High volumes of hepatitis C (HCV)-infected detainees pass through US jails. However, short lengths of stay and competing priorities upon release complicate linkage to HCV care. We investigated linkage rates for patients with HCV following release from New York City (NYC) jails and describe a care coordination program (CCP) we initiated in June 2015 to improve linkage rates. Methods. We conducted a pre- and post-intervention study to assess rates of linkage related to the CCP. We used NYC Department of Health surveillance data to assess pre-intervention linkage rates for patients with chronic HCV seen in a correctional health clinic at Bellevue Hospital Center from January 2014 to June 2015. Linkage was defined as an HCV viral load or genotype <90 days in the community after release from an index incarceration. The CCP consists of a needs assessment, HCV education, and appointment scheduling for detainees, followed by reminder calls and appointment escort by a community patient navigator after re-entry. Statistical significance was determined using x2 tests. Results. Of 52 patients in the pre-intervention group, 24 (46.2%) were released from their index jail stay. Of those released, 10 of 24 (42%) were reincarcerated within a median of 247 days (IQR 129-318). The remaining 28 individuals were not released from their index incarceration and transferred to state prison. Of the 26 enrolled in the CCP as of April 2016, 13 (50%) have been released (6 linked, 4 pending linkage, and 3 not linked), 9 (34.6%) have not yet been released, and 4 (15.4%) have been transferred to state prison. Criteria for linkage to care within <90 days in the pre-intervention and intervention groups, respectively, were met by 3 of 24 (12.5%) versus 5 of 9 thus far (55.6%) (p = 0.01) and overall by 11 of 24 (45.8%) versus 6 of 9 thus far (66.7%) (p = 0.29). Conclusion. Pre-intervention linkage rates were low among HCV-infected detainees. While this study is ongoing, linkage in <90 days was significantly higher in the intervention group though not overall. These data provide early evidence that an integrated community-based CCP with jail-based transitional care coordinators may be effective in improving timely linkage to HCV care following release from jail
EMBASE:627784051
ISSN: 2328-8957
CID: 3904792

Preventing Infections in Children with Cancer

Lighter-Fisher, Jennifer; Stanley, Kaitlin; Phillips, Michael; Pham, Vinh; Klejmont, Liana M
PMID: 27252180
ISSN: 1526-3347
CID: 2122362

Virologic and serologic outcomes of mono versus dual HBV therapy and characterization of HIV/HBV coinfection in a US cohort

Kang, Minhee; Hollabaugh, Kimberly; Pham, Vinh; Koletar, Susan L; Wu, Kunling; Smurzynski, Marlene; Aberg, Judith A
OBJECTIVES: To characterize HIV/hepatitis B virus (HBV) coinfection in the AIDS Clinical Trials Group Longitudinal Linked Randomized Trials cohort and compare long-term HBV outcomes between regimens with 1 (MONO) or 2 (DUAL) anti-HBV agents. DESIGN: A retrospective study of coinfected AIDS Clinical Trials Group Longitudinal Linked Randomized Trials subjects who received regimens containing anti-HBV agent(s). METHODS: Stored samples at baseline and weeks 16, 32, 48, 144, and 240 were tested for HBV DNA, HBV e antigen (HBeAg), HBV e antibody (HBeAb), and hepatitis D virus (HDV) antibody. Resistance and genotype were tested in samples with HBV DNA >600 IU/mL. MONO versus DUAL analyses were limited to HBV treatment-naive subjects (Naive-MONO, Naive-DUAL). RESULTS: Of 150 study subjects, median age was 40 years, 96% were male; 57% white, 26% black, 13% Hispanic. Baseline median CD4 was 224 cells per cubic millimeter, HIV RNA 4.48 log10 copies/mL, HBV DNA 6.30 log10 IU/mL; 59% HBeAg positive and 65% HBeAb negative; HBV genotypes A = 69%, G = 18%, D = 7%, <2% for A/G, B, C, F, H. Coinfection with HDV was 2%. There were 49 Naive-MONO (lamivudine) and 22 Naive-DUAL (11 lamivudine + tenofovir, 11 emtricitabine + tenofovir) with detectable HBV DNA. In the 240-week follow-up, HBV DNA suppression was not significantly higher in Naive-DUAL (P = 0.14); lower baseline HBV DNA (P < 0.01) was associated with suppression. Among 32 Naive-MONO subjects with detectable HBV DNA at baseline and results at week 48, 41% suppressed; among such 15 Naive-DUAL subjects, 53% suppressed. HBeAg and HBeAb analyses showed similar trends. CONCLUSIONS: While consistent trends toward increased HBV DNA suppression, HBeAg loss and HBeAb seroconversion were observed in Naive-DUAL compared with Naive-MONO, they were not statistically significant. Overall, HDV coinfection was low.
PMCID:4169110
PMID: 24694927
ISSN: 1944-7884
CID: 2471742

Giant PPD Reaction With Positive Quantiferon-TB Gold in a Patient With Lepromatous Leprosy [Letter]

Murthy, Vivek K.; Horowitz, Harold W.; Pham, Vinh P.; Levis, William R.
ISI:000309569900002
ISSN: 1545-9616
CID: 181742

Virologic Outcome of Using Tenofovir/Emtricitabine to Treat Hepatitis B in HIV-Coinfected Patients

Engell, Christian A; Pham, Vinh Philip; Holzman, Robert S; Aberg, Judith A
Goal. To study the effect of combination antiviral therapy with tenofovir and emtricitabine or lamivudine with and without prior monotherapy with lamivudine. Study. We reviewed charts of 31 HIV-/HBV-coinfected patients. Twelve 3TC-naive patients initially received tenofovir plus emtricitabine. Nineteen epivir experienced patients who had previously failed epivir were given tenofovir plus emtricitabine. Results. Baseline median HBV DNA was similar in the epivir-naive (5.8x10(7) copies/mL) and experienced group (7.3x10(7) copies/mL, P = .65). The median time to complete suppression of HBV was 466 days in the naive group and 877 days in the experienced (P = .001). After 12 months, 6/10 (60%) naive patients and 3/14 (21%) experienced patients had HBV DNA below the detectionlimit (P = .067). After 24 months, 5/5 (100%) naive patients and 4/13 (31%) experienced patients had an undetectable HBV DNA level (P = .015). Conclusions. The median time to suppression of HBV DNA was significantly shorter among treatment naive patients. There was a significantly greater proportion of naive patients with suppressed HBV DNA at 24 months. Our results support using initial dual therapy in those with HIV/HBV coinfection
PMCID:3168392
PMID: 21991507
ISSN: 2090-4401
CID: 138717