Implementation of a comprehensive intervention focused on hospitalized patients with HIV by an existing stewardship program: successes and lessons learned.

BACKGROUND: Several national organizations have advocated for inpatient antiretroviral stewardship to prevent the consequences of medication-related errors. This study aimed to evaluate the impact of a stewardship initiative on outcomes in people with HIV (PWH). METHODS: A pharmacist-led audit and review of adult patients admitted with an ICD-10 code for HIV was implemented to an existing antimicrobial stewardship program. A quasi-experimental, retrospective cohort study was conducted comparing PWH admitted during pre- and post-intervention periods. Rates of antiretroviral therapy (ART)-related errors and infectious diseases (ID) consultation with linkage to care were evaluated through selection of a random sample of patients receiving ART in each period. Length of stay (LOS) and mortality were assessed by analyzing all admissions in the post-intervention period. Clinical outcomes including LOS, 30-day all-cause hospital readmission, and in-hospital and 30-day mortality in the post-intervention group were stratified by patients not on ART, on ART at admission, and started on ART as a result of the intervention. RESULTS: A total of 100 patients in the pre-intervention period and 103 patients in the post-intervention period were included to assess ART-related errors and linkage to care. A reduction in errors (70.0 versus 25.7%, p < 0.001) and increased linkage to care (19.0 versus 39.6%, p < 0.01) were demonstrated. Of 389 admissions during the post-intervention period, 30-day mortality rates were similar between PWH on ART at admission and those initiated on ART during admission (5% versus 8%, respectively), but less than those not on ART (21%). A longer LOS was observed in the patients started on ART during admission (5 days if ART started during admission versus 3 days if not started during admission, p < 0.01). CONCLUSIONS: This interdisciplinary intervention was successful in reducing inpatient ART-related errors and increasing ID consultation with linkage to care among PWH.

Empiric aztreonam is associated with increased mortality compared to beta-lactams in septic shock.

PURPOSE: To determine if aztreonam as initial empiric treatment of adult septic shock is associated with increased mortality compared to the use of anti-pseudomonal beta-lactam agents. METHODS: This was a multicenter, retrospective cohort study of 582 adult emergency department patients admitted to 12 acute care facilities within a single health system from January 2014 to December 2017 with septic shock receiving either aztreonam or an anti-pseudomonal beta-lactam for empiric treatment and discharged with an infection-related ICD-9 or ICD-10 code. The primary endpoint was in-hospital mortality. RESULTS: Initial exposure to aztreonam was associated with increased hospital mortality compared to treatment with an anti-pseudomonal beta-lactam agent (22.7% vs. 12.9%, OR = 1.98, 95% CI: 1.27-3.11). When adjusted for APACHE II score, the treatment group effect on mortality remained statistically significant (OR = 1.74, 95% CI: 1.08-2.80). Aztreonam use was also associated with increased utilization of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.01). There was no difference in hospital or intensive care unit length of stay in surviving patients between the two groups. CONCLUSIONS: Compared to anti-pseudomonal beta-lactams, empiric treatment with aztreonam is associated with increased mortality and greater antibiotic exposure among patients with acute septic shock. These findings suggest that treatment with anti-pseudomonal beta-lactams should be prioritized over allergy avoidance whenever feasible.

Novel developments in the treatment of acute bacterial skin and skin structure infections.

Introduction: Acute bacterial skin and skin structure infection (ABSSSI) represents a major burden for healthcare systems. The increased prevalence of Methicillin-resistant Staphylococcus aureus, combined with the limited availability of microbiologic data when treating ABSSSI, has led to a need for more convenient, less toxic anti-MRSA agents. Recent approvals have added several agents to the antibiotic armamentarium that provide an expanded spectrum of activity and ease of administration compared to older agents. Areas covered: In this review, the authors discuss updated approaches to the management of ABSSSI. They also provide a review of recent FDA approved antibiotics and emerging investigational agents for treatment of ABSSSI. Expert opinion: Several new antibiotic agents have received FDA approval through the revised guidance on ABSSSI clinical trials with advantages of activity against MRSA and ease of administration. In theory, this may translate to reducing the utilization of healthcare resources by allowing for earlier discharge and reducing the need for outpatient parenteral therapy. While the approval of new agents offers the opportunity to improve and simplify treatment of ABSSSI, it is more important now than ever to use these agents in a responsible manner.

Effect of a multifaceted stewardship intervention on antibiotic prescribing and outcomes for acute bacterial skin and skin structure infections.

BACKGROUND: Acute bacterial skin and skin structure infections (ABSSSI) are a leading cause of hospitalization, but are often treated inappropriately in the inpatient setting. A multifaceted stewardship intervention was implemented to encourage prescribing of guideline-concordant therapy (GCT). OBJECTIVE: To examine the impact of this initiative on antimicrobial prescribing practices and patient outcomes. METHODS: This was a single-center, retrospective study of adult inpatients admitted with a primary or secondary diagnosis of ABSSSI, classified by type and severity based on signs of systemic infection. Patients treated during the pre-intervention period (pre-IP) were compared with patients treated during the post-intervention period (post-IP). The primary endpoint was receipt of GCT. Secondary endpoints included receipt of anti-anaerobic antibiotic (AAA) or broad-spectrum antibiotics (BSA). RESULTS: A total of 125 patients were included, 64 in the pre-IP and 61 in the post-IP. There was a statistically significant increase in prescribing of GCT during the post-IP compared with the pre-IP (14% versus 56%, p < 0.0001) and a decrease in use of AAA (56% versus 34%, p = 0.01). No difference was observed with use of BSA (16% versus 15%, p = 0.89). Use of the computerized order set during the post-IP was low (18%). There was a numerical, but non-significant reduction in 30-day readmission (14.1% versus 6.6%, p = 0.17). CONCLUSION: The multifaceted intervention was effective for improving prescribing of GCT for ABSSSI. Given low use of the computerized order set, improved prescribing seemed to be driven by provider education. Strategies around ongoing education may be key to sustain positive results of stewardship interventions.