Beta-Lactam Allergy De-labeling in a Pediatric Hospital.

OBJECTIVE: To assess the ability to de-label pediatric patients of their beta-lactam allergy by using a newly implemented institutional protocol and to identify potential barriers to the de-labeling process. METHODS: All patients with reported allergies to prespecified beta-lactam antibiotics were eligible for a -beta-lactam allergy interview. Following the interview, patients were grouped into 4 risk categories-no risk, low risk, moderate risk, and high risk-and assessed for intervention eligibility. Potential interventions included de-labeling based on the interview alone or proceeding to an oral amoxicillin challenge with or without penicillin allergy skin testing. RESULTS: Of the 62 patients eligible for beta-lactam allergy interviews, 40% (n = 25) were de-labeled. Among de-labeled patients, 60% (n = 15) were de-labeled on the basis of the interview alone. Additionally, no failures were documented in patients who underwent an oral amoxicillin challenge or penicillin skin testing. Barriers to performing oral amoxicillin challenges or penicillin skin testing included concomitant systemic steroid or antihistamine use, refusal of intervention, and insufficient resources to perform penicillin skin testing. CONCLUSIONS: There was a high frequency of patients de-labeled of their beta-lactam allergies in this study. Increased education to patients, parents, and providers on the de-labeling process, as well as increased personnel available to coordinate and perform de-labeling interventions, may result in more beta-lactam allergy de-labeling.

Implementation of a pharmacy residency wellness program: Impact on burnout and mindfulness and lessons learned.

BACKGROUND AND PURPOSE: Attention to wellness in the pharmacy workplace is occurring. To maintain accreditation, pharmacy residency programs must incorporate wellness and resilience initiatives. EDUCATIONAL ACTIVITY AND SETTING: Orlando Health created a pharmacy residency wellness program for post-graduate year one (PGY-1) and post-graduate year two (PGY-2) pharmacy residents to address wellness and burnout. The wellness program included assignment of a mentor, development of a personal wellness plan, completion of monthly reflections, and wellness and resiliency training. FINDINGS: Pharmacy residents anonymously completed the Oldenburg Burnout Inventory (OLBI) and Mindful Attention Awareness Scale (MAAS) at the beginning and end of the residency year. A total of nine pharmacy residents were eligible to participate in the wellness program. Eight residents completed the pre-survey, and seven residents completed the post-survey. No change was observed in the overall median OLBI score (pre-program = 35 [IQR 31.5-37.3] and post-program = 36 [IQR 31-37.5]; P = .683). Similar results were found on the OLBI for disengagement and exhaustion, correlating with low burnout risk. There was no change in the overall median MAAS score (pre-program = 3.7 [IQR 3.6-4.1] and post-program = 3.8 [IQR 3.5-3.9]; P = 1.000). Overall, feedback from the pharmacy residents after program completion was positive. SUMMARY: Pharmacy residents participating in the wellness program at our institution had low risk for burnout and a high level of mindfulness pre- and post-program completion. Pharmacy residents enjoyed participating in the wellness program and found the program to be valuable, supporting its continued implementation.

Implementation of an Automatic 48-Hour Vancomycin Hard-Stop in a Pediatric Community Hospital.

OBJECTIVE: Previous studies evaluating antimicrobial time-outs and required stop dates on antimicrobial orders indicate that these strategies are effective in decreasing antimicrobial duration and cost without a negative impact on patient outcomes. Few have evaluated use of a hard-stop strategy. The purpose of this study was to determine the feasibility and impact of a vancomycin hard-stop at 48 hours of therapy on vancomycin use. METHODS: This retrospective review compared 2 groups, a hard-stop pre-implementation group from April 2018 through March 2019 and a hard-stop post-implementation group from May 2019 through April 2020. The primary outcome was change in days of therapy (DOT) per ordered course of vancomycin therapy. Secondary outcomes included DOT per 1000 patient days (PD), number of courses continued beyond 48 hours, number of vancomycin concentrations drawn and drug acquisition cost. RESULTS: A total of 554 courses of vancomycin were prescribed (228 in the pre-implementation group and 326 in the post-implementation group). The median DOT per ordered course of vancomycin was 1.58 days (IQR, 1.00-2.59) in the pre-implementation group compared with 1.55 days (IQR, 1.00-1.99) in the post-implementation group (p = 0.51). Fewer vancomycin courses continued beyond 48 hours after hard-stop implementation (23% versus 33%) and fewer vancomycin concentrations were obtained in the post-implementation period than in the pre-implementation period despite more ordered courses of vancomycin therapy, 114 concentrations versus 153 concentrations, respectively. Overall, the total yearly drug acquisition cost savings to the pharmacy equated to $3000. CONCLUSIONS: Implementation of a vancomycin hard-stop at 48 hours of therapy is a feasible antimicrobial stewardship tool that may have significant clinical and operational impacts.

The Effect of Rapid Initiation Versus Delayed Initiation of Antibiotics in Pediatric Patients With Sepsis.

OBJECTIVE: The purpose of this study was to determine if administration of antibiotics within 1 hour of meeting sepsis criteria improved patient outcomes versus antibiotics administered greater than 1 hour after meeting sepsis criteria in pediatric patients. The Surviving Sepsis Campaign's international guidelines recommend appropriate antimicrobial therapy be administered within 1 hour of recognition of severe sepsis or septic shock. Data regarding outcomes in pediatric patients with sepsis regarding antibiotic timing are currently limited. METHODS: This was a retrospective chart review of 69 pediatric patients admitted between July 1, 2013, and June 30, 2016, with a diagnosis of sepsis. RESULTS: The primary outcome of in-hospital mortality was 7.1% in the within 1 hour group versus 14.6% in the greater than 1 hour group (p = 0.3399). Median hospital length of stay was significantly shorter in the within 1 hour group (15.4 versus 39.2 days, p = 0.0022). Median intensive care unit length of stay was also significantly shorter in the within 1 hour group (3.1 versus 33.6 days, p = 0.0191). There were no differences between groups for pediatric intensive care unit admission, end organ dysfunction, time to intubation, or time on the ventilator. CONCLUSIONS: Pediatric patients who receive antimicrobial therapy within 1 hour of meeting sepsis criteria had improved hospital and intensive care unit length of stay. This study supports the Surviving Sepsis Guidelines recommendation to administer antibiotics within 1 hour in pediatric patients with sepsis or septic shock.

Optimization of Aztreonam in Combination With Ceftazidime/Avibactam in a Cystic Fibrosis Patient With Chronic Stenotrophomonas maltophilia Pneumonia Using Therapeutic Drug Monitoring: A Case Study.

ABSTRACT: In this clinician-therapeutic drug monitoring (TDM) consultant interaction, the authors describe the use of TDM in an 11-year-old female patient with cystic fibrosis receiving ceftazidime/avibactam and aztreonam for the treatment of persistent pulmonary exacerbations caused by Stenotrophomonas pneumonia. Serum drug concentrations at a steady state confirmed inadequate antimicrobial exposure, and continuous infusions of both ceftazidime/avibactam and aztreonam were required to optimize the percentage of time when free drug remained above the minimum inhibitory concentration (MIC), known as fT > MIC. After dose adjustment, this continuous infusion strategy resulted in 100% target attainment for fT > MIC. This case illustrates the importance of TDM, and the logistical issues encountered with the use of alternative dosing strategies in pediatric patients with CF.

Severe Acute Respiratory Syndrome Coronavirus-2 Pneumonia in a Newborn Treated With Remdesivir and Coronavirus Disease 2019 Convalescent Plasma.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel pandemic virus. Mounting evidence supports the possibility of vertical transmission, which at the present time appears to be rare. We report a newborn with vertically acquired SARS-CoV-2 who developed acute respiratory failure and received remdesivir and coronavirus disease 2019 convalescent plasma.

High-level ceftaroline resistance in a paediatric patient with invasive methicillin-resistant Staphylococcus aureus infection without previous ceftaroline exposure.

WHAT IS KNOWN AN OBJECTIVE: Our objective is to report a paediatric case of high-level ceftaroline resistance without previous ceftaroline exposure. CASE DESCRIPTION: A 20-month-old, 12 kg, female with invasive MRSA infection presented with high-level ceftaroline resistance with no previous ceftaroline exposure. WHAT IS NEW AND CONCLUSION: To our knowledge, our case is the first report of high-level ceftaroline resistance evident in a paediatric patient with invasive infection due to MRSA, without history of prior ceftaroline exposure. This case illustrates the importance of weighing the risk of resistance with the benefits of use when starting therapy empirically prior to susceptibility results, even in patients without previous drug exposure.