Implementation of a pharmacy-driven rapid bacteremia response program.

PURPOSE: This report describes a comprehensive pharmacy-driven rapid bacteremia response program. SUMMARY: This novel program positioned the pharmacy department at a large, community health system to receive and respond to critical microbiologic diagnostic testing results, 24/7/365. The program empowered pharmacists to provide centralized, comprehensive care including assessing blood culture Gram stain results, adjusting antibiotic therapy per protocol, ordering repeat blood cultures, analyzing and interpreting rapid molecular diagnostic test results, placing orders for contact isolation, and communicating antibiotic recommendations to the treatment team. In the first year after program implementation, 2,282 blood culture Gram stains and 2,046 rapid diagnostic test results were called in to the pharmacy department. The program reduced the median time to effective therapy in patients who did not already have active antimicrobial orders from over 10 hours to less than 1 hour. Based on the Gram stain results, antibiotics were started per protocol in 34.2% of patients. Based on the rapid molecular diagnostic test results, adjustments were made to antibiotic regimens in 55.7% of cases after discussion with a provider. Of these adjustments, 39.9% were for escalation of antibiotics and 37.7% were for de-escalation of antibiotics. CONCLUSION: By expanding the scope of pharmacy practice, barriers to optimizing clinical care were overcome.

Limited impact of a nudge comment in promoting de-escalation to first-generation cephalosporins in urinary tract infections.

In this study, we evaluated the impact of a microbiology nudge on de-escalation to first-generation cephalosporins in hospitalized patients with urinary tract infections secondary to Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis isolates with minimum inhibitory concentrations (MICs) ≤ 16 µg/mL. De-escalation to first generation-cephalosporins was uncommon at MICs = 4-16 µg/mL.

Fluoroquinolone stewardship at a community health system: A decade in review.

Objective: To describe inpatient fluoroquinolone use and susceptibility data over a 10-year period after the implementation of an antimicrobial stewardship program (ASP) led by an infectious diseases pharmacist starting in 2011. Design: Retrospective surveillance study. Setting: Large community health system. Methods: Fluoroquinolone use was quantified by days of therapy (DOT) per 1,000 patient days (PD) and reported quarterly. Use data are reported for inpatients from 2016 to 2020. Levofloxacin susceptibility is reported for Pseudomonas aeruginosa and Escherichia coli for inpatients from 2011 to 2020 at a 4 adult-hospital health system. Results: Inpatient fluoroquinolone use decreased by 74% over a 5-year period, with an average decrease of 3.45 DOT per 1,000 PD per quarter (P < .001). Over a 10-year period, inpatient levofloxacin susceptibility increased by 57% for P. aeruginosa and by 15% for E. coli. P. aeruginosa susceptibility to levofloxacin increased by an average of 2.73% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = -0.99 (P = .002). E. coli susceptibility to levofloxacin increased by an average of 1.33% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = -0.95 (P = .015). Conclusions: A substantial decrease in fluoroquinolone use and increase in P. aeruginosa and E. coli levofloxacin susceptibility was observed after implementation of an antimicrobial stewardship program. These results demonstrate the value of stewardship services and highlight the effectiveness of an infectious diseases pharmacist led antimicrobial stewardship program.

Sterility and Stability Testing of Preservative-free Albuterol.

BACKGROUND: Continuous albuterol administration (CAA) is commonly used in hospitalized patients for treatment of asthma exacerbations. Due to higher dose requirements, CAA requires large volumes of albuterol obtained from multidose vials containing benzalkonium chloride (BAC). BAC is a common pharmaceutical preservative and potent bronchoconstrictor, which may antagonize the bronchodilation effects of albuterol. Some institutions are using preservative-free (PF) albuterol for their CAA. However, no published data currently exist to support the extended sterility or stability of this formulation. OBJECTIVE: To evaluate the sterility and stability of PF-albuterol. METHODS: Sterility testing was conducted for PF- and BAC-albuterol when stored at room temperature. Samples were incubated for 10 days in aerobic and anaerobic blood culture media to assess for bacterial growth. Stability of both albuterol formulations at high (0.67 mg/mL) and low (0.17 mg/mL) concentrations was determined at room temperature and under refrigeration. High performance liquid chromatography was used to evaluate samples up to 168 hours after preparation. RESULTS: No bacterial growth was witnessed from either albuterol formulation at day 10 of observation. Both high and low concentrations of PF-albuterol and BAC-albuterol were stable at room temperature for up to 168 hours. There were no differences in stability between storage conditions for any formulation. CONCLUSIONS: Under the current study conditions, there was no difference in sterility or stability for PF-albuterol when compared with BAC-albuterol. Thus, based on the findings of this study, PF-albuterol is sterile and stable up to 168 hours when stored at room temperature or under refrigerated conditions. The findings of this study do not confirm the therapeutic efficacy of PF-albuterol compared with BAC-albuterol for the treatment of asthma exacerbations. Further studies are warranted to determine the efficacy of PF-albuterol verses BAC-albuterol when used for CAA.

Effect of Intranasal Mupirocin Prophylaxis on Methicillin-Resistant Staphylococcus aureus Transmission and Invasive Staphylococcal Infections in a Neonatal Intensive Care Unit.

The use of monthly intranasal mupirocin was associated with a significant reduction in the rate of methicillin-resistant Staphylococcus aureus transmission and Staphylococcus aureus invasive infection in a large neonatal intensive care unit. Resistance to mupirocin emerged over time, but it was rare and was not associated with adverse clinical outcomes.Infect Control Hosp Epidemiol 2018;39:741-745.

Comparison of BD Phoenix AP Workflow with Vitek 2.

The BD Phoenix AP instrument reduced the manual setup time for the Phoenix system by 50%. For batches of 14 organisms, the average manual manipulation time per isolate was 89.5 s for BD Phoenix by the use of the AP instrument and 101 s for Vitek 2 (P<0.001).

BD Phoenix and Vitek 2 detection of mecA-mediated resistance in Staphylococcus aureus with cefoxitin.

The BD Phoenix (BD Diagnostics, Sparks, MD) and Vitek 2 (bioMérieux, Durham, NC) automated susceptibility testing systems have implemented the use of cefoxitin to enhance the detection of methicillin (meticillin)-resistant Staphylococcus aureus (MRSA). To assess the impact of this change, 620 clinically significant S. aureus isolates were tested in parallel on Phoenix PMIC/ID-102 panels and Vitek 2 AST-GP66 cards. The results for oxacillin and cefoxitin generated by the automated systems were compared to those generated by two reference methods: mecA gene detection and MICs of oxacillin previously determined by broth microdilution according to CLSI guidelines. Testing of isolates with discordant results was repeated to attain a majority or consensus final result. There was 100% final agreement between the results of the two reference methods. For the 448 MRSA and 172 methicillin-susceptible S. aureus isolates tested, the rates of categorical agreement of the results obtained with the automated systems with those obtained by the reference methods were 99.8% for the Phoenix panels and 99.7% for the Vitek 2 cards. A single very major error occurred on each instrument (0.2%) with different MRSA isolates. The only major error was attributed to the Vitek 2 system overcalling oxacillin resistance. In 16 instances (9 on the Phoenix system, 7 on the Vitek 2 system), an oxacillin MIC in the susceptible range was correctly changed to resistant by the expert system on the basis of the cefoxitin result. The inclusion of cefoxitin in the Phoenix and Vitek 2 panels has optimized the detection of MRSA by both systems.