3児の親さん薬剤師のブログ

とある薬剤師です。感染症治療を考える素材をちょこっと提供。https://note.mu/twin1980。

IDweek 2018 Poster : Antimicrobial Stewardship: Interventions to Improve Outcomes ①

IDWeek Poster にASP関連は多数あります。

最近、結果に興味があるので以下をピックアップ。

 

Antimicrobial Stewardship: Interventions to Improve Outcomes

https://idsa.confex.com/idsa/2018/webprogram/Session10451.html

 195. The Effect of Two Antibiotic Stewardship Interventions in a Telemedicine Practice

 

感想 : フィードバックは重要

 

Background: Direct-to-patient (DTP) telemedicine has been noted to have highly variable antibiotic prescribing practices. This study explores the effect of education and individualized provider prescribing feedback on antibiotic prescribing for acute upper respiratory tract infections (ARTIs) in a telemedicine practice.

Methods: Doctor on Demand is a national DTP video visit medical practice that provides primary and mental health care to 1.6 million people. In April 2016, 62 physicians were randomized to two antibiotic stewardship intervention groups: Group A received education on best practices for antibiotic prescribing for sinusitis, pharyngitis and bronchitis, and Group B received education plus individualized and practice-wide feedback reports on antibiotic prescribing rates for two consecutive months (Apr-May) and again in October. In November, both groups received feedback reports. Antibiotic prescribing rates for all three conditions were tracked for both groups for the baseline period (January to March) and throughout the study duration.

Results: During the baseline period, antibiotic prescribing rates for the three conditions combined was 71% for Group A and 69% for Group B. Antibiotic prescribing rates for both groups throughout the baseline and study periods are displayed in Figure 1. For Group A, prescribing rates declined from 71% (baseline) to 66% in May and for Group B declined from 69% (baseline) to 55%. During June-September, the monthly prescribing rate remained 66-69% for Group A and 56-57% for Group B. In November, following the additional individualized feedback report provided to both groups, the prescribing rate was 63% for Group A and 46% for Group B.

Conclusion: Individualized prescribing feedback reports coupled with education to telemedicine providers was more effective than education alone in reducing unnecessary antibiotic prescriptions for ARTIs. These findings should be used to promote antibiotic stewardship across telemedicine and other care settings.

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197. Implementation of a Prospective, Pharmacist-Led Methicillin-Resistant Staphylococcus aureusNasal PCR Screening Pilot Protocol to Reduce Overutilization of Vancomycin

 

感想  : 鼻腔 PCR はどうだろうか? そもそもリスク因子がある重症肺炎以外にVCMは使用しないな。。

 

Background:

The methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) has a negative predictive value of 95.2-99.2% for MRSA pneumonia. Negative MRSA nasal PCR results can be used as an effective tool to discontinue unnecessary empiric vancomycin therapy.

Methods:

This single-center, pre-post quasi experimental pilot study evaluated the impact of a pharmacist-led MRSA nasal PCR screening protocol on vancomycin days of therapy (DOT) in patients with pneumonia. All adult patients with IV vancomycin ordered for pneumonia admitted to non-intensive care units were included. Patients who received nasal mupirocin, transitioned to hospice during admission, or had another indication requiring vancomycin were excluded. Pharmacists ordered a MRSA nasal PCR, per protocol, upon order verification. Negative results were used to recommend vancomycin discontinuation when appropriate. Prospective data were compared to a random retrospective cohort during a similar time frame the previous year. The primary outcome was vancomycin DOT before and after protocol implementation. Secondary outcomes included length of stay, quantity of vancomycin levels obtained, in-hospital mortality, acute kidney injury incidence, adherence to the protocol, and need for antimicrobial escalation.

Results:

A total of 130 patients were included (n = 65, pre-intervention; n = 65, post-intervention). No statistically significant differences were observed in the demographics between the two groups. The median reduction in vancomycin DOT was 1.4 days [2.9 days (IQR 1.8-4.1) vs 1.5 days (IQR 0.7-2.3); p < 0.001]. The percentage of IV vancomycin ordered for pneumonia was reduced by 5.2% (19.6% vs 14.4%; p = 0.036). The protocol also resulted in a decreased median number of serum vancomycin levels (p < 0.001). No statistically significant differences were observed in the secondary outcomes and there were no adverse clinical outcomes. Protocol adherence was 67.9% overall.

Conclusion:

Implementation of a pharmacist-led MRSA surveillance protocol significantly reduced vancomycin days of therapy, reduced serum vancomycin levels, and had no unintended adverse consequences for respiratory tract infections. Results from this pilot project will be used to expand this protocol systemwide.

 

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198. Pharmacist-Led Antimicrobial Prompting During Interdisciplinary Team Rounds As a Novel Antimicrobial Stewardship Intervention

 

感想 : んー。新規性がよく分からないです。勉強します。

  • Prior to rounds, the clinical pharmacist reviewed charts for patients with urinary tract infections, skin and soft tissue infections and pneumonia
  • During daily interdisciplinary team rounds, if the medicine team’s antimicrobial choice was not concordant with institutional prescribing guidance, the clinical pharmacist made a recommendation.
  • Acceptance and rejection of recommendations were documented by the clinical pharmacist
  • The medical charts of thirty patients treated for urinary tract infections, skin and soft tissue infections and pneumonia were reviewed in both the pre and post intervention periods for concordance with institutional prescribing guidance.

 

Background: There is a need to develop successful antibiotic stewardship interventions that do not require ID physicians. Our hospital implemented a pharmacist-driven intervention to prompt critical assessment of antibiotic regimens during interdisciplinary team rounds. We evaluated the acceptance of this intervention and the effects on concordance with institutional prescribing guidance.

Methods: This quality improvement initiative took place between November 2016 and June 2017 on a medical ward in an urban, level 1 trauma, public teaching hospital. During interdisciplinary team rounds, if the medicine team's antimicrobial choice was not concordant with institutional prescribing guidance, the clinical pharmacist made a recommendation. We assessed prescribing for urinary tract infection, skin and soft tissue infection, and pneumonia pre and post intervention. Prescribing was classified as overall guideline-concordant if the antibiotic choices and duration of therapy were consistent with institutional guidance.

Results: Thirty cases from each period were evaluated. Recommendations to the medical team were made on 63% (92/146) of days and on 31% (205/664) of patients on antibiotics. The most common recommendation was regarding days of therapy (Fig 1). The recommendations were accepted in 76% (156/205) of cases. (Fig 2). There were improvements in both the inpatient (70% to 83%, p=0.22) and discharge (64% to 86%, p=0.35) antibiotic choices and overall guideline concordance (53% to 63%, p= 0.43); however, these were not statistically significant. Concordance with duration of therapy was similar between the periods (76% vs 77%, p=0.94) (Fig 3).

Conclusion: During interdisciplinary rounds, prompting by pharmacists to critically assess antibiotic regimens is a feasible antibiotic stewardship intervention that does not require ID expertise, is generally accepted by physicians, and may increase guideline-concordant antibiotic selection.

 

 

199. The Urgent Need for Urgent Care Antimicrobial Stewardship: Evaluating Prescribing and Patient Outcomes Associated with a Pharmacist-led Stewardship Program

 

感想 : 協働プロトコールもいいかも

 

Background: Antimicrobial resistance is one of the most serious threats to public health. Antimicrobial stewardship initiatives have begun to expand from acute care to ambulatory care settings. While many programs have demonstrated pharmacist-led stewardship successes in inpatient and emergency department (ED) settings, there is a paucity of literature exploring these initiatives in urgent care (UC) sites. This study aimed to determine the impact of implementing a pharmacist-led antimicrobial stewardship program (ASP) in the UC setting.

Methods: A retrospective quasi-experimental study was conducted evaluating patients from two health system-affiliated UC sites with positive urine or wound culture results following discharge. In April 2015, the health system's infectious diseases and ED pharmacists, with support from UC providers, implemented empiric therapy guidelines and a collaborative practice agreement allowing for pharmacist-led culture follow-up via a stewardship-focused protocol. The primary outcome of this study was to compare guideline-concordant antibiotic prescribing (defined as the combination of appropriate agent, dose, and duration of therapy) between the pre-ASP and post-ASP groups. Secondary outcomes included comparing the number of patients who required follow-up, time to follow-up, UC or ED revisits within 72 hours, and hospital admission within 30 days between groups.

Results: 300 patients were included in the study (pre-ASP n=150, post-ASP n=150). Total guideline-concordant prescribing for all diagnoses was significantly improved in the post-ASP group compared to the pre-ASP group (41.3% vs 53.3%, p=0.037). Guideline-concordant antibiotic selection improved in the post-ASP group (51% vs 68%, p=0.01) while dose (70 % vs 74%, p=0.287) and duration (61% vs 65%, p=0.283) were similar between groups. Follow-up was required for 27 (18%) patients in the pre-ASP group vs 16 (10.7%) in the post-ASP group (p=0.07), however median time to follow-up call was longer in the post-ASP group (71 vs 38 hours, p<0.001). There were no differences between groups in UC (p=1.0) and ED revisits (p=1.0) within 72 hours or hospital admissions within 30 days (p=0.723).

Conclusion: A pharmacist-led urgent care ASP was associated with significantly improved guideline-concordant antimicrobial prescribing.

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