さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense a ID pharmacist. Another face is an investor.

IDweek 2018 Poster : Antimicrobial Stewardship: Interventions to Improve Outcomes ②

 IDweek 2018 Poster、続きです。

 

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

 

 200. Pharmacist Prescribing and Care for Patients with Uncomplicated Urinary Tract Infections in the Community: Antimicrobial Utilization and Stewardship Results of the RxOUTMAP Study

 

感想 : 米国薬剤師はマジメですね。

 

Background: Urinary tract infections (UTI) are common infections that often result in antibacterial use that is suboptimal. There are some Canadian provinces where pharmacists have the authorization to prescribe medications for the treatment of uncomplicated UTI. Pharmacists are accessible primary care professionals who have an important role to play in antimicrobial stewardship. Our objective was to evaluate the appropriateness of antibacterial prescribing by pharmacists for patients with uncomplicated UTI.

Methods: We conducted a prospective registry trial in 39 community pharmacies in the Canadian province of New Brunswick. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (Pharmacist-Initial Arm) or if they presented with a prescription for an antibacterial to treat UTI from a physician (Physician-Initial Arm). Pharmacists assessed patients and if they had complicating factors or red flags for systemic illness of pyelonephritis, they were excluded from the study. Pharmacists either prescribed antibacterial therapy, modified antibacterial therapy, provided education only, or referred to physician, as appropriate. Antibacterial therapy prescribed was compared between the study arms.

Results: A total of 748 patients were enrolled (87% in the Pharmacist-Initial Arm). The most commonly prescribed agents in the Pharmacist-Initial Arm were nitrofurantoin (88%), sulfamethoxazole-trimethoprim (TMP-SMX) (8%), and fosfomycin (2%) vs nitrofurantoin (54%), TMP-SMX (26%), and fluoroquinolones (11%) in the Physician-Initial Arm. Nitrofurantoin was prescribed for 5 days in 97% of Pharmacist-Initial orders as compared to Physician-Initial orders where 65% were for greater than 5 days. TMP-SMX was prescribed for 3 days in 88% of Pharmacist-Initial compared to Physician-Initial where 63% were for greater than 3 days. Therapy was guideline concordant in 95% of Pharmacist-Initial compared to 35% of Physician-Initial (p < 0.001). For guideline-discordant therapy from physicians, pharmacists prescribed to optimize therapy for 46% of patients.

Conclusion: Treatment was more guideline-concordant when initiated by pharmacists, with longer treatment durations and more fluoroquinolones prescribed by physicians.

 

211. Does Pharmacist-Driven Methicillin-Resistant Staphylococcus aureus PCR Nasal Screening Decrease Time to De-Escalation of MRSA Coverage in Patients with Pneumonia?

 

感想 : MRSA肺炎は、実は少ないと思っているので、anti-MRSA therapy をアグレッシブに考えるかどうかは、否定的。ただし、ICU症例など超重症例に対しては、参考になり得る。

 

Background:

Vancomycin and linezolid are antibiotics used in cases where methicillin-resistant Staphylococcus aureus (MRSA) is suspected, including in cases where MRSA is suspected to be the cause of pneumonia. MRSA nasal PCR has been shown to have a high negative predictive value when used to rule out MRSA pneumonia. The purpose of the current study was to determine whether a pharmacist-driven MRSA PCR nasal screening protocol would decrease the time to de-escalation or discontinuation of anti-MRSA therapy when utilized for pneumonia.

Methods:

Patients were analyzed in two cohorts, those who received vancomycin or linezolid therapy from October 2012-February 2013 (before pharmacist-driven MRSA nasal PCR protocol; n=88) and those who received vancomycin from October 2016-February 2017 (pharmacist-driven MRSA nasal PCR protocol; n=105). During the study period, pharmacists were given the authority, via protocol to order an MRSA nasal PCR when vancomycin or linezolid was ordered for the indication of pneumonia. Subsequently, after a negative MRSA nasal PCR, pharmacists would contact the prescriber, and let the prescriber know that the MRSA PCR was negative, and then discontinue anti-MRSA therapy. The primary outcome was duration in hours of active anti-MRSA therapy. Secondary outcomes evaluated were number of anti-MRSA antibiotic doses ordered, and the number of vancomycin troughs ordered.

Results:

Patients in the pre-pharmacist driven cohort received vancomycin or linezolid for a median of 44.19 hours, whereas patients in the pharmacist-driven MRSA PCR protocol period received anti-MRSA therapy for a median of 19.1 hours (p<0.0001). Additionally, prior to initiation of the pharmacist-driven MRSA nasal swab protocol, patients received 349 doses of anti-MRSA therapy, compared with 283 doses in the pharmacist MRSA nasal swab protocol group (p<0.0001). There were also fewer vancomycin troughs ordered in the pharmacist MRSA nasal swab protocol group (76 vs 48, p<0.0009).

Conclusion:

A pharmacist-driven protocol for ordering MRSA nasal PCR led to a statistically significant decrease in the time to discontinuation of vancomycin or linezolid for suspected MRSA pneumonia when the MRSA nasal PCR was negative.

 

218. IV to PO Conversion of Antimicrobials: Small Intervention, Big Impact

 

感想 : IV/POの流動化は、注目しているカテゴリー。"low hanging fruit (簡単な仕事) "と思われていることは、意外ですね。システム化されていないため、提案は疲れます。

 

Background:

Appropriate conversions from intravenous (IV) to oral (PO) therapy early in the hospital stay can promote patient comfort and satisfaction while decreasing unnecessary costs and adverse events related to IV catheters. Although IV to PO conversion as a stewardship intervention is considered “low hanging fruit”, the time spent on review can be extensive and reporting can be challenging. Utilization of an automated decision support system allows for easy monitoring of IV to PO switches as well as identification of ways to enhance the efficiency and effectiveness of the program. The primary objective was improving IV to PO conversions through an automated system and measuring outcomes electronically without manual chart review. Desired metrics were percentage of eligible antimicrobials ordered as PO, number of conversions, and cost avoidance.

Methods:

A protocol was approved by the Pharmacy and Therapeutics committee allowing pharmacists to auto-convert medications from IV to PO when meeting pre-specified criteria. These identification criteria were implemented electronically using a traffic light decision support system to prioritize eligible patients (Fig 1). Education was provided both in person and as pocket cards with guidance on eligible antimicrobials for IV to PO conversions. Metrics were based on monthly antimicrobial utilization data and displayed as a dashboard (Fig 2).

Results:

Monthly metrics provided the stewardship team feedback on the effectiveness of the IV to PO program and identified areas for improvement. From January 2017 to January 2018, cost avoidance from ordering PO as opposed to IV agents was $524,788 with 1,843 IV to PO conversions performed by both providers and pharmacists. A total of 65% of the eligible antimicrobials were ordered via the PO route. Based on these findings a multifaceted approach to further expand the initiative was undertaken.

Conclusion:

The IV to PO decision support system improves the efficiency of IV to PO review process and reduces time spent reviewing charts of patients who do not meet criteria for conversion. The development of automated monthly metrics is an efficient method to assess the effectiveness of the program as well as identify key areas for future development.

 

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220. Taking Off with Antimicrobial Intervention Rounds (AIR): Successes of a Pilot Stewardship Service at a Tertiary-Care VA Medical Center

 

感想 : AIRという略語知りませんでした。なかなかアグレッシブな取り組み。アレルギーへの取り組みは重要。

 

Background: Prospective audit and feedback is one of the core strategies of an antimicrobial stewardship program (ASP). Here, we hypothesized that the addition of AIR to our extant ASP would enhance appropriate use of parenteral (IV) antibiotics (ABs) on a large inpatient medical service.

Methods: Adult patients on medicine wards beginning in 10/2017 and not followed by the Infectious Diseases (ID) service were included for stewardship intervention if they were on IV ABs ≥48 h. Recommendations were classified into: 1) duration of therapy; 2) dose adjustment; 3) IV to oral conversion; 4) adverse event prevention; 5) AB avoidance; 6) anti-pseudomonal or 7) vancomycin de-escalation; 8) AB discontinuation; 9) ID consult; 10) Δ alternative AB; 11) allergy assessment; or 12) diagnostics. Early impact of the interventions was assessed after 3 months via the Standardized Antimicrobial Administration Ratio (SAAR) and compared to the 3-month, pre-AIR period.  The SAAR is used to benchmark facilities’ AB use against those of similar complexity; SAAR = 1 indicates that observed = predicted use.

Results: For 158 interventions made, the most common syndromes were pneumonia (41%), skin & soft tissue (29.4%) and urinary tract infection (17.7%).  Intervention categories other than 4, 9 and 11 had acceptance rates >85% (Fig. 1).   The SAAR decreased from the pre- to post-AIR period in terms of agents for:  broad-spectrum use in HAI (SAAR relative ratio [RR]: 0.80, 95% CI [0.73-0.88]); MRSA (SAAR RR: 0.81, 95% CI [0.73-0.91]); and all indications (SAAR RR: 0.86, 95% CI [0.82-0.90]).  During the same periods, surgical wards without AIR showed no Δ in AB use.

Conclusion: The majority of AB use recommendations delivered by a pharmacist-physician stewardship team were highly accepted by medical providers and led to a 15-20% decrease in overall AB use, without adverse effect during the immediate post-intervention period.  Potential clinical benefits, such as decreased rates of Clostridium difficile disease, will need to be measured as the AIR program advances.  It is worth noting that interventions for AB allergy assessment were least accepted by providers, possibly due to time required to comply.  Design of prospective audit and feedback programs may need to address this potential deficiency.

 

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