Andrea Pallotta

Antimicrobial stewardship program to reduce antiretroviral medication errors in hospitalized patients with human immunodeficiency virus infection.

OBJECTIVE Evaluate antimicrobial stewardship interventions targeted to reduce highly active antiretroviral therapy (HAART)- or opportunistic infection (OI)-related medication errors and increase error resolution. DESIGN Retrospective before-after study. SETTING Academic medical center. PATIENTS Inpatients who were prescribed antiretroviral therapy before the intervention (January 1, 2011, to October 31, 2011) and after the intervention (July 1, 2012, to December 31, 2012). Patients treated with lamivudine or tenofovir monotherapy for hepatitis B were excluded. METHODS Antimicrobial stewardship interventions included education, modification of electronic medication records, collaboration with the infectious diseases (ID) department, and prospective audit and review of HAART and OI regimens by an ID clinical pharmacist. RESULTS Data for 162 admissions from the preintervention period and 110 admissions from the postintervention period were included. The number of admissions with a medication error was significantly reduced after the intervention (81 [50%] of 162 admissions vs 37 (34%) of 110 admissions; P < .00)1. A total of 124 errors occurred in the preintervention group (mean no. of errors, 1.5 per admission), and 43 errors occurred in the postintervention group (mean no. of errors, 1.2 per admission). The most common error types were major drug interactions and dosing in the preintervention group and renal adjustment and OI-related errors in the postintervention group. A significantly higher error resolution rate was observed in the postintervention group (36% vs 74%; P < .001). After adjustment for potential confounders with logistic regression, admission in the postintervention group was independently associated with fewer medication errors (odds ratio, 0.4 [95% confidence interval, 0.24-0.77]; P = .005). Overall, presence of an ID consultant demonstrated a higher error resolution rate (32% without a consultation vs 68% with a consultation; P = .002). CONCLUSIONS Multifaceted, multidisciplinary stewardship efforts reduced the rate and increased the overall resolution of HAART-related medication errors.

Comparison of serum concentrations between different dosing strategies of posaconazole delayed-release tablet at a large academic medical centre

It is unclear if the prophylaxis dose of 300 mg/day is sufficient for achieving serum concentrations targeting the treatment of invasive fungal infections. To evaluate differences between PCZ serum concentrations in patients receiving the DRT vs the OS and in patients receiving higher doses than 300 mg/day of the DRT, a retrospective review was conducted on inpatients who received PCZ for either treatment or prophylaxis. Baseline demographics including comorbid conditions, indication and dose of therapy were collected. Serum trough concentrations were collected at steady state. Fifty‐seven patients received PCZ during the study period. A total of 35 levels were collected (DRT n = 18, OS n = 17). Patients receiving the DRT had levels >0.7 mcg/mL 100% of the time compared to 58.8% in those receiving the OS. No significant difference was seen in serum concentrations at 300 mg/day (n = 14) vs 400 mg/day (n = 8) of the DRT (1.55 mcg/mL (1.08‐2.50) vs 2.5 mcg/mL (1.85‐2.70), P = .19). The DRT leads to more consistent levels in the therapeutic range than the OS. Standard dosing of 300 mg/day with DRT achieves adequate concentrations for prophylaxis and treatment of IFIs, although further data are needed to determine optimal serum concentrations for treatment.

Infectious diseases consult improves vaccination adherence in kidney transplant candidates

BACKGROUND Vaccines prevent infections and avoid related complications. Low rates in immunocompromised patients are concerning due to increased morbidity. Vaccinations are less effective when administered post-transplant and should be administered prior. We describe pre-transplant vaccination rates among kidney or kidney-pancreas transplant recipients. METHODS Retrospective review including adults receiving kidney or kidney-pancreas allografts at Cleveland Clinic from October 2013 to October 2016. Pre-transplant vaccinations, serologies, and transplant data were collected. RESULTS 393 patients were included; median age was 53 years with most (46%) being Caucasian males. Influenza vaccination rate was 48%; receipt of at least one pneumococcal vaccine was 77%. Vaccination rates were higher among dialysis patients for pneumococcal, hepatitis B, and varicella vaccines; rates were also higher with infectious diseases consults. CONCLUSIONS Vaccination rates at our institution for kidney or kidney-pancreas transplant candidates are consistent with previous literature. Rates were higher for candidates with infectious diseases consults or receiving dialysis.

Evaluation of Antimicrobial Stewardship–Related Alerts Using a Clinical Decision Support System:

Background: Information technology, including clinical decision support systems (CDSS), have an increasingly important and growing role in identifying opportunities for antimicrobial stewardship–related interventions. Objective: The aim of this study was to describe and compare types and outcomes of CDSS-built antimicrobial stewardship alerts. Methods: Fifteen alerts were evaluated in the initial antimicrobial stewardship program (ASP) review. Preimplementation, alerts were reviewed retrospectively. Postimplementation, alerts were reviewed in real-time. Data collection included total number of actionable alerts, recommendation acceptance rates, and time spent on each alert. Time to de-escalation to narrower spectrum agents was collected. Results: In total, 749 alerts were evaluated. Overall, 306 (41%) alerts were actionable (173 preimplementation, 133 postimplementation). Rates of actionable alerts were similar for custom-built and prebuilt alert types (39% [53 of 135] vs 41% [253 of 614], P = .68]. In the postimplementation group, an intervention was attempted in 97% of actionable alerts and 70% of interventions were accepted. The median time spent per alert was 7 minutes (interquartile range [IQR], 5-13 minutes; 15 [12-17] minutes for actionable alerts vs 6 [5-7] minutes for nonactionable alerts, P < .001). In cases where the antimicrobial was eventually de-escalated, the median time to de-escalation was 28.8 hours (95% confidence interval [CI], 10.0-69.1 hours) preimplementation vs 4.7 hours (95% CI, 2.4-22.1 hours) postimplementation, P < .001. Conclusions: CDSS have played an important role in ASPs to help identify opportunities to optimize antimicrobial use through prebuilt and custom-built alerts. As ASP roles continue to expand, focusing time on customizing institution specific alerts will be of vital importance to help redistribute time needed to manage other ASP tasks and opportunities.

Internally-Developed Antimicrobial Use Benchmarking at a Large Academic Medical Center and Integrated Health System

Vasilios Athans, PharmD, BCPS1, Elizabeth Neuner, PharmD, BCPS (AQ-ID)1, Andrea Pallotta, PharmD, BCPS (AQ-ID), AAHIVP1, Jeffrey Chalmers, PharmD1, Eric Vogan, BSPS, MS1, Xin Jiang, MS1, Thomas Fraser, MD, FSHEA2, Steven Gordon, MD, FIDSA, FSHEA2 1Department of Pharmacy, Cleveland Clinic 2 Department of Infectious Diseases, Cleveland Clinic Contact information: Vasilios Athans, PharmD, BCPS 9500 Euclid Ave. Cleveland, OH, 44195 E-mail: athansv@ccf.org

Evaluation of a Clinical Decision Support System for Antimicrobial De-escalation at a Large Academic Medical Center

components of antimicrobial stewardship programs (ASPs). TheraDocTM, a CDSS, has both pre-built as well as customizable stewardship alerts. Prior studies have demonstrated clinical benefit but also a low rate of actionable alerts (24-36%). A pilot study was undertaken to assess the time and value of the CDSS, both pre-built and custom built alerts, for ASP interventions with a focus on de-escalation. Methods: 15 different types of alerts (1 pre-built and 14 custom) were chosen for the initial ASP review. Pre-intervention, alerts were generated retrospectively from March 1-31, 2014. Post intervention, alerts were reviewed for ASP intervention by a pharmacist in real-time from May 19June 20, 2014. Data collection included the total actionable (an intervention was or could have been attempted), acceptance of recommendation, and time spent for each type of alert. For de-escalation alerts, time to de-escalation to a more narrow spectrum agent was collected. Results: 749 alerts were evaluated (373 pre) and (376 post). The primary service was medical (52% vs. 57%) and there was an infectious diseases consult in 48% and 47% of alerts in pre vs. post groups, respectively. Overall, 306 (41%) alerts were actionable (173 pre and 133 post). Custom built alerts were more actionable (53/95, 56%) vs. pre-built alerts (253/614, 41%), p<0.01. The most common alert types were drug-bug mismatch, custom de-escalation, and drug-interaction alerts. In the post group, an intervention was attempted in 97% of actionable alerts and 70% (91/131) of interventions were accepted. The average time spent per alert was 7 minutes, with actionable alerts taking average 15 min and non-actionable 6 min, p<0.01. For de-escalation alerts, time to de-escalation was 28.8 hours in pre vs. 4.7 hours in the post group, p<0.01. Conclusions: ASP programs evaluating CDSS should consider customizing alerts to improve rate of actionable alerts and minimize time spent on non-actionable alerts. Overall, the use of CDSS as part of an ASP helped identify targets for de-escalation and decreased broad spectrum antimicrobial usage. Abstract Methods Results