James R. Beardsley

Show Me the Money: Long-Term Financial Impact of an Antimicrobial Stewardship Program

The financial impact of an antimicrobial stewardship program in operation for more than 11 years was determined by calculating the reduction in antimicrobial expenditures minus program labor costs. Depending on the method of inflation adjustment used, the program was associated with average cost savings of

The Addition of Intravenous Metronidazole to Oral Vancomycin is Associated With Improved Mortality in Critically Ill Patients With Clostridium difficile Infection

920,070 to

Optimizing Empiric Antibiotic Therapy in Patients with Severe β-Lactam Allergy

2,064,441 per year.

Short-term outcomes of an employer-sponsored diabetes management program at an ambulatory care pharmacy clinic

BACKGROUND The optimal therapy for critically ill patients with Clostridium difficile infection (CDI) is not known. We aimed to evaluate mortality among critically ill patients with CDI who received oral vancomycin (monotherapy) vs oral vancomycin with intravenous (IV) metronidazole (combination therapy). METHODS A single-center, retrospective, observational, comparative study was performed. Patients with a positive C. difficile assay who received oral vancomycin while bedded in an intensive care unit (ICU) between June 2007 and September 2012 were evaluated. Patients meeting ≥3 of the following criteria were included: albumin <2.5 g/dL, heart rate >90 bpm, mean arterial pressure <60 mmHg, white blood cell count ≥15 000 cells/mL, age >60 years, serum creatinine ≥1.5 times baseline, or temperature ≥100.4°F. Patients in the combination therapy group received IV metronidazole within 48 hours after initiating vancomycin. Patients <18 years or with unrelated gastrointestinal disease were excluded. The primary outcome was in-hospital mortality. Patients were matched using Acute Physiology and Chronic Health Evaluation II scores. RESULTS Eighty-eight patients were included, 44 in each group. Patient characteristics were similar although more patients in the combination group had renal disease. Mortality was 36.4% and 15.9% in the monotherapy and combination therapy groups, respectively (P = .03). Secondary outcomes of clinical success, length of stay, and length of ICU stay did not differ between groups. CONCLUSIONS Our data are supportive of the use of combination therapy with oral vancomycin and IV metronidazole in critically ill patients with CDI. However, prospective, randomized studies are required to define optimal treatment regimens in this limited population of CDI patients.

Implementation of a Standardized Discharge Time-out Process to Reduce Prescribing Errors at Discharge

ABSTRACT Antibiotic selection is challenging in patients with severe β-lactam allergy due to declining reliability of alternate antibiotics. Organisms isolated from these patients may exhibit unique resistance phenotypes. The objective of this study was to determine which alternate antibiotics or combinations provide adequate empirical therapy for patients with β-lactam allergy who develop Gram-negative infections at our institution. We further sought to determine the effects of risk factors for drug resistance on empirical adequacy. A retrospective analysis was conducted for adult patients hospitalized from September 2009 to May 2010 who had a severe β-lactam allergy and a urine, blood, or respiratory culture positive for a Gram-negative organism and who met predefined criteria for infection. Patient characteristics, culture and susceptibility data, and predefined risk factors for antibiotic resistance were collected. Adequacies of β-lactam and alternate antibiotics were compared for all infections and selected subsets. The primary outcome was adequacy of each alternate antibiotic or combination for all infections. One hundred sixteen infections (40 pneumonias, 67 urinary tract infections, and 9 bacteremias) were identified. Single alternate agents were adequate less frequently than β-lactams and combination regimens. Only in cases without risk factors for resistance did single-agent regimens demonstrate acceptable adequacy rates; each factor conferred a doubling of risk for resistance. Resistance risk factors should be considered in selecting empirical antibiotics for Gram-negative pathogens in patients unable to take β-lactams due to severe allergy.

Influence of an Institution-Specific Sepsis Protocol on the Adequacy of Empiric Antimicrobial Therapy

PURPOSE The impact of a collaborative, employer-sponsored diabetes management program on glycemic control and other clinical endpoints over 6-12 months is reported. METHODS In a retrospective, chart-based evaluation, glycosylated hemoglobin (HbA(1c)) and related health status indicators were assessed among first-year enrollees in the Healthy Outcome Partnership for Employees (HOPE) with Diabetes Program, an ongoing program sponsored by the Wake Forest Baptist Health (WFBH) system. Diabetes management services were provided by pharmacists in collaboration with providers inside and outside the WFBH system. The primary endpoint was the mean change in HbA(1c) during follow-up averaging 8.2 months; secondary endpoints included changes in blood pressure, cholesterol, and triglyceride levels. RESULTS Among the 98 patients included in the data analysis (75.5% women, 72.4% Caucasian), the mean HbA(1c) value decreased significantly during the study period (from 7.8% to 7.1%, p < 0.01); the proportion of patients at the recommended goal of an HbA(1c) of ≤7.0% rose from 40.8% to 56.1% (p < 0.01). HOPE Program enrollees also experienced significant improvements in mean triglyceride, total cholesterol, and blood pressure values (p < 0.05 for all). A subgroup of patients with initially poor glycemic control (HbA(1c) of ≥8.0%) had a mean HbA(1c) reduction of 1.7 percentage points during the study (p < 0.01), suggesting that the greatest benefits occurred in the highest-risk patients. CONCLUSION Among patients seen for at least six months at an employer-sponsored ambulatory care diabetes clinic managed by pharmacists, significant improvements from baseline in clinical end-points including HbA(1c) and blood pressure were demonstrated.

State of Privileging in Pharmacy: A Survey of Vizient-Affiliated Institutions

Background To reduce prescribing errors occurring on discharge from the hospital, a standardized discharge time-out process was implemented on a general medicine service at Wake Forest Baptist Medical Center. In the time-out process, the multidisciplinary care team reviewed the patients medical records together to determine the optimal discharge medication regimen. This regimen was recorded on a time-out form and then was used to develop the patients discharge documents. Objective To evaluate the impact of a standardized discharge time-out process on prescribing errors that occur as patients are discharged from a general medicine service. Methods The medical records of all patients discharged from a general medicine service during 60-day periods before (“pre-group”) and after (“post-group”) implementation of a standardized discharge time-out process were retrospectively reviewed by an internal medicine physician to determine the presence of discharge prescribing errors. Results There were 142 and 124 evaluable patients in the pre- and post-groups, respectively. Compliance with the time-out process was 93% in the post-group. At least 1 prescribing error was detected in 49 (34.5%) of the discharges in the pre-group and 17 (13%) of the discharges in the post-group (P < .0001). All of the errors noted in the post-group occurred in discharges in which a clinical pharmacist was not involved. Conclusions A multidisciplinary, standardized discharge time-out process was associated with a dramatic reduction in prescribing errors when patients were discharged from a general medicine service. The time-out process is one strategy to improve patient safety at hospital discharge.

607Identification of Viral Infection Using a Polymerase Chain Reaction (PCR)-based Respiratory Virus Panel (RVP) Decreases Antibacterial Use

Objective A sepsis protocol including institution-specific antibiotic recommendations based on local susceptibility patterns was implemented at our institution. The purpose of this investigation was to determine the impact of these recommendations on the adequacy of initial empiric therapy in patients with severe sepsis admitted to the intensive care unit. Methods This was a single-center, retrospective, observational study conducted in a medical intensive care unit at a university-affiliated medical center. Charts of patients identified as having sepsis in our sepsis database from November 2004 to September 2006 were retrospectively reviewed. Adequacy of initial therapy was assessed, as were the number of antibiotics used per patient and 28-day mortality. Results One hundred nine patients met inclusion criteria for the evaluation. Thirty-eight patients were in the pre-protocol group and 71 patients were in the post-protocol group. Adequacy of initial therapy increased from 68% pre protocol to 85% post protocol (P < 0.05). A secondary analysis showed that if antibiotic recommendations had been followed exactly according to protocol, the number of antibiotics per patient would decrease from 2.47 to 2.11 (P = 0.017) without changing adequacy of initial treatment. Conclusion Implementation of a sepsis protocol containing institution-specific antibiotic recommendations was associated with an increased percent of patients receiving adequate empiric antibiotic therapy. Strictly adhering to the institution-specific antibiotic recommendations could result in fewer antibiotics used per patient without reducing the adequacy of empiric treatment.

IMPROVING THE TIMING OF ANTIMICROBIAL PROPHYLAXIS THROUGH A TOTAL QUALITY MANAGEMENT APPROACH

Purpose: The process of privileging pharmacists is an important step in developing optimal pharmacy practice models. Currently, little published literature exists detailing the status of pharmacist privileging efforts. The objective of this study is to assess and characterize a snapshot of the current and future state of privileging practices in pharmacy at Vizient academic medical centers (AMCs) and their affiliate institutions. Methods: An electronic survey questionnaire was sent to Vizient pharmacy directors and their affiliates to assess institutional privileging practices and identify perceived or actual barriers. The survey was divided into 2 pathways based on the current status of privileging at the institution. Results: In total, 46 directors of pharmacy completed the survey. Only 33% (15/46) of pharmacy directors indicated they had a current privileging process in place. About 70% (21/30) of institutions without an established privileging process indicated they were considering establishing a process. For institutions without an established privileging process, most pharmacy directors identified a lack of organizational support and resources as barriers to implementation. Conclusion: Although credentialing and privileging is considered a national priority to aid in expanding and enhancing pharmacists’ scope of practice, our survey demonstrated that few respondents currently have a privileging process in place. The results from this study may highlight important barriers and keys to success to be considered when implementing a privileging process.

Using Local Microbiologic Data To Develop Institution-Specific Guidelines for the Treatment of Hospital-Acquired Pneumonia

607. Identification of Viral Infection Using a Polymerase Chain Reaction (PCR)-based Respiratory Virus Panel (RVP) Decreases Antibacterial Use Kristina Rokas, PharmD; Elizabeth Palavecino, MD; James Beardsley, PharmD; James Johnson, PharmD; Vera Luther, MD; Christopher Ohl, MD; John Williamson, PharmD; Wake Forest Baptist Health, Winston-Salem, NC; Pathology, Wake Forest School of Medicine, Winston Salem, NC; IM-Section on Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC