Matthew A. Moffa

Tracking Colistin-Treated Patients to Monitor the Incidence and Outcome of Carbapenem-Resistant Gram-Negative Infections

BACKGROUND Existing surveillance mechanisms may underestimate the incidence of carbapenem-resistant gram-negative infections (CRGNIs). Although carbapenem resistance increases the risk of death, the trend in mortality over time is unknown. METHODS A retrospective cohort study was conducted at 40 academic medical centers using a discharge database to identify adult hospital admissions without cystic fibrosis in 2006-2012 and received intravenous colistin for >3 consecutive days or died during therapy (termed colistin cases). The primary outcomes were the number of colistin cases per 100,000 admissions per year and change in the hospital mortality rate over time compared with the rate of discharges to home. Secondary outcomes included median overall and intensive care unit lengths of stay. RESULTS From 2006 to 2012, a total of 5011 unique patients were identified as colistin cases. The number per 100,000 admissions per year increased from 35.56 to 92.98 during the 7-year study (P < .001). The odds of in-hospital death among colistin cases (compared with discharge to home) decreased by a mean of 5.2%/y (P = .04), whereas discharge to an institution (P = .24) or hospice (P = .89) remained steady over time. The median overall and intensive care unit lengths of stay decreased by 7.5 and 6 days, respectively (P < .001). In a 4-hospital chart review, 81.6% of colistin cases were found to have culture-positive CRGNIs. Conversely, 53% of extensively drug-resistant bloodstream CRGNIs at 2 of these hospitals met colistin case criteria. CONCLUSIONS Colistin cases represent a severely ill population with a high probability of having culture-confirmed CRGNIs. Colistin tracking is a novel strategy for monitoring the incidence and mortality of CRGNIs, particularly those caused by extensively drug-resistant bacteria. Although the incidence of colistin cases nearly tripled within 7 years, more of these patients are surviving hospitalization and going home.

Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients

BackgroundSkin and soft tissue infections (SSTIs) are a leading cause for hospitalizations in the United States. Few studies have addressed the appropriateness of antibiotic therapy in the management of SSTIs without complicating factors. We aimed to determine the appropriateness of antibiotic treatment duration for hospitalized adult patients with uncomplicated SSTIs.MethodsThis was a retrospective analysis performed at two academic medical centers in Pittsburgh, Pennsylvania on patients aged 18 years and older with primary ICD-9 code for SSTIs admitted August 1st, 2014–March 31st, 2015. The primary outcome was the appropriateness of antibiotic treatment duration for uncomplicated SSTIs. Secondary objectives included the appropriateness of antibiotic agent spectrum, duration of inpatient length of stay (LOS), utilization of blood cultures and advanced imaging modalities, and re-hospitalization for SSTI within 30 days of discharge from the index admission.ResultsA total of 163 episodes were included in the cohort. The mean duration of total antibiotic therapy was 12.6 days. Appropriate duration was defined as receipt of total antibiotic duration of less than 10 days and occurred in 20.2% of patients. Twenty eight percent of patients received antibiotics for greater than 14 days. Seventy three (44.8%) patients received greater than 24 h of inappropriate extended spectrum gram-negative coverage; 65 (39.9%) received anaerobic coverage.ConclusionsIn the majority of patients, treatment duration was excessive. Inappropriate broad spectrum antibiotic selection was utilized with regularity for SSTIs without complicating factors. The management of uncomplicated SSTIs represents a significant opportunity for antimicrobial stewardship.

Effect of Antimicrobial Stewardship Program Guidance on the Management of Uncomplicated Skin and Soft Tissue Infections in Hospitalized Adults

Objective To assess the effect of an antimicrobial stewardship program (ASP)–bundled initiative on the appropriate use of antibiotics for uncomplicated skin and soft tissue infections (uSSTIs) at 2 academic medical centers in Pittsburgh, Pennsylvania. Patients and Methods A retrospective preintervention and postintervention study was conducted to compare management of patients admitted with uSSTIs before and after the implementation of the bundled initiative. The preintervention period was from August 1, 2014, through March 31, 2015, and the postintervention period was from August 1, 2015, through March 31, 2016. Results A total of 160 patients were included in the preintervention cohort, and 163 were included in the postintervention cohort. Compared with the preintervention group, the mean duration of therapy decreased (12.5 days vs 8.8 days; P<.001) and an appropriate duration of less than 10 days increased in more patients (20.6% [33 of 160] vs 68.7% [112 of 163]; P<.001) in the postintervention period. Fewer patients were exposed to antimicrobials with extended gram-negative (44.4% [71 of 160] vs 9.2% [15 of 163]; P<.001), anaerobic (39.4% [63 of 160] vs 9.8% [16 of 163]; P<.001), and antipseudomonal (16.3% [26 of 160] vs 1.8% [3 of 163]; P<.001) coverage. The mean length of stay decreased from 3.6 to 2.2 days (P<.001) without an increase in 30-day readmissions (6.3% [10 of 160] vs 4.9% [8 of 163]; P=.64). The ASP made recommendations for 125 patients, and 96% were accepted. Conclusion Implementation of an ASP-bundled approach aimed at optimizing antibiotic therapy in the management of uSSTIs led to shorter durations of narrow-spectrum therapy as well as shorter hospital length of stay without adversely affecting hospital readmissions.

Role of Technology in Antimicrobial Stewardship

Because of the increasing plague of antimicrobial resistance and antibiotic misuse, antimicrobial stewardship programs (ASPs) are now a mandatory entity in all US hospitals. ASPs can use technological advances, such as the electronic medical record and clinical decision support systems, to impact a larger patient population with more efficiency. Additionally, through the use of mobile applications and social media, ASPs can highlight and propagate educational information regarding antimicrobial utilization to patients and providers in a widespread and timely manner. In this article, the authors describe how technology can play an important role in antimicrobial stewardship.

Impact of an antimicrobial stewardship program on healthcare-associated Clostridium difficile rates at a community-based teaching hospital

We conducted a pre-intervention/post-intervention study to assess the rate of healthcare-associated Clostridium difficile infections (HA-CDI) before and after the implementation of an antimicrobial stewardship program (ASP). Upon implementation of our ASP, the usage of targeted antimicrobials, including ceftriaxone, clindamycin, fluoroquinolones and carbapenem antibiotics, were significantly reduced. There was also a significant reduction in HA-CDI/1000 patient-days following ASP implementation (0.84 vs. 0.28; P = 0.035).

Acute Exacerbations of Chronic Obstructive Pulmonary Disease With a Low Procalcitonin Concentration: Impact of Antibiotic Therapy

BACKGROUND Patients admitted with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) often are prescribed antibiotics. Studies have shown that the use of procalcitonin (PCT) to guide the decision to initiate antibiotic therapy in AECOPD has resulted in less antibiotic use and similar outcomes compared with standard of care. We evaluated patients with AECOPD and low PCT concentrations to determine whether antibiotic therapy was associated with improved outcomes. METHODS We retrospectively evaluated adult patients admitted with AECOPD who had a peak PCT concentration <0.25 µg/mL. Patients were evaluated based on their antibiotic exposure: ≤24 hours vs >24 hours. We also evaluated outcomes based upon the duration of azithromycin therapy: ≤24 hours vs >24 hours. The primary outcome was all-cause 30-day readmissions. Secondary outcomes included length of stay (LOS) and COPD-related 30-day readmissions. RESULTS One hundred sixty-one and 195 patients received ≤24 hours vs >24 hours of antibiotic therapy, respectively. The cohort with ≤24 hours of antibiotics had a shorter LOS (2.8 vs 3.7 days; P = .01). There were no differences in all-cause 30-day readmissions (15.5% vs 17.4%; P = .63) or COPD-related 30-day readmissions (11.2% vs 12.3%; P = .74). Additionally, patients receiving ≤24 hours of azithromycin had a shorter LOS (3.0 vs 3.8 days; P = .002) and there were no differences in all-cause 30-day readmissions (16.2% vs 17.1%; P = .82) or COPD-related 30-day readmissions (11.9% vs 11.6%; P = .94). CONCLUSIONS For adult patients hospitalized with nonsevere AECOPD and low PCT concentrations, antibiotic therapy beyond 24 hours did not improve outcomes.

Impact of Procalcitonin Guidance on the Management of Adults Hospitalized with Pneumonia

Abstract Background Community-acquired pneumonia and healthcare-associated pneumonia are often treated with prolonged antibiotic therapy. Procalcitonin (PCT) has effectively and safely reduced antibiotic use for pneumonia in controlled studies. However, limited data exist regarding PCT guidance in real-world settings for management of pneumonia. Methods A retrospective, preintervention/postintervention quality improvement study was conducted to compare management for patients admitted with pneumonia before and after implementation of PCT guidance at two teaching hospitals in Pittsburgh, Pennsylvania. The preintervention period was March 1, 2014 through October 31, 2014, and the post-intervention period was March, 1 2015 through October 31, 2015. Results A total of 152 and 232 patients were included in the preintervention and postintervention cohorts, respectively. When compared with the preintervention group, the mean duration of therapy decreased (9.9 vs. 6.1 days; P < 0.001). More patients received an appropriate duration of 7 days or less (26.9% vs. 66.4%; P < 0.001). Additionally, mean hospital length of stay decreased in the postintervention group (4.9 vs. 3.5 days; P = 0.006). Pneumonia-related 30-day readmission rates (7.2% vs. 4.3%; P = 0.99) were unaffected. In the postintervention group, patients with PCT levels < 0.25 µg/l received shorter mean duration of therapy compared with patients with levels >0.25 µg/l (8.0 vs. 4.6 days; P < 0.001) as well as reduced hospital length of stay (3.9 vs. 3.2 days; P = 0.02). Conclusion In this real-world practice study, PCT guidance led to shorter durations of total antibiotic therapy and abridged inpatient length of stay without affecting hospital re-admissions. Disclosures All authors: No reported disclosures.

Accurate Identification of Infection Source in Burn Trauma Patients With Central Line Infection to Determine Appropriate Treatment Option As Well As Proper Public Reporting

With the advent of the Patient Safety Movement in the late 1990s and the CMS (Centers for Medicare & Medicaid Services) nonreimbursement program for never events, there has been much focus on the prevention and accurate identification of health care–associated infections such as central line–associated bloodstream infections (CLABSIs). There has certainly been a national effort to decrease the occurrence of these infections. With the implementation of patient safety initiatives such as the central line prevention bundle, there has been a considerable reduction in the number of CLABSIs except for patients with burn trauma. Because of the compromised nature of these patients, the number of CLABSIs has not decreased similarly to other types of patients. In addition, these patients may have a secondary infection that was not accurately or timely identified. With CLABSIs, proper identification of primary and secondary infections is very important, particularly when identifying treatment options and ensuring accurate public reporting of health care–associated infection information.