Tanaya Bhowmick

Collaboration between an antimicrobial stewardship team and the microbiology laboratory can shorten time to directed antibiotic therapy for methicillin-susceptible staphylococcal bacteremia and to discontinuation of antibiotics for coagulase-negative staphylococcal contaminants

BACKGROUND Rapid identification of Gram-positive cocci in clusters (GPCC) in positive blood cultures (pBC) may limit exposure to unnecessary or inappropriate antibiotics. METHODS Inpatients with pBC showing GPCC between October 2013 and December 2017 were included. In the baseline period (BL), final ID and susceptibility results were reported in the electronic medical record (EMR) within 48 h of telephoned Gram stain report. The laboratory introduced rapid phenotypic identification and direct susceptibility testing (INT1), later replaced by PCR (INT2). In the last Intervention (INT3), Antimicrobial Stewardship Response Team (ASRT) contacted providers with PCR results and recommendations. RESULTS Time to directed therapy (TDT) for MSSA and coagulase-negative Staphylococci (CoNS) decreased from BL to INT3 (48.5-17.9 h, 50.3-16.4 h, respectively). Time to ID from BL to INT3 for MSSA and CoNS also decreased (23.2-1.9 h, 44.7-2.8, respectively). CONCLUSIONS TDT can be improved by modification of reporting methods with utilization of an ASRT.

Antimicrobial Stewardship in the Treatment of Infections Among Patients With Cystic Fibrosis

Purpose of ReviewTo describe potential antimicrobial stewardship program strategies to enhance the optimization of antimicrobial therapy for patients with cystic fibrosis (CF).Recent FindingsCystic fibrosis is a complex medical condition known for its frequent pulmonary exacerbations attributed to microorganisms which are treated with antimicrobials administered by various routes. Due to exposure to antimicrobials from an early age, both as eradication regimens and for chronic colonization, this patient population often has drug-resistant organisms colonizing their respiratory tract. With CF patients surviving well into adulthood, preservation of antimicrobials is more essential now than ever. Antimicrobial stewardship programs have been shown to optimize antimicrobial use in the hospital and outpatient setting, but interventions applied to CF patients are not as well documented. For hospitalized patients, stewardship programs develop antibiotic dosing and monitoring guidelines and treatment algorithms. In addition to these approaches, the CF population may benefit from review of different routes or methods of administration of antimicrobials to optimize pharmacokinetics and pharmacodynamics. These include inhaled antibiotics and prolonged infusions.SummaryIn the CF population that is exposed to frequent courses of antimicrobials, we propose that collaboration with a stewardship program to engage in optimization of antimicrobial administration would benefit both patients and health care providers. Moreover, given that the majority of antibiotics that CF patients receive are prescribed and administered in the outpatient setting, antimicrobial stewardship to promote judicious use of antibiotics in the outpatient setting should be explored.

Medical Students Have Limited Awareness, Knowledge, Beliefs, and Experiences of Pre-exposure Prophylaxis (PrEP) for HIV Prevention

Abstract Background While studies of healthcare professionals have shown increasing awareness, knowledge, positive beliefs, and prescribing practices of emtricitabine/tenofovir pre-exposure prophylaxis (PrEP) for HIV prevention, PrEP is still underutilized in clinical practice. PrEP knowledge is associated with increased prescription so early education of healthcare professionals is recommended, but the extent of PrEP education in medical school is unknown. In this analysis, we describe medical students’ awareness, knowledge, beliefs, and experiences regarding PrEP. Methods Medical students at 18 US allopathic medical schools completed a survey on knowledge, beliefs, and experiences of PrEP in May–June 2016. Knowledge was assessed with a 10-question quiz on PrEP facts. No incentives to complete the survey were offered. Data were summarized by frequency (%) for categorical variables and with means (SD) for continuous variables. Chi-squared tests were used to examine differences between knowledge of PREP and other categorical variables. Results The study population (N = 1588) included women (53%), non-Caucasians (27%), and non-heterosexuals (15%). Median age was 25 (range 21–53). Forty-eight home states, including D.C., and 21 home countries were represented. 18% of fourth-year students were never taught about PrEP in medical school, compared with 40% of first-year students (P < 0.001). Overall, 28% of students were unaware of PrEP. Those unaware believed patients without HIV will not adhere to PrEP (P < 0.001). Awareness was associated with knowing someone with HIV besides a patient and experience caring for HIV-infected, intravenous drug-using, and LGBTQ people (P < 0.001). Higher knowledge scores were associated with confidence in determining a patient’s candidacy for PrEP and, for third- and fourth-year students, having recommended PrEP in the clinical setting (P < 0.001). Overally, 57% believed that behavioral intervention should be tried before prescribing PrEP, 45% believed that patients would not adhere to PrEP, and 22% worried that PrEP is not effective. Conclusion We show in an 18-site study that medical students have limited awareness, knowledge, positive beliefs, and experiences of PrEP. Given these findings and the underutilization of PrEP by current practitioners, we recommend increasing the inclusion of PrEP in medical student education. Disclosures All authors: No reported disclosures.

Does a Negative Rapid Diagnostic Test for Detection of Candida Bloodstream Infection Lead to Less Antifungal Use

Abstract Background Candida species are the fourth leading cause of nosocomial bloodstream infections in the United States, however incidence is low and most patients who receive empiric treatment do not actually have candidemia. Unfortunately, detection, identification and susceptibility testing using standard instrumented blood culture systems and routine microbiological techniques takes 4–10 days. Astute clinicians may empirically treat patients with antifungal therapy (AFT) prior to having any results, often leading to unnecessary coverage for candida infection for up to 10 days. The T2 Candida Panel is an FDA-approved assay that rapidly detects the presence of 5 Candida species directly from whole blood in 3–5 hours. We determined whether AFT decisions were altered based on negative (neg) results of a T2 assay. Methods We performed a retrospective chart review of the first 50 patients at our institution from March 1, 2016 to March 1, 2017 with a neg T2 Candida assay result (data collection is ongoing). If a patient had multiple valid T2 assays, only the first result was used for analysis. The patients’ medical records were reviewed for use and duration of empiric AFT, results of blood cultures, treatment modification, underlying illness, risk factors for candida infection, length of stay, and 14-day mortality from the time of the T2 assay. Results Twenty-four patients were never started on AFT. Of the 26 who received AFT, it was stopped in 15 (57%) following T2 results (median time to stop empiric AFT = 2 days (1–16)). The reasons for continuing AFT in the cases of neg T2 assays included hematologic malignancy patients who were on long-term prophylaxis with antifungals (6 patients), empiric use in a case of severe sepsis (1 patient), and positive culture results despite neg T2 assay in 4 patients: 1 patient with C. lusitaniae in blood culture, 1 patient with C. parapsilosis from positive culture of medical device, 1 patient with neg T2 but positive blood cultures from 2 days prior for C. albicans (was on antifungal therapy at time of test), 1 patient with C. guilliermondii in blood culture. Conclusion We conclude that a neg T2 Candida assay affects empirical use of AFT in certain patient populations and may be useful in controlling the overuse of antifungal agents. Disclosures All authors: No reported disclosures.

Do Positive Anaerobic Culture Results Affect Physicians’ Clinical Management Decisions?

Abstract Background Aerobic and anaerobic cultures from body fluids, abscesses, and wounds are ordered routinely. Prior studies have shown that the results of anaerobic blood cultures do not frequently lead to changes in patient management. Methods We performed a retrospective chart review to determine whether positive results of anaerobic tissue and fluid cultures (excluding blood) affect physicians’ treatment approaches. Of 3234 anaerobic cultures, 174 unique patient admissions had positive cultures and met inclusion criteria. Results Only 18% (n = 31) of patient charts with positive cultures had documented physician acknowledgment (90.3% of acknowledgments by infectious diseases physicians), with 9% (n = 15) leading to change in antibiotic regimens based on results. Seventy percent of all patients received initial empiric antibiotics active against anaerobes. Of the remaining 30% (inappropriate, unknown, or no empiric coverage), 1 regimen change was documented after culture results were known. Conclusions Given the lack of management change based on results of anaerobic wound cultures, the value of routine anaerobic culturing is of questionable utility.