Vera P. Luther

Antimicrobial stewardship for inpatient facilities

Antibiotic stewardship aims to improve patient care and reduce unwanted consequences of antimicrobial overuse or misuse, including lowered efficacy, emergence of antimicrobial resistance, development of secondary infections, adverse drug reactions, increased length of hospital stay, and additional healthcare costs. Recent guidelines make specific recommendations for the development of institutional programs to enhance antimicrobial stewardship. Optimally, such programs should be comprehensive, multidisciplinary, supported by hospital and medical staff leadership, and should employ evidence-based strategies that best fit local needs and resources. An infectious diseases physician and clinical pharmacist with infectious diseases training are recommended as core members of the multidisciplinary team, although a hospitalist with interest (and perhaps additional training) in antimicrobial therapy may be able to fill the void. Program directors and core members should be compensated for their time. Principal proactive strategies--with evidence supporting their consideration--include prospective audits, with intervention and feedback, formulary restriction, and preauthorization. Other strategies include persistent one-on-one education, guidelines adapted to local needs, and informatics to support clinical decision making. Intervention goals are to prevent unnecessary antimicrobial starts, to streamline or de-escalate therapy early in its course, and to convert from parenteral to oral therapy, optimize dosing, and ensure the appropriate length of therapy. Most community hospitals, if sufficiently resourced, should be able to implement a successful antimicrobial stewardship program. Evidence suggests that good antimicrobial stewardship can lead to less overall and inappropriate antimicrobial use, lower drug-related costs, reductions in Clostridium difficile-associated disease, and, in some studies, less emergence of antimicrobial resistance.

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

Health Care Provider Education as a Tool to Enhance Antibiotic Stewardship Practices

2,064,441 per year.

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

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.

Antimicrobial Stewardship Education for Medical Students

Antibiotic stewardship education for health care providers provides a foundation of knowledge and an environment that facilitates and supports optimal antibiotic prescribing. There is a need to extend this education to medical students and health care trainees. Education using passive techniques is modestly effective for increasing prescriber knowledge, whereas education using active techniques is more effective for changing prescribing behavior. Such education has been shown to enhance other antibiotic stewardship interventions. In this review, the need and suggested audience for antibiotic stewardship education are highlighted, and effective education techniques are recommended for increasing knowledge of antibiotics and improving their use.

Corticosteroids in the treatment of hepatic tuberculosis: case report and review of the literature.

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.

Antimicrobial Stewardship Training for Infectious Diseases Fellows: Program Directors Identify a Curriculum Need

TO THE EDITOR—We commend Dr Abbo and colleagues for their study, which highlights the need to standardize and enhance appropriate antimicrobial prescribing and stewardship curricula in US medical student education [1]. Ninety percent of surveyed fourth-year medical students felt that they would like more education on the appropriate use of antimicrobials; only one-third felt adequately prepared to apply principles of appropriate antimicrobial prescribing. The authors found significant heterogeneity in how students from the 3 medical schools accessed appropriate antimicrobial prescribing information. Of concern, the study also identified gaps in medical students’ knowledge regarding antimicrobial management of common infections. Their findings confirm and precisely describe our anecdotal experience that medical students desire, and would benefit from, organized and formal instruction on appropriate antibiotic use. To help medical schools address this need, Wake Forest School of Medicine, the Centers for Disease Control and Prevention (CDC), and the Association of American Medical Colleges (AAMC) recently developed and piloted an antimicrobial stewardship curriculum for use in US medical schools. This curriculum contains materials for both the preclinical and clinical years of instruction. The preclinical material consists of three 45minute didactic slide presentations with facilitator notes entitled “Antibiotic Resistance and Its Relationship to Antibiotic Use,” “ ‘Get Smart About Antibiotics’: An Introduction to Prudent Antibiotic Use,” and “Common Respiratory Tract Infections: Evaluation and Therapy.” Corresponding exam questions are provided in US Medical Licensing Examination format. Prerecorded audio with slide presentations of each lecture is also available. For the clinical years, the curriculum contains 5 small-group activities with facilitator guides that are intended for use during family medicine, internal medicine, surgery, pediatrics, and emergency medicine clerkships. The small-group activities highlight antibiotic stewardship principles through case-based scenarios and focus on the appropriate diagnosis and management of common infections where antibiotics are often misused in both the inpatient and outpatient arenas. The curriculum materials are available for any medical school to use and can be accessed and downloaded free of charge at http://www.wakehealth.edu/ASCurriculum.

Problematic communications during 2016 fellowship recruitment in internal medicine

Abstract The role of corticosteroid therapy in addition to anti-tuberculous agents in the treatment of hepatic tuberculosis is unclear. We describe a 54-y-old female with hepatic tuberculosis and worsening hepatitis after initiation of anti-tuberculosis therapy. She experienced considerable clinical improvement and ultimately a complete recovery upon the receipt of adjunctive corticosteroids.

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

A needs assessment survey of infectious diseases (ID) training program directors identified gaps in educational resources for training and evaluating ID fellows in antimicrobial stewardship. An Infectious Diseases Society of America-sponsored core curriculum was developed to address that need.