Whitney R. Buckel

Ceftaroline in Combination With Trimethoprim-Sulfamethoxazole for Salvage Therapy of Methicillin-Resistant Staphylococcus aureus Bacteremia and Endocarditis

No clinical trials have investigated the use of ceftaroline fosamil for salvage therapy of methicillin-resistant Staphylococcus aureus bacteremia and endocarditis. We report data on 29 patients who received ceftaroline ± another antimicrobial for this indication. Ninety percent of patients had microbiologic cure and 31% had treatment success with a median follow-up of 6 months.

Gut Check: Clostridium difficile Testing and Treatment in the Molecular Testing Era

We evaluated the impact of nursing education and stewardship interventions on Clostridium difficile testing and treatment appropriateness. Diarrhea documentation increased for those with positive tests (45% to 70%); pretreatment laxative use decreased (50% to 19%). Appropriate treatment increased for severe infection (57% to 93%), but all asymptomatically colonized patients were treated.

Impact of Implementing Antibiotic Stewardship Programs in 15 Small Hospitals: A Cluster-Randomized Intervention

Background Studies on the implementation of antibiotic stewardship programs (ASPs) in small hospitals are limited. Accreditation organizations now require all hospitals to have ASPs. Methods The objective of this cluster-randomized intervention was to assess the effectiveness of implementing ASPs in Intermountain Healthcares 15 small hospitals. Each hospital was randomized to 1 of 3 ASPs of escalating intensity. Program 1 hospitals were provided basic antibiotic stewardship education and tools, access to an infectious disease hotline, and antibiotic utilization data. Program 2 hospitals received those interventions plus advanced education, audit and feedback for select antibiotics, and locally controlled antibiotic restrictions. Program 3 hospitals received program 2 interventions plus audit and feedback on the majority of antibiotics, and an infectious diseases-trained clinician approved restricted antibiotics and reviewed microbiology results. Changes in total and broad-spectrum antibiotic use within programs (intervention versus baseline) and the difference between programs in the magnitude of change in antibiotic use (eg, program 3 vs 1) were evaluated with mixed models. Results Program 3 hospitals showed reductions in total (rate ratio, 0.89; confidence interval, .80-.99) and broad-spectrum (0.76; .63-.91) antibiotic use when the intervention period was compared with the baseline period. Program 1 and 2 hospitals did not experience a reduction in antibiotic use. Comparison of the magnitude of effects between programs showed a similar trend favoring program 3, but this was not statistically significant. Conclusions Only the most intensive ASP intervention was associated with reduction in total and broad-spectrum antibiotic use when compared with baseline. Clinical Trials Registration NCT03245879.

Antimicrobial stewardship knowledge, attitudes, and practices among health care professionals at small community hospitals

Background Very little is known about antimicrobial stewardship knowledge, attitudes, and practices (KAP) among health care practitioners in small, community hospitals (SCHs) compared to large community hospitals (LCHs). Objective To compare infectious diseases (ID) clinical resources and describe KAP pertaining to antimicrobial stewardship among prescribers, pharmacists, and administrators from a large hospital network including a comparison between SCHs and LCHs. Methods An anonymous 48-item antimicrobial stewardship KAP survey was administered to pharmacists, prescribers, and administrators at 15 SCH (<200 beds) and 5 LCHs (>200 beds) within an integrated health care network. Results In total, 588 (14%) completed the survey: 198 from SCHs and 390 from LCHs. Most respondents were familiar or very familiar with the term antimicrobial stewardship and felt that antimicrobial stewardship was necessary. Most pharmacists and prescribers agreed that antimicrobials were overused at their hospital. However, SCH pharmacists and prescribers were more likely to disagree that antibiotic resistance is a significant problem locally. Pharmacists saw restrictions as a reasonable method of controlling antibiotic use more than prescribers. SCH practitioners were less familiar with IDSA guidelines and less likely to rely on ID specialists to a greater extent than LCH practitioners. Most respondents strongly agreed they would like more antimicrobial education. Conclusion SCH and LCH pharmacists, prescribers, and administrators are aware of antimicrobial resistance and overuse and agree that antimicrobial stewardship programs are necessary. SCHs are less likely to contact ID for information. These results support the development of antimicrobial stewardship programs at SCHs, while recognizing the significant differences in availability and utilization of resources.

Antimicrobial Stewardship in Community Hospitals

Antibiotic stewardship programs are needed in all health care facilities, regardless of size and location. Community hospitals that have fewer resources may have different priorities and require different strategies when defining antibiotic stewardship program components and implementing interventions. By following the Centers for Disease Control and Prevention Core Elements and using the strategies suggested in this article, readers should be able to design, develop, participate in, or improve antibiotic stewardship programs within community hospitals.

Broad- versus Narrow-Spectrum Oral Antibiotic Transition and Outcomes in Health Care–associated Pneumonia

Rationale: Guidelines recommend a switch from intravenous to oral antibiotics once patients who are hospitalized with pneumonia achieve clinical stability. However, little evidence guides the selection of an oral antibiotic for patients with health care‐associated pneumonia, especially where no microbiological diagnosis is made. Objectives: To compare outcomes between patients who were transitioned to broad‐ versus narrow‐spectrum oral antibiotics after initially receiving broad‐spectrum intravenous antibiotic coverage. Methods: We performed a secondary analysis of an existing database of adults with community‐onset pneumonia admitted to seven Utah hospitals. We identified 220 inpatients with microbiology‐negative health care‐associated pneumonia from 2010 to 2012. After excluding inpatient deaths and treatment failures, 173 patients remained in which broad‐spectrum intravenous antibiotics were transitioned to an oral regimen. We classified oral regimens as broad‐spectrum (fluoroquinolone) versus narrow‐spectrum (usually a &bgr;‐lactam). We compared demographic and clinical characteristics between groups. Using a multivariable regression model, we adjusted outcomes by severity (electronically calculated CURB‐65), comorbidity (Charlson Index), time to clinical stability, and length of intravenous therapy. Measurements and Main Results: Age, severity, comorbidity, length of intravenous therapy, and clinical response were similar between the two groups. Observed 30‐day readmission (11.9 vs. 21.4%; P = 0.26) and 30‐day all‐cause mortality (2.3 vs. 5.3%; P = 0.68) were also similar between the narrow and broad oral antibiotic groups. In multivariable analysis, we found no statistically significant differences for adjusted odds of 30‐day readmission (adjusted odds ratio, 0.56; 95% confidence interval, 0.06‐5.2; P = 0.61) or 30‐day all‐cause mortality (adjusted odds ratio, 0.55; 95% confidence interval, 0.19‐1.6; P = 0.26) between narrow and broad oral antibiotic groups. Conclusions: On the basis of analysis of a limited number of patients observed retrospectively, our findings suggest that it may be safe to switch from broad‐spectrum intravenous antibiotic coverage to a narrow‐spectrum oral antibiotic once clinical stability is achieved for hospitalized patients with health care‐associated pneumonia when no microbiological diagnosis is made. A larger retrospective study with propensity matching or regression‐adjusted test of equivalence or ideally a prospective comparative effectiveness study will be necessary to confirm our observations.

541: RISK OF RESISTANT MICROORGANISMS WITH PROLONGED ANTIBIOTIC PROPHYLAXIS FOR INTRACRANIAL DEVICES

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) between groups. Results: 35 patients were enrolled through the first four mo of study (August-November, 2014), of whom 21 (60%) were men. Mean (SD) age was 48.2 (23) yr. Fourteen patients (40%) had severe TBI and twenty (57%) had mild TBI. Mean pre-hospital GCS was 10.4 and mean APACHE III score was 42.3. Five (14%) had history of coronary artery disease, and none had pre-existing heart failure. Five patients (14%) developed cardiac dysfunction after TBI. Three patients had mild reduction in the left ventricular ejection fraction (LVEF) (45–54%), and two had moderately reduced LVEF (30–44%). Regional wall motion abnormalities were identified in three patients. There were no statistically significant differences in duration of mechanical ventilation, hospital and ICU length of stay, and mortality between patients who developed cardiac dysfunction compared to patients who did not develop cardiac dysfunction, but comparison was limited by small sample size. Conclusions: Cardiac dysfunction occurs after a TBI but the incidence appears to be lower than the published literature.