4 results
Implementing a health-system–wide antibiotic stewardship program in ambulatory surgery centers
- Kasey Hickman, Nicolas Forcade, Mandelin Cooper, Shivanne Bhagwandeen, Brandy Russell
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 3 / Issue S2 / June 2023
- Published online by Cambridge University Press:
- 29 September 2023, p. s27
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Background: In 2016, the CDC released the Core Elements of Outpatient Antibiotic Stewardship, which extended the requirements previously released for hospital facilities and nursing homes to the outpatient setting. Several regulatory agencies focused on outpatient antimicrobial use. However, The Joint Commission and the Ambulatory Surgery Center (ASC) Leapfrog Group excluded ambulatory surgery centers from their medication management standards and questions. Due to the public health and patient safety benefits of implementing an antimicrobial stewardship program (ASP) and increasing regulatory interest in the matter, the Hospital Corporation of America (HCA) Ambulatory Surgery Division formally launched a nationwide ASP for its ambulatory surgery centers in March 2021. Methods: HCA is a large healthcare system with 146 ASCs in 16 states in 2021. The structure of the ASCs are local surgery centers with a medical director, a nurse responsible for infection prevention, and a pharmacist at a regional level. The types of surgeries vary based on location and ASC site. In 2019, a multidisciplinary team formed the corporate planning committee. The program was modeled after the CDC Core Elements and The Joint Commission’s requirements for an ASP. Each ASC was asked to build a local ASP team, led by a local physician and a regionally based pharmacist. In addition, a stewardship goal was established to update all preoperative antibiotic surgical-site infection prophylaxis order sets. The corporate committee provided educational resources, including evidence-based guidelines for appropriate antibiotic selection for surgical-site infections. They collected antibiotic cost per case as a baseline metric to track and analyze. Pediatric, ophthalmic, and gastrointestinal endoscopic procedures were excluded from the program. Results: From January 1, 2020, through December 31, 2021, including only centers that were operational during this period and excluding single specialty endoscopy centers, antibiotic cost per case decreased annually from $2.38 to $1.84 (t = 4.157; P < .005), and the postoperative infection rate also declined from 0.370 to 0.304 (t = 2.079; P = .040). Conclusions: Our findings suggest that implementing a health-system–wide outpatient antibiotic stewardship program in the ambulatory surgery center setting is feasible and may contribute to decreased antibiotic cost per case and improved postoperative surgical site infection rates.
Disclosures: None
Standardized Antimicrobial Administration Ratio (SAAR) Clinical Outcomes Assessment in a Large Community Healthcare System
- Hayley Burgess, Mandelin Cooper, Laurel Goldin, Kenneth Sands
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s390
- Print publication:
- October 2020
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Background: Research on the association between the standardized antimicrobial administration ratio (SAAR) and clinical outcomes is lacking. Objective: We compared SAAR and patient outcomes in 97 acute-care facilities affiliated with a large healthcare system. Methods: Facilities were classified using the broad-spectrum hospital-onset (BSHO) SAAR for medical, surgical, and medical-surgical wards as low, moderate, or high antimicrobial use: low use SAAR, <0.8; moderate use SAAR, 0.95–1.05; and high-use SAAR, >1.2. Data were included from patients aged ≥18 years who were discharged between the first quarter of 2018 and the second quarter of 2019, had nonmissing matching criteria, BMI between 10 and 90, and at least 1 BSHO medication administered in a medical, surgical, or medical-surgical ward. Patients were matched for gender, age group, BMI category, year and quarter of discharge, ICU stay, and diagnosis-related group (DRG). Eligible drugs included all routes for cefepime, ceftazidime, doripenem, imipenem/cilastatin, meropenem, and piperacillin/tazobactam and IV only for amikacin, aztreonam, gentamicin, and tobramycin. Outcomes were evaluated in a pairwise manner using t tests or χ2 tests. Results: Each of the 3 study groups consisted of 6,327 patients, 51% of whom were men; average age, 63 years; 70% of whom were obese or overweight, and 19% of whom had an ICU stay. The most common DRG code was infectious and parasitic diseases (57%) followed by digestive system (9%), respiratory system (7%), and kidney and urinary tract (6%). High antibiotic use was associated with longer length of stay and a higher estimated cost per visit. Low antibiotic use was associated with higher rate of mortality and a lower rate of readmissions compared to moderate use. The low-usage group did not exhibit a statistically significant difference in mortality, readmissions, or rate of C. difficile compared to the high-usage group. Conclusions: The optimal antibiotic utilization group varied among outcomes. Further evaluation of outcomes is needed for the SAAR to understand the ranges and the relationship between the measure and clinical outcomes.
Funding: None
Disclosures: None
Procalcitonin Use in a Large Community Healthcare System
- Mandelin Cooper, Hayley Burgess, Jeffrey Cuthbert, Edward Joel Septimus, Heather Signorelli
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s360
- Print publication:
- October 2020
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Background: Appropriate testing of blood procalcitonin (PCT) can potentially inform antibiotic de-escalation in patients with severe infections. When used along with observed clinical improvements, PCT testing can support antimicrobial stewardship. However, this testing must be used optimally to ensure that it is actionable, cost-effective, and provides patient benefit. Although this test is widely used, little is known about the appropriateness of this testing in select populations. Methods: In this retrospective review, we evaluated PCT monitoring patterns and appropriateness of use and relationship to antibiotic days of therapy in a system of community hospitals. We evaluated the use of PCT testing in patients with known confounders, namely pregnancy, chronic kidney disease, or neutropenia, which we classified as “inappropriate use” because these conditions can affect the interpretation of PCT results. We also evaluated the relationship between PCT testing and antibiotic days of therapy for patients with sepsis, pneumonia, or lower respiratory tract infections. Results: In a 1-year period, ∼206,302 PCT tests were performed at 146 facilities, an average of ∼1,413 per facility per year. Approximately 27.7% of these tests were given to patients who were pregnant or had a confounding comorbidity such as chronic kidney disease or neutropenia. Of these “inappropriate” tests, >90% were given to patients with chronic kidney disease. Older patients (aged 60–80 years, n = 93,021) were more likely to receive a PCT test while also having a confounding comorbidities; 24% of older patients with a PCT test also had chronic kidney disease. Of all patients with a PCT test and chronic kidney disease, ∼76% were also diagnosed with either sepsis, pneumonia, or lower respiratory tract infections. Conclusions: Confounding conditions can affect PCT levels independently of infection. Additionally, some clinicians use PCT tests as probes for other physiological maladies. This analysis demonstrated that there is opportunity for education about the appropriate use of this test, how to interpret results in the presence of confounding conditions, and how to transform PCT test results into actions that facilitate antimicrobial stewardship and better patient care.
Funding: None
Disclosures: None
Clinical Metrics for a Large Healthcare System’s Antimicrobial Management Program
- Hayley Burgess, Joan Kramer, Elizabeth Hofammann, Mandelin Cooper
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s7
- Print publication:
- October 2020
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Background: Clinical metrics and outcomes for evaluation of antimicrobial management programs (AMP) are challenging and inconsistent throughout the United States. Here, we present the results of the development of clinical metrics to measure and trend AMP outcomes within 161 acute-care facilities affiliated with a large healthcare system. Methods: Key AMP metrics were implemented in 2018 using 2017 as baseline: use of fluoroquinolones in UTIs, dosing of vancomycin, de-escalation, and intravenous (IV)-to-oral conversion of targeted drugs. Fluoroquinolone (FQ) and UTI metric evaluated all inpatients who received at least 1 dose of a FQ based on barcoded medication administration (BCMA) data and urinary tract infections were based on cystitis ICD-10 coding. Vancomycin dosing metric evaluated inpatient vancomycin troughs within therapeutic range during the admission. De-escalation metric evaluated for patients on a broad-spectrum antibiotic with a positive culture and sensitivity to narrower antibiotics. The IV-to-oral ratio was used to monitor targeted medications. Nonantimicrobial medications appropriate for IV-to- oral conversion were included in the ratio. Goals were established for each metric using the 75th percentile and ranges for “at goal,” “close to goal,” and “not at goal” were established using green–yellow–red color coding. Metrics were monitored via a systemwide dashboard that included all affiliated facilities. Data were shared monthly to key stakeholders including physicians, pharmacists, and senior leadership. Results: From 2017 to the third quarter of 2019, the FQ and UTI metric decreased 55%. This reduction in the FQ usage in UTI metric correlated with a reduction of 26.7 days of therapy (DOT) per 1,000 days present for FQ and a 50% reduction in FQ DOT for all affiliated facilities. The vancomycin dosing metric improved 2.9% from 75.2% of patients to 78.1% of patients with at least 1 vancomycin trough within range during the admission, which represents ~2,000 more patients with dosing in the target range over baseline. The de-escalation metric improved by 7% overall from 2018 to the third quarter of 2019, which translates to ~1,600 more patients with therapy de-escalated. The IV-to-oral ratio metric improved 5.5%, which means that ~180,000 more oral dosages were administered. Conclusions: Implementing AMP program clinical metrics in a large health system positively influenced antimicrobial medication therapy management for patients. Monitoring of process metrics should be considered for all AMP programs to advance antibiotic stewardship.
Funding: None
Disclosures: None