9 results
Use of clinical decision support for antibiotic stewardship in the emergency department and outpatient clinics: An interrupted time-series analysis
- James S. Ford, Brittany L. Morgan Bustamante, Mehr Kaur Virk, Nancy Ramirez, Cynthia G. Matsumoto, Daniel Jin Lee, Scott MacDonald, Larissa May
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- Journal:
- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 3 / Issue 1 / 2023
- Published online by Cambridge University Press:
- 26 April 2023, e80
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Objective:
To evaluate the impact of implementing clinical decision support (CDS) tools for outpatient antibiotic prescribing in the emergency department (ED) and clinic settings.
Design:We performed a before-and-after, quasi-experimental study that employed an interrupted time-series analysis.
Setting:The study institution was a quaternary, academic referral center in Northern California.
Participants:We included prescriptions for patients in the ED and 21 primary-care clinics within the same health system.
Intervention:We implemented a CDS tool for azithromycin on March 1, 2020, and a CDS tool for fluoroquinolones (FQs; ie, ciprofloxacin, levofloxacin, and moxifloxacin) on November 1, 2020. The CDS added friction to inappropriate ordering workflows while adding health information technology (HIT) features to easily perform recommended actions. The primary outcome was the number of monthly prescriptions for each antibiotic type, by implementation period (before vs after).
Results:Immediately after azithromycin-CDS implementation, monthly rates of azithromycin prescribing decreased significantly in both the ED (−24%; 95% CI, −37% to −10%; P < .001) and outpatient clinics (−47%; 95% CI, −56% to −37%; P < .001). In the first month after FQ-CDS implementation in the clinics, there was no significant drop in ciprofloxacin prescriptions; however, there was a significant decrease in ciprofloxacin prescriptions over time (−5% per month; 95% CI, −6% to −3%; P < .001), suggesting a delayed effect of the CDS.
Conclusion:Implementing CDS tools was associated with an immediate decrease in azithromycin prescriptions, in both the ED and clinics. CDS may serve as a valuable adjunct to existing antimicrobial stewardship programs.
Patterns of Oral Antibiotic Use and Excess Duration at Hospital Discharge
- Corey Medler, Nicholas Mercuro, Helina Misikir, Nancy MacDonald, Melinda Neuhauser, Lauri Hicks, Arjun Srinivasan, George Divine, Marcus Zervos
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s522-s523
- Print publication:
- October 2020
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Background: Antimicrobial stewardship (AMS) interventions have predominantly involved inpatient antimicrobial therapy. However, for many hospitalized patients, most antibiotic use occurs after discharge, and unnecessarily prolonged courses of therapy are common. Patient transition from hospitalization to discharge represents an important opportunity for AMS intervention. We describe patterns of antibiotic use selection and duration of therapy (DOT) for common infections including discharge antibiotics. Methods: This retrospective cross-sectional analysis was derived from an IRB-approved, multihospital, quasi-experiment at a 5-hospital health system in southeastern Michigan. The study population included patients discharged from an inpatient general and specialty practice ward on oral antibiotics from November 2018 through April 2019. Patients were included with the following diagnoses: skin and soft-tissue infections (SSTIs), community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), respiratory viral infections, acute exacerbation of chronic obstructive pulmonary disease (AECOPD), intra-abdominal infections (IAIs), and urinary tract infections (UTIs). Other diagnoses were excluded. Data were extracted from medical records including antibiotic indication, selection, and duration, as well as patient characteristics. Results: In total, 1,574 patients were screened and 800 patients were eligible for inclusion. The most common antibiotic indications were respiratory tract infections, with 487 (60.9%) patients. These included 165 AECOPD cases (20.6%) and 200 CAP cases (25%) with no multidrug resistant organism (MDRO) risk factors; 57 patients (7.1%) with MDRO risk factors; HAP in 7 patients (0.9%); and influenza in 58 patients (7.2%). Also, 205 (25.6%) patients were diagnosed with UTIs: 71 with cystitis (8.9%), 86 (10.8%) with complicated UTI (cUTI), and 48 (6%) with pyelonephritis. Furthermore, 125 patients (15.6%) were diagnosed with SSTI: 59 (7.4%) purulent and 66 (8.3%) nonpurulent. 31 (3.9%) patients had an IAI. The most commonly used antibiotics were cephalosporins in 536 patients (67%), azithromycin in 252 patients (31.5%), and fluroquinolones and tetracyclines in 231 patients (28.9%). Fluroquinolones were the most frequent antibiotic prescribed at discharge in 210 patients (26.3%). Figure 1 displays the average DOT relative to specific indications. The median duration of total antibiotic therapy exceeded institutional guideline recommendation for multiple conditions, including AECOPD (7 days vs recommended 5 days), CAP with COPD (8.3 vs 7 days ), CAP without COPD (7.7 vs 5 days), and pyelonephritis (11 vs 7–10 days). Also, 269 (33.6%) patients received unnecessary therapy; 218 (27.3%) of these were due to excess duration. Conclusions: Among a cross-section of hospitalized patients, the average DOT, including after discharge, exceeded the optimal therapy for many patients. Further understanding of patterns and influences of antibiotic prescribing is necessary to design effective AMS interventions for improvement.
Funding: This work was completed under CDC contract number 200-2018-02928.
Disclosures: None
Implementation Methods for a Collaborative Pharmacist-Led Antimicrobial Stewardship Intervention at Hospital Discharge
- Corey Medler, Nicholas Mercuro, Nancy MacDonald, Allison Weinmann, Melinda Neuhauser, Lauri Hicks, Arjun Srinivasan, George Divine, Marcus Zervos, Susan Davis
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s268-s269
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- October 2020
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Background: Unnecessary and prolonged antibiotic use is an important driver of antimicrobial resistance, increasing patient harm and resource utilization. Antimicrobials prescribed at hospital discharge represent an important opportunity to intervene and optimize therapy. Objective: We describe the implementation of a pharmacist-led multidisciplinary antimicrobial stewardship (AMS) intervention at transition of care (TOC) to improve antibiotic selection and duration. Methods: This intervention an IRB-approved multihospital, quasi-experimental, 3-phase stepped-wedge project in a 5-hospital health system. The setting included a large, urban, academic medical center in Detroit, Michigan, and 4 community hospitals in southeastern Michigan. AMS is provided by a pharmacist and infectious diseases physician at each site. For the AMS TOC intervention, pharmacists implemented 3 strategies: (1) early identification of patients to be discharged on oral antibiotics; (2) collaborative planning and communication regarding guideline-recommended antibiotic selection and duration; and (3) facilitation of discharge antibiotic prescription with appropriate stop date. Process improvements were modified to fit the academic and community hospital practice models. The process was implemented in general and specialty practice wards at each hospital site. Prior to implementation in October 2018, pharmacists were trained on tools to standardize identification, collaboration, and documentation. Pocket cards were used to augment education and electronic medical record (EMR) templates standardized documentation. Physicians and nurses on participating units were educated on the rationale and process. Following initiation, ongoing feedback was provided regularly to pharmacists to discuss challenges and to identify solutions. Process measures included the total number of patients receiving the intervention monthly, as indicated by pharmacist AMS TOC notes placed. Protocol adherence was evaluated in 25 randomly selected patients in each study phase each month. Adherence was defined as a pharmacist preparing discharge prescriptions and a placing note in the EMR. Results: Over the study period, 1,558 patient encounters received AMS TOC facilitation by a pharmacist. Monthly protocol adherence ranged from 29% to 87% (higher in academic institutions than community) (Fig. 1). Months of low protocol adherence were associated with times of reduced staffing and onboarding a large group of new employees or trainees. Additional barriers included discharges over weekends. The most common area needing clarification was how to count days of therapy to determine the appropriate stop date. A guide of how to count days of therapy was created to assist. Conclusions: Pharmacist-led antimicrobial stewardship at discharge is a feasible intervention in both academic and community settings. Identifying potential barriers and assessing strategies with multidisciplinary healthcare teams allows for optimal implementation and intervention rollout.
Funding: This work was completed under CDC contract number 200-2018-02928.
Disclosures: None
Improving Prescribing Practices at Hospital Discharge With Pharmacist-Led Antimicrobial Stewardship at Transitions of Care
- Nicholas Mercuro, Corey Medler, Nancy MacDonald, Rachel Kenney, Melinda Neuhauser, Lauri Hicks, Arjun Srinivasan, George Divine, Marcus Zervos, Susan Davis
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s289-s290
- Print publication:
- October 2020
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Background: Antimicrobial stewardship (AMS) is recommended in hospital, postacute, and outpatient settings. Transitions of care (TOC) are important in each of these settings; however, AMS efforts during TOC have been limited. Beginning in October 2018, we sequentially implemented a pharmacist-led multidisciplinary review of oral antimicrobial therapy prescribed at hospital discharge from general and specialty medicine wards across a health system. Pharmacists facilitated data input of discharge prescriptions following early identification and collaborative discussion of patients to be discharged on oral antimicrobials The purpose of this study was to evaluate the impact of AMS during TOC. Methods: This project was an IRB-approved stepped-wedge, quasi-experimental study in a 5-hospital health system that included hospitalized adults with skin, urinary, intra-abdominal, and respiratory tract infections who had been discharged from general and specialty wards with oral antimicrobials. Patients with complicated infections, neutropenia, or who were transferred from an outside hospital were excluded. The primary end point was optimization of antimicrobial therapy at time of hospital discharge, defined by correct selection, dose, and duration according to institutional guidance. Outcomes were compared before and after the intervention. Results: In total, 800 patients were included: 400 in the preintervention period and 400 in the postintervention period. Among this cohort, 252 (63%) received the intervention by a pharmacist per protocol during TOC. Patients had similar comorbid conditions before and after the intervention. Preintervention patients were more likely to be discharged from community hospitals. Before the intervention, 36% of discharge regimens were considered optimized, compared to 81.5% after the intervention (P < .001); this difference was largely driven by a reduction in patients receiving a duration of therapy beyond the clinical indication (44.5 vs 10%; P < .001). We observed similar clinical resolution, 30-day readmission, and adverse drug events (ADEs) between the pre- and postintervention periods. Postdischarge antimicrobial duration of therapy was reduced from 4 days (range, 3–5) to 3 days (range, 2–4) (P < .001) Severe ADEs occurred more frequently in the preintervention group (9 vs 3.3%; P = .001), which was driven by isolation of multidrug-resistant pathogens (7 vs 2.5%; P = .003) and Clostridioides difficile (1.8 vs 0.5%; P = .094). Patients who received optimal therapy at discharge were less likely to develop an ADE (aOR, 0.530; 95% CI, 0.363–0.773). Conclusions: Implementation of an AMS TOC protocol reduced antimicrobial days, optimized therapy selection, and reduced duration. This intervention was associated with improved safety without compromise of clinical effectiveness. To increase patient safety, AMS programs should target antimicrobial optimization during TOC.
Funding: This work was completed under CDC contract number 200-2018-02928.
Disclosures: None
Strengthening primary health care through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors
- Ruta K. Valaitis, Linda O’Mara, Sabrina T. Wong, Marjorie MacDonald, Nancy Murray, Ruth Martin-Misener, Donna Meagher-Stewart
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- Journal:
- Primary Health Care Research & Development / Volume 19 / Issue 4 / July 2018
- Published online by Cambridge University Press:
- 12 April 2018, pp. 378-391
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Aim
The aim of this paper is to examine Canadian key informants’ perceptions of intrapersonal (within an individual) and interpersonal (among individuals) factors that influence successful primary care and public health collaboration.
BackgroundPrimary health care systems can be strengthened by building stronger collaborations between primary care and public health. Although there is literature that explores interpersonal factors that can influence successful inter-organizational collaborations, a few of them have specifically explored primary care and public health collaboration. Furthermore, no papers were found that considered factors at the intrapersonal level. This paper aims to explore these gaps in a Canadian context.
MethodsThis interpretative descriptive study involved key informants (service providers, managers, directors, and policy makers) who participated in one h telephone interviews to explore their perceptions of influences on successful primary care and public health collaboration. Transcripts were analyzed using NVivo 9.
FindingsA total of 74 participants [from the provinces of British Columbia (n=20); Ontario (n=19); Nova Scotia (n=21), and representatives from other provinces or national organizations (n=14)] participated. Five interpersonal factors were found that influenced public health and primary care collaborations including: (1) trusting and inclusive relationships; (2) shared values, beliefs and attitudes; (3) role clarity; (4) effective communication; and (5) decision processes. There were two influencing factors found at the intrapersonal level: (1) personal qualities, skills and knowledge; and (2) personal values, beliefs, and attitudes. A few differences were found across the three core provinces involved. There were several complex interactions identified among all inter and intra personal influencing factors: One key factor – effective communication – interacted with all of them. Results support and extend our understanding of what influences successful primary care and public health collaboration at these levels and are important considerations in building and sustaining primary care and public health collaborations.
Antimicrobial Stewardship in Outpatient Settings: A Systematic Review
- Dimitri M. Drekonja, Gregory A. Filice, Nancy Greer, Andrew Olson, Roderick MacDonald, Indulis Rutks, Timothy J. Wilt
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 36 / Issue 2 / February 2015
- Published online by Cambridge University Press:
- 22 December 2014, pp. 142-152
- Print publication:
- February 2015
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Objective
Evaluate the effect of outpatient antimicrobial stewardship programs on prescribing, patient, microbial outcomes, and costs.
DesignSystematic review
MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (eg, infectious conditions, prescription services) evaluating stewardship programs in outpatient settings and reporting outcomes of interest. Data regarding study characteristics and outcomes were extracted and organized by intervention type.
ResultsWe identified 50 studies eligible for inclusion, with most (29 of 50; 58%) reporting on respiratory tract infections, followed by multiple/unspecified infections (17 of 50; 34%). We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use, and low-strength evidence that other stewardship interventions are associated with improved prescribing. Patient-centered outcomes, which were infrequently reported, were not adversely affected. Medication costs were generally lower with stewardship interventions, but overall program costs were rarely reported. No studies reported microbial outcomes, and data regarding outpatient settings other than primary care clinics are limited.
ConclusionsLow- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient settings improve antimicrobial prescribing without adversely effecting patient outcomes. Effectiveness depends on program type. Most studies were not designed to measure patient or resistance outcomes. Data regarding sustainability and scalability of interventions are limited.
Infect Control Hosp Epidemiol 2014;00(0):1–11
Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review
- Brittin Wagner, Gregory A. Filice, Dimitri Drekonja, Nancy Greer, Roderick MacDonald, Indulis Rutks, Mary Butler, Timothy J. Wilt
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 35 / Issue 10 / October 2014
- Published online by Cambridge University Press:
- 10 May 2016, pp. 1209-1228
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- October 2014
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Objective
Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.
DesignSystematic review.
MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.
ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.
ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.
53 - Targeted therapies in breast cancer
- from Part 3.1 - Molecular pathology: carcinomas
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- By Nancy E. Hynes, Friedrich Miescher Institute for Biomedical Research, Basel, Switzerland, Gwen MacDonald, Department of Haematology, Imperial College, London, UK
- Edited by Edward P. Gelmann, Columbia University, New York, Charles L. Sawyers, Memorial Sloan-Kettering Cancer Center, New York, Frank J. Rauscher, III
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- Molecular Oncology
- Published online:
- 05 February 2015
- Print publication:
- 19 December 2013, pp 598-605
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Summary
Introduction
Our molecular understanding of breast cancer has increased significantly over the past 20 years. This has resulted in a system of breast cancer classification that is dependent upon their expression of specific proteins, thus breast cancers are often described as estrogen-receptor (ER) positive, ERBB2 over-expressing, or triple negative for ER, progesterone receptor (PR), and ERBB2 expression. In addition, molecular profiling has further refined the classification of breast cancers into five main subgroups, based on distinct gene-expression patterns: luminal A, luminal B, ERBB2 positive, basal, and normal breast-like (1). These groups correlate with many clinical parameters, including patient survival. This has encouraged the rational development of targeted cancer therapies, some of which are in clinical use. The classic example of a treatment that was developed based on our understanding of the biology of the tumor is tamoxifen, a selective ER modulator that interferes with the ligand-stimulated functions of the receptor. For the past 35 years tamoxifen has been the gold standard adjuvant or first-line therapy for patients with ERα- positive tumors and new ER-targeted therapies such as selective receptor down-regulators and aromatase inhibitors are now being used in clinics. The role of ER in breast cancer, the treatments that have been developed to target it and their clinical efficacy are discussed elsewhere (2).
In this review we will discuss the ERBB2 receptor tyrosine kinase (RTK), which has been successfully targeted by antibody-based approaches and by tyrosine kinase inhibitors (TKIs). We will also discuss an emerging target whose inhibition leads to blockade of DNA single-strand break repair in breast tumors with BRCA mutations. Finally, combination treatments targeting different pathways are generally more successful than single treatments in cancer therapy. We will discuss approaches being investigated to combine targeting of ERBB2, ERα, and PI3K.
Cytokine/neurotrophin interaction in the aged central nervous system
- NANCY J. MACDONALD, FRANCESCO DECORTI, TODD C. PAPPAS, GIULIO TAGLIALATELA
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- Journal:
- The Journal of Anatomy / Volume 197 / Issue 4 / November 2000
- Published online by Cambridge University Press:
- 06 February 2001, pp. 543-551
- Print publication:
- November 2000
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Age-associated neurodegenerative diseases such as Alzheimer's disease are characterised by neuronal impairment that leads to cognitive deficits. As certain affected neurons depend on trophic factors such as neurotrophins (NTs), impairment in NT function has been suggested to be a component of neuronal damage associated with such disorders. Age-related neurodegenerative diseases are also characterised by high levels of proinflammatory cytokines such as tumour necrosis factor alpha (TNFα) in the CNS. Because TNFα receptors and certain NT receptors share a high degree of homology and are capable of activating similar signalling pathways, one possibility is that altered cytokine levels may affect NT function in the aged or diseased CNS. Here we wish briefly to review the evidence suggesting a role for cytokine and NT in the onset of age-associated neurodegenerative diseases. We propose that cytokine/NT interactions may alter neuronal homeostasis, thus possibly contributing to some of the neuronal degeneration occurring during such age-associated CNS diseases.