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IntroductionBlood cultures are of limited utility in non-severe community-acquired pneumonia, though routinely recommended for severe community-acquired pneumonia or healthcare-associated pneumonia, due to perceived greater bacteremia risk, particularly with multidrug resistant organisms. The utility of this practice is unknown. MethodsIn this observational cohort study, we abstracted data from medical records for consecutive hospitalizations for pneumonia by adults to an academic medical center from 2014-2015. The primary outcomes included bacteremia, multidrug resistant organism bacteremia, and appropriate management changes attributed to culture results, stratified by pneumonia classification (non-severe community-acquired pneumonia, severe community-acquired pneumonia, or healthcare-associated pneumonia) and likelihood the bacteremia was due to pneumonia versus another infection. We assessed the diagnostic test performance of ≥1 guideline-defined risk factors for bacteremia in non-severe community-acquired pneumonia, for whom cultures are routinely recommended. ResultsOf 456 pneumonia hospitalizations, 30 (6.6%) had bacteremia, with a greater incidence in severe community-acquired pneumonia (14.7%) than non-severe communityacquired pneumonia (7.8%) and healthcare-associated pneumonia (6.6%; p=0.12). Seventeen bacteremia cases were likely due to pneumonia (3.7%). Only 2 (0.4%) had multidrug resistant organisms (both healthcare-associated pneumonia), 1 of whom was due to pneumonia. Appropriate management changes occurred in 8 cases (1.8%; 7 deescalation and 1 escalation of antibiotics); only 1 with bacteremia likely due to pneumonia (de-escalation). The one case of appropriate antibiotic escalation occurred in a patient with vancomycin-resistant enterococcus unrelated to pneumonia. Having ≥1 guideline-defined risk factors did not identify bacteremia in non-severe communityacquired pneumonia (positive likelihood ratio, 1.10, 95% CI, 0.61-1.99). ConclusionRoutine blood cultures in pneumonia have extremely low yield and utility irrespective of severity and risk.

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Interventions to improve the safety and efficiency of manual sterile compounding are needed. This study evaluated the impact of a technology-assisted workflow system (TAWS) on sterile compounding safety (checks, traceability, and error detection), and efficiency (task time). Methods Observations were conducted in an oncology pharmacy transitioning from a manual to a TAWS process for sterile compounding. Process maps were generated to compare manual and TAWS checks and traceability. The numbers and types of errors detected were collected, and task times were observed directly or via TAWS data logs. Results Analysis of safety outcomes showed that, depending on preparation type, 3 to 4 product checks occurred in the manual process, compared to 6 to 10 checks with TAWS use. TAWS checks (barcoding and gravimetric verification) produced better traceability (documentation). The rate of incorrect-drug errors decreased with technology-assisted compounding (from 0.4% [5 of 1,350 preparations] with the manual process to 0% [0 of 1,565 preparations] with TAWS use; P < 0.02). The TAWS increased detection of (1) errors in the amount of drug withdrawn from vials (manual vs TAWS, 0.4% [5/1,350] vs 1.2% [18/1565]; P < 0.02), and (2) errors in the amount of drug injected into the final container (manual vs TAWS, 0% [0/1,236] vs 0.9% [11/1,272]; P < 0.002). With regard to efficiency outcomes, TAWS use increased the mean mixing time (manual vs TAWS, 275 seconds vs 355 seconds; P < 0.001), had no significant impact on average visual checking time (manual vs TAWS, 21.4 seconds vs 21.6 seconds), and decreased average physical checking time (manual vs TAWS, 58.6 seconds vs 50.9 seconds; P < 0.001). Conclusion In comparison to manual sterile compounding, use of the TAWS improved safety through more frequent and rigorous checks, improved traceability (via superior documentation), and enhanced error detection. Results related to efficiency were mixed.

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