Background Infections caused by extended-spectrum ß-lactamase (ESBL) producing organisms pose a unique challenge for infection control. The preferred agents for treatment of infections due to ESBL-producing bacteria are carbapenems. Data from prior studies suggest that hypoalbuminemia may have a profound effect on the pharmacodynamic properties of ertapenem. Our hypothesis is that ertapenem usage in patients with hypoalbuminemia will lead to negative clinical outcomes such as infection recurrence, hospital readmission, and mortality when compared to subjects with higher albumin levels. Methods This was a retrospective, observational, single-centered, cohort study of hospitalized patients at Loyola University Medical Center between January 2010 and August 2020. Patients were divided into 2 groups to include those who received ertapenem with serum albumin >2.5 g/dL and those who received ertapenem with serum albumin < 2.5 g/dL. The primary outcome of interest was 30-day all-cause mortality. Baseline characteristics that were collected included age, sex, nutrition status, patient comorbidities. Data regarding predictors of mortality within 24 hours of initiation of ertapenem including the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Charlson Comorbidity Index (CCI) was also collected. Study Criteria Results Of the 146 subjects that were included, 73 patients had serum albumin levels of < 2.5 g/dL during treatment with ertapenem. 30 day all-cause mortality was 19.7% for subjects with low albumin and 9.6% for subjects with normal albumin levels (p=0.09). Our study found that although not statistically significant, there is potentially a clinical significance between hypoalbuminemia and our primary endpoint, 30-day all-cause mortality, with higher rates of mortality in the low albumin group and a 9.6% between group difference. This data suggests that in subjects with hypoalbuminemia, treatment with once-daily ertapenem may lead to suboptimal outcomes regarding patient mortality. Outcome Data Conclusion The present study data suggests that in subjects with hypoalbuminemia, treatment with ertapenem dosed as a once-daily intravenous infusion may be associated with suboptimal clinical outcomes that may include an increased mortality, hospital readmission, and length of stay. Disclosures All Authors: No reported disclosures.
Pneumonia is common in the intensive care unit (ICU), infecting 27% of all critically ill patients. Given the high prevalence of this disease state in the ICU, optimizing antimicrobial therapy while minimizing toxicities is of utmost importance. Inappropriate antimicrobial use can increase the risk of antimicrobial resistance, Clostridiodes difficile infection, allergic reaction, and other complications from antimicrobial use (e.g., QTc prolongation, thrombocytopenia). This review article aims to discuss methods to optimize antimicrobial treatment in patients with pneumonia, including the following: procalcitonin use, utilization of methicillin-resistant Staphylococcus aureus nares testing to determine need for vancomycin therapy, utilization of the Biofire® FilmArray® pneumonia polymerase chain reaction (PCR), and microbiology reporting techniques.
Background The Joint Commission highlighted handshake stewardship (HS) as a leading practice in antimicrobial stewardship (AMS). However, intervention and outcomes data in adult populations are lacking. Additionally, limited human resources remain a barrier to widespread implementation of HS services. In February 2022, our antimicrobial stewardship program (ASP) expanded to include a HS service supporting adult internal medicine patients managed by hospitalist staff at an academic medical center. Here we aim to describe the interventions made to support and improve care in this population. Methods This was a single-center, retrospective quality improvement initiative at a 547-bed academic medical center. Beginning in February 2022, the ASP structure expanded to include 2-week rotations between HS, general infectious diseases (ID) consult rounds, and whole house AMS (a combination of prospective audit and feedback and pre-authorization). During the HS rotation, all prescribed antimicrobials were prospectively reviewed Monday-Friday by the ID pharmacist and recommendations to improve quality, safety, and transitions of care were discussed in-person during daily rounds with hospitalists. Interventions were documented daily and data generated between February 1, 2022 and April 30, 2022 were reviewed to categorize the impact of the expanded service. Results A total of 316 interventions were made for 101 unique patients over a 3-month period. We observed 286 accepted interventions (90.5%) during the intervention period. On average, the HS pharmacist reviewed 24 charts per day and spent 68 minutes in chart review, 16 minutes in rounds, and 23 minutes in other direct communication with providers per day. Table 1 and Figure 1 describe the distribution of interventions by type and indication. Table 2 quantifies the number of days broad spectrum antibiotics were avoided directly attributable to interventions. Since implementation, the HS service has contributed to an estimated cost savings of $73,470.19 for our hospital. Table 1.Intervention by TypeFigure 1.Antibiotic Indication for Cases with Interventions Conclusion Implementation of HS in two adult internal medicine teams was associated with many interventions with high acceptance by hospitalist staff. Interventions led to tangible reductions in broad spectrum antibiotic days of therapy and cost. Disclosures Sonali Kalathiya, PharmD, MPH, BCIDP, Blueprint Medicines: Spouse is employed by Blueprint Medicines|Blueprint Medicines: Stocks/Bonds.
Background It is not uncommon for patients to have a labeled allergy to antibiotics without thorough investigation of their adverse reactions. The adverse reactions described by some patients are not immune-mediated and these patients are incorrectly labeled as having an antibiotic allergy. As clinical testing for antibiotic allergy is expensive and time intensive, recent initiatives have successfully used patient interviewing to differentiate non-immune mediated reactions from true antibiotic allergies. We investigated the prevalence of patients with non-immune mediated reactions to antibiotics among patients with documented antibiotic allergy by using a standardized questionnaire in the outpatient setting. Methods Patients with a documented antibiotic allergy were identified and recruited from 2 clinics located in the greater Chicagoland area. Subjects completed one standardized questionnaire regarding each of their previous adverse reaction to antibiotics. We then evaluated the questionnaire responses to extricate the non-immune-mediated adverse reactions. The full symptom classification can be found in Table 1 and Table 2. Results 98 patients were recruited with a total of 159 antibiotic questionnaires completed. At the patient level, 18 individuals had no immune-mediated reactions despite antibiotic allergy labels: 18.37% (95% CI: 10.7%, 26.3%). At the antibiotic level, 35 labels had corresponding clinical histories that were likely non-immune mediated: 22.0% (95% CI: 14.7%, 29.4%). Macrolides (8/11, 72.7%), nitrofurantoin (1/2, 50%), and amoxicillin/clavulanate (2/8, 25%) were the antibiotics with the highest percentage of corresponding clinical histories that were likely non-immune mediated (Figure 1). Penicillin was the most prevalently listed antibiotic allergy (43/159, 27.0%), followed by sulfonamides (25/159, 15.7%) and fluoroquinolones (21/159, 13.2%). Conclusion This study demonstrated the feasibility of using a standardized questionnaire to discern true antibiotic allergies from non-immune mediated adverse reactions. The improved accuracy of documented allergies allows for better optimization of antibiotic prescribing. Disclosures All Authors: No reported disclosures.
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