OBJECTIVE Identification of organisms directly from positive blood culture by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has the potential for improved clinical outcomes through earlier organism identification and shorter time to appropriate clinical intervention. The uses of this technology in pediatric patients and its impact in this patient population have not been well described. METHODS Direct from positive blood culture organism identification via MALDI-TOF was implemented in September 2019. A quality improvement project was performed to assess its impact on admissions for contaminant blood cultures and time to effective and optimal antimicrobials and clinical decision-making. A pre- and post-implementation retrospective review for consecutive September through February time periods, was conducted on patients with positive monomicrobial blood cultures. Statistics were evaluated using Mann-Whitney U and χ2 tests. RESULTS One hundred nineteen patients with 131 unique blood cultures (65 in pre- and 66 in post-implementation) were identified. Time to identification was shorter, median 35.4 hours (IQR, 22.7–54.3) versus 42.3 hours (IQR, 36.5–49) in post- and pre-groups, respectively (p = 0.02). Patients were less likely to be admitted for a contaminated blood culture in the post-implementation, 26% versus 11% in the pre-implementation (p = 0.03) group. In patients treated for bacteremia, there was a shorter time to optimal therapy from Gram stain reporting in the post-implementation (median 42.7 hours [IQR, 27.2–72]) versus pre-implementation (median 60.8 hours [IQR, 42.9–80.6]) (p = 0.03). CONCLUSIONS Direct from positive blood culture identification by MALDI-TOF decreased time to effective and optimal antimicrobials and decreased unnecessary admission in pediatric patients for contaminated blood cultures.
Background Prospective audit and feedback (PAF) is a core strategy of antimicrobial stewardship programs (ASPs). To improve communication of PAF recommendations to the inpatient pediatric infectious diseases (ID) consult service, the ASP pharmacists at our hospital were integrated into ID rounds. The purpose of this study was to assess the impact of ASP pharmacy participation in ID rounds on the rate of ASP recommendations. Methods Prior to implementation of the ASP pharmacist rounding service, the ASP pharmacist did not routinely attend rounds or communicate PAF recommendations directly to the ID consult service. Starting 1/3/22, the ASP pharmacists had daily (M-F) in-person discussions with the ID team regarding their patients’ antimicrobials. Audits performed between 1/4/21-12/30/21 and 1/3/22-4/29/22 on patients with an ID consult were included in the non-rounding cohort (NRC) and rounding cohort (RC), respectively. We compared PAF recommendation rates, characteristics, and acceptance rates between the two cohorts. Results There was an increase in PAF recommendation rate in the RC compared to NRC (188/485 [39%] vs 359/1234 [29%], p < 0.001). Antibiotics were the antimicrobial category mostly likely to have a recommendation and the rate of antibiotic PAF recommendations was higher in the RC compared to the NRC (132/341 [39%] vs. 271/934 [29%], p = 0.001) (Table 1). The most common recommendation types in both cohorts were to optimize the antimicrobial dose and antimicrobial discontinuation. Recommendations were more frequently communicated to the ID team in the RC compared to NRC (125/188 [66%] vs. 107/359 [30%], p < 0.001). The recommendation acceptance rate was similar between the two cohorts (159/188 [85%] RC vs. 290/359 [81%] NRC, p = 0.29). CNS: Central nervous system; IV: Intravenous; NRC: Non-rounding cohort; PAF: Prospective audit and feedback; PO: Per os, oral; RC: Rounding cohort; SSTI: Skin and soft tissue infection; UTI: Urinary tract infection. Conclusion Implementation of a pediatric ASP pharmacist rounding service increased the PAF recommendation rate and improved recommendation communication with the pediatric ID consult service. Participation in rounds may better inform ASP pharmacist PAF recommendations. Future studies describing the potential benefit to the ID team by having an ASP pharmacist present on rounds are warranted. ASPs should consider formal integration of ASP pharmacists as part of the ID consult service to further improve the quality of antimicrobial prescribing. Disclosures All Authors: No reported disclosures.
Background Approximately 30% of children are discharged from the hospital with an antimicrobial prescription; nearly a third of these prescriptions are suboptimal. Although the best approach to antimicrobial stewardship of discharge prescriptions remains uncertain, prospective audit and feedback (PAF) has improved inpatient antimicrobial use. We aimed to identify and characterize suboptimal discharge antimicrobial prescribing and assess the impact of inpatient PAF on the quality of discharge antimicrobial prescribing at a free-standing children’s hospital. Methods A retrospective review of enteral discharge antimicrobial prescriptions between 12/1/20-5/31/21 and parenteral antimicrobial prescriptions sent to our hospital’s infusion pharmacy between 3/1/21-5/31/21 was performed to determine if suboptimal or not. A prescription was determined to be suboptimal if the antimicrobial choice, dose, frequency, duration, formulation, or indication was not consistent with institutional and/or national guidelines. Data collection included the antimicrobial, indication, and prescribing medical service. Prescriptions were evaluated for a corresponding inpatient PAF for the same drug and indication and then stratified based on inpatient PAF completion. Results A total of 1192 discharge prescriptions for 698 unique patients over 834 hospital encounters were reviewed. Overall, 243 (20%) prescriptions were identified as suboptimal; reasons were duration (16%), dose (8%), frequency (5%), or antimicrobial choice, formulation, or route (≤1%). Prescriptions for cephalexin had the highest rate of suboptimal prescribing (80/167, 48%), followed by amoxicillin-clavulanate (89/203, 44%). A corresponding inpatient PAF was identified for 675 (57%) of discharge antimicrobial prescriptions. Inpatient PAF prior to discharge resulted in fewer suboptimal discharge prescriptions for the same antimicrobial (8% vs. 36%, p < 0.001). Conclusion Antimicrobial prescribing at inpatient discharge was suboptimal in 1 of every 5 prescriptions. Inpatient PAF was associated with improved antimicrobial prescribing at hospital discharge. Antimicrobial stewardship programs should continue to explore ways to capture and intervene on antimicrobials prescribed at discharge. Disclosures Hayden T. Schwenk, MD, MPH, Nothing to disclose
Objective: To characterize pharmacodynamic dosing strategies used at children’s hospitals using a national survey. Design: Survey. Setting: Children’s hospitals. Participants: Volunteer sample of antimicrobial stewardship program (ASP) respondents. Methods: A nationwide survey was conducted to gain greater insight into the current adoption of nontraditional dosing methods and monitoring of select β-lactam and fluoroquinolone antibiotics used to treat serious gram-negative infections in pediatric populations. The survey was performed through the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. Results: Of the 75 children’s hospitals that responded, 68% of programs reported adoption of pharmacodynamically optimized dosing using prolonged β-lactam infusions and 35% using continuous β-lactam infusions, although use was infrequent. Factors including routine MIC monitoring and formal postgraduate training and board certification of ASP pharmacists were associated with increased utilization of pharmacodynamic dosing. In addition, 60% of programs reported using pharmacodynamically optimized ciprofloxacin and 14% reported using pharmacodynamically optimized levofloxacin. Only 20% of programs monitored β-lactam levels; they commonly cited lack of published guidance, practitioner experience, and laboratomory support as reasons for lack of utilization. Less physician time dedicated to ASP programs was associated with lower adoption of optimized dosing. Conclusions: Use of pharmacodynamic dosing through prolonged and continuous infusions of β-lactams have not yet been routinely adopted at children’s hospitals. Further guidance from trials and literature are needed to continue to guide pediatric pharmacodynamic dosing efforts. Children’s hospitals should utilize these data to compare practices and to prioritize further research and education efforts.
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