Impact of a syndrome-specific antibiotic stewardship intervention on antipseudomonal antibiotic use in inpatient diabetic foot infection management

Abstract

Objective: To demonstrate that a syndromic stewardship intervention can safely reduce antipseudomonal antibiotic use in the treatment of inpatient diabetic foot infections (DFIs). Intervention and method: From November 2017 through March 2018, we performed an antimicrobial stewardship intervention that included creation of a DFI best-practice guideline, implementation of an electronic medical record order set, and targeted education of key providers. We conducted a retrospective before-and-after study evaluating guideline adherent antipseudomonal antibiotic use 1 year before and after the intervention using interrupted time-series analysis. Setting: University of Nebraska Medical Center, a 718-bed academic medical center in Omaha, Nebraska. Patients: The study included 193 adults aged ≥19 years (105 in the preintervention group and 88 in the postintervention group) admitted to non–intensive care units whose primary reason for antibiotic treatment was diabetic foot infection (DFI). Results: Guideline-adherent use of antipseudomonal antibiotics increased from 39% before the intervention to 68% after the intervention (P ≤ .0001). Antipseudomonal antibiotic use decreased from 538 days of therapy (DOT) per 1,000 DFI patient days (PD) before the intervention to 272 DOT per 1,000 DFI PD after the intervention (P < .0001), with a statistically significant decrease in both level of use and slope of change. We did not detect any changes in length of stay, readmission, amputation rate, subsequent positive Clostridioides difficile testing, or mortality. Conclusions: Our 3-component intervention of guideline creation, implementation of an order set, and targeted education was associated with a significant decrease in antipseudomonal antibiotic use in the management of inpatient DFIs. DFIs are common and should be considered as opportunities for syndromic stewardship intervention.

Fear of Missing Organisms (FOMO): the discordance among broad-spectrum empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy for diabetic foot infections and lower extremity osteomyelitis

“…Our findings are consistent with previous studies in the United States noting discrepancies between empiric anti-MRSA and antipseudomonal therapies and microbiologic results with these organisms. 6,11,12 In contrast, in Western Australia, Hand et al 13 found a significant difference between the frequency of empiric antipseudomonal therapy and the frequency of isolation of P. aeruginosa in microbiologic testing; however, there was no significant difference between the frequency of empiric anti-MRSA therapy and the frequency of isolation of MRSA in microbiologic testing, 12.6% versus 11.9%, respectively. Notably, Western Australia has a wellestablished screening program for patients at high risk of MRSA with positive results prompting an electronic flag in the patient's medical record.…”

“…Several studies have identified risk factors independently associated with isolation of MRSA and/or resistant gram-negative organisms; 7,11,12,14 however, these risk factors may have poor PPV and may lead to significant overuse of empiric broad-spectrum therapies. Our study focused on the NPV of risk factors with the goal of identifying patients for whom empiric broad-spectrum therapies could be withheld.…”

Staphylococcus aureus Is the Predominant Pathogen in Hospitalised Patients with Diabetes-Related Foot Infections: An Australian Perspective

“…The local AMS program should target interventions towards lowering the inappropriate use of piperacillin-tazobactam in this setting as the overuse of antimicrobials has been shown to lead to increased costs and adverse clinical events [28]. Furthermore, the overuse of antipseudomonal antibiotics in DFIs does not lead to better patient outcomes [29].…”