Implementation and optimization of molecular rapid diagnostic tests for bloodstream infections.

PURPOSE: The implementation and optimization of molecular rapid diagnostic tests (mRDTs) as an antimicrobial stewardship intervention for patients with bloodstream infections (BSIs) are reviewed. SUMMARY: All U.S. acute care hospitals accredited by the Joint Commission are required to implement an antimicrobial stewardship program (ASP). Of the many interventions available to ASPs, mRDTs have demonstrated consistent, meaningful results on antimicrobial optimization and patient outcomes. Even among infectious diseases and antimicrobial stewardship-trained pharmacists, significant knowledge and familiarity gaps exist regarding available mRDTs and how best to implement and optimize them. Given the paucity of infectious diseases and/or antimicrobial stewardship-trained pharmacists, the mandates for establishing ASPs will require non-infectious diseases/antimicrobial stewardship-trained pharmacists to implement stewardship interventions, which may include mRDTs, within their institution. Optimization of mRDTs requires adequate diagnostic stewardship, specifically evaluating how mRDT implementation may decrease costs and assist in meeting antimicrobial stewardship regulatory requirements. Knowledge of how these technologies will augment existing microbiology and antimicrobial stewardship workflow is essential. Finally, selecting the right mRDT necessitates familiarity with the instrument's capabilities and with the institutional antibiogram. CONCLUSION: mRDTs have demonstrated the ability to be one of the most powerful antimicrobial stewardship interventions. Pharmacists required to implement an ASP in their institution should consider mRDTs as standard of care for patients with BSIs.

The Role of Antimicrobial Stewardship in the Clinical Microbiology Laboratory: Stepping Up to the Plate.

We report the development of a collaborative relationship between antimicrobial stewardship and clinical microbiology that incorporates stewardship practices into daily laboratory rounds. Antimicrobial stewardship involvement on rounds was a welcomed and effective initiative with substantial rates of intervention. New opportunities to positively impact use of antimicrobials and laboratory resources were realized.

Impact of an Antimicrobial Stewardship Program on Antimicrobial Utilization, Bacterial Susceptibilities, and Financial Expenditures at an Academic Medical Center.

Background: Antimicrobial stewardship programs (ASPs) have the potential to improve patient outcomes, decrease microbial resistance, increase patient safety, and decrease costs. However, to justify the costs involved with providing an ASP, it is necessary to assess its impact in achieving these outcomes on an ongoing basis. Objective: The purpose of this study was to characterize the overall impact of the ASP at an Academic medical center. Methods: Quasi-experimental, before and after stewardship program implementation, retrospective analyses of quarterly antimicrobial utilization, bacterial susceptibilities, and antibiotic acquisition costs were utilized. Results: Mean stewardship-focused antibiotic utilization was 510.3 defined daily doses (DDD) per 1,000 patient days for the pre-ASP period and 426.4 DDD per 1,000 patient days for the ASP period (16.4% decrease; p < .001). Significant changes in Pseudomonas aeruginosa susceptibility to tobramycin (8% increase; p = .006) and piperacillin-tazobactam (8% decrease; p = .024) were noted. Changes in susceptibility of Staphylococcus aureus to methicillin (7% increase, p = .012) were also observed. ASP-focused antibiotic expenditures decreased from $4,028,068 in fiscal year (FY) 2010 to $2,135,173 in FY2013 (p = .01). Conclusions: ASP initiatives were associated with an observed reduction in stewardship-focused antibiotic utilization. Significant changes in susceptibilities of some bacteria were noted but did not seem to consistently reflect antibiotic utilization changes. Significant decreases in antimicrobial expenditures were observed. Observed outcomes are temporally related to shifts in antimicrobial selection through the initiation of stewardship program-driven antibiotic policy changes. These outcomes have been used to justify and expand our stewardship program moving forward.

Impact of a rapid multiplex polymerase chain reaction blood culture identification technology on outcomes in patients with vancomycin-resistant Enterococcal bacteremia.

BACKGROUND: Early appropriate antibiotic selection is associated with favorable clinical outcomes. We evaluated the clinical impact of rapid detection of vancomycin-resistant Enterococcal bacteremia (VREB) by the FilmArray blood culture identification (BCID) panel coupled with antimicrobial stewardship program (ASP) interventions. METHODS: Hospitalized adult patients with VREB identified by conventional methods (CM) were compared to patients with VREB identified by BCID. Real time alerts of BCID results were provided to the ASP for intervention. Outcomes were compared between groups. RESULTS: Sixty-eight patients with VREB were included (CM, n = 45; BCID, n = 23). No significant differences in demographics, pre-existing conditions, or clinical characteristics were observed. Significant reductions were demonstrated between CM and BCID groups in median hours to organism identification (47.7 versus 18.2, p < 0.001), to identification of vancomycin resistance from time of culture positivity (50.1 versus 1.2, p < 0.001), and time to effective therapy (50.3 versus 20.8, p < 0.001). Differences between CM and BCID did not reach statistical significance for mortality (35.6% versus 26.1%), 30-day readmission rate (31.0% versus 17.6%), intensive care length of stay [LOS] (8.0 versus 7.0 days), post-culture LOS (14.6 versus 14.1 days) or median hospital costs per patient ($95,826 versus $53,195). CONCLUSIONS: In patients with VREB, rapid organism and resistance detection by the BCID panel with ASP intervention significantly reduced time to initiation of effective therapy by over 24 hours. Non-significant improvements in clinical outcomes were observed. Additional studies are needed to determine the full implications of BCID technology on patient outcome.

Impact of a Stewardship-Initiated Restriction on Empirical Use of Ciprofloxacin on Nonsusceptibility of Escherichia coli Urinary Isolates to Ciprofloxacin.

STUDY OBJECTIVE: To evaluate the impact of a stewardship-initiated restriction on empirical use of ciprofloxacin on the nonsusceptibility of Escherichia coli urinary isolates to ciprofloxacin over time while controlling for the use of other key antibiotics with gram-negative activity. DESIGN: Retrospective single-center study. SETTING: Large tertiary and quaternary care academic medical center. ISOLATES: Of 3714 E. coli urinary isolates. MEASUREMENTS AND MAIN RESULTS: The susceptibilities of the E. coli urinary isolates to ciprofloxacin, ceftriaxone, cefepime, piperacillin-tazobactam, meropenem, trimethoprim-sulfamethoxazole, and nitrofurantoin obtained over a 7-year period (January 1, 2006-December 31, 2012) from adult inpatients were evaluated for potential relationships with antibiotic use over time by using multiple variable regression analysis. After introduction of the restriction on empirical use of ciprofloxacin in the first quarter of 2011, ciprofloxacin use declined from 141.1-39.8 defined daily doses/1000 patient-days, and the percentage of E. coli isolates that were not susceptible to ciprofloxacin decreased from 41.5-32.8%. With all antibiotics evaluated included in the model, no apparent relationships were found between the percentage of E. coli isolates nonsusceptible to ciprofloxacin and antibiotic use. However, when nonsignificant variables were eliminated (p>0.20), ciprofloxacin use was found to be positively associated with the percentage of E. coli isolates nonsusceptible to ciprofloxacin (p=0.037), whereas ceftriaxone use was negatively associated (p=0.045). CONCLUSION: The restriction and subsequent reduction of ciprofloxacin use was found to have a positive effect on the susceptibility of E. coli urinary isolates to ciprofloxacin.

Unanticipated Multiplex PCR-Based Identification of Polymicrobial Blood Culture Resulting in Earlier Isolation, Determination of Susceptibilities, and Optimization of Clinical Care.

We describe a case of polymicrobial bloodstream infection with six organisms identified by multiplex PCR that was initially thought to be a monomicrobial infection. Early recognition of specific Gram-positive, Gram-negative, and fungal organisms and resistance elements allowed significantly more rapid optimization of therapy.

Evaluation of urinalyses ordered for diagnosis of urinary tract infections at an inpatient psychiatric hospital.

OBJECTIVE: A retrospective study was conducted to assess the diagnosis and treatment of urinary tract infections (UTIs) using urinalyses (UA)s at a psychiatric hospital. METHOD: Patients admitted between July 2010 and June 2011 receiving at least one UA during inpatient psychiatric hospitalization were included. Pregnant patients and those with a UA receiving antibiotic treatment in the emergency department were excluded. The primary objective of the study was to characterize and assess the appropriateness of UAs ordered for the diagnosis of UTIs. Secondary objectives included analyzing frequency of cultures obtained, appropriateness of empiric antibiotics, and de-escalation of therapy if warranted. RESULTS: Thirty-nine percent (n = 891/2292) of patients admitted received a UA at least once during their hospitalization. Of 203 patients further evaluated, 78% were asymptomatic, 11% were older than 65 years of age with altered mental status (AMS) or dementia, and 11% had typical UTI symptoms. Thirty-one patients were given antibiotics for a UTI during their stay, with a majority of those being asymptomatic (n = 19/31). CONCLUSIONS: A significant proportion of UAs ordered at a psychiatric hospital were inappropriate. When patients were treated, empiric antibiotic selection and length of treatment were appropriate in most instances.

Antimicrobial stewardship in the management of community-acquired pneumonia.

PURPOSE OF REVIEW: Antimicrobial stewardship can be applied to the management of community-acquired pneumonia (CAP) to optimize management while maintaining or improving the quality of patient outcomes. We discuss such applications, in general, and review the relevant recent literature. RECENT FINDINGS: Clinical pathways or care plans are a means to standardize care for a given disease state and thus improve or optimize the utilization of treatment modalities while at the same time maintaining or improving patient outcomes. Most recent publications describe the application of clinical pathways for the management of CAP in both pediatric and adult populations, reporting success in achieving compliance with national treatment guidelines. As a variation of clinical management pathways, audit tools have also been described that assist in determining the location and length of therapy and proper route of administration of antimicrobial agents with the aim of optimal resource utilization. Emerging rapid diagnostic tools allowing for early identification of pathogens and their antimicrobial susceptibility have great promise for early optimization of therapy for CAP. SUMMARY: There is a growing body of evidence that antimicrobial stewardship initiatives can be applied successfully and effectively to the management of CAP, benefiting both healthcare systems and patients. Such successful applications will likely grow as new techniques and technologies continue to evolve.