HPV vaccination rates in 9- and 10-year-olds following a pharmacist-led intervention.

BACKGROUND: The American Cancer Society and the American Academy of Pediatrics recommend administering the human papillomavirus (HPV) vaccine to children aged 9 and 10 years to improve on-time vaccination rates as they continue to be below national goal. Pharmacist-led interventions using the electronic health record (EHR) may be an effective way to increase these rates. OBJECTIVE: This study aimed to evaluate change in first-dose HPV vaccination rate in 9- and 10-year-olds before and after a multifaceted HPV outreach initiative. METHODS: A pre-post, quasi-experimental study involving a pharmacist-led intervention was implemented at 2 primary care offices within a large health care network. Adolescents aged 9 and 10 years during the entire intervention period were included. Between November 1, 2021, and March 31, 2022, an education session was provided by an ambulatory care pharmacist to each primary care team regarding the HPV vaccine and eligibility of 9- and 10-year-olds. On June 1, 2022, a direct message was sent via the EHR to parents or guardians of eligible patients describing eligibility, risks and benefits, and best practice recommendations. The primary end point evaluated change in first-dose HPV vaccination rates in 9- and 10-year-olds measured 6 months after direct messaging. Secondary outcomes evaluated EHR message receipt, adverse events, and program revenue. Nominal outcomes were assessed with McNemar's test or Cochran's Q test using SPSS software; P < 0.05 was considered significant. RESULTS: A total of 367 patients aged 9 and 10 years were eligible for HPV vaccination. After the intervention, 45 patients were vaccinated with vaccination rate increasing from 0.5% to 12.8% (P < 0.001). A total of 288 (78.5%) had access to EHR messaging with 203 (55.3%) having confirmed receipt of the message. No adverse reactions were reported within 7 days of vaccination. Most patients (76%) had private insurance, followed by Medicaid (22.6%) and uninsured (1.4%). Approximate revenue of the program was $4129.89. CONCLUSIONS: A multifaceted intervention using education and EHR direct messaging significantly increased HPV vaccination rates in 9-and-10-year-olds.

Reprint of: Impact of altered mental status on antibiotic prescribing and outcomes in hospitalized patients presenting with pyuria.

BACKGROUND: Pyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance. OBJECTIVES: The purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes. METHODS: This retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia. RESULTS: Two-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing. CONCLUSIONS: Inappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.

Impact of altered mental status on antibiotic prescribing and outcomes in hospitalized patients presenting with pyuria.

BACKGROUND: Pyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance. OBJECTIVES: The purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes. METHODS: This retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia. RESULTS: Two-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing. CONCLUSIONS: Inappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.

Implementation of antimicrobial stewardship weekend coverage within a community hospital with a PGY-2 infectious diseases pharmacy resident.

OBJECTIVES: The goal of this study was to describe the impact of expanding inpatient ASP weekend coverage with a newly established infectious diseases postgraduate second-year (ID-PGY-2) pharmacy residency program through quantification of inpatient ASP interventions. Secondary end points included comparing weekend stewardship activities before and after an ID-PGY-2 incorporated staffing model shift based on intervention quantity, type, and impact to weekends. METHODS: This retrospective cohort study was conducted evaluating weekend Antimicrobial stewardship program (ASP) interventions documented within the electronic health record between July 1, 2021, and December 31, 2022. Groups included a single clinical pharmacist, 2 new postgraduate first-year (PGY-1) pharmacy residents, 2 experienced PGY-1 pharmacy residents, and an ID-PGY-2 responsible only for ASP coverage. RESULTS: Eight weekends of interventions were collected per group. The median (interquartile range [IQR]) number of ASP interventions per weekend increased during ID-PGY-2 resident weekends (34 [28.75-35]) compared to a clinical pharmacist alone (5 [4-10], P < 0.001), and both new (2.5 [1.25-4], P < 0.001) and experienced (6 [3.5-10.5], P < 0.001) PGY-1 resident groups. The ID-PGY-2 resident initiated statistically significantly more interventions per protocol and interventions requiring communication with providers. The acceptance rate for interventions made via communication was similar between groups (ID-PGY-2 86.3% vs. clinical pharmacist 87.7% vs. new PGY-1 100% vs. experienced PGY-1 90.5%, P = 0.541). CONCLUSION: Expansion of ASP services to include weekend clinical coverage with an ID-PGY-2 pharmacy resident significantly increased weekend ASP interventions in a community teaching hospital.

A Statewide Collaborative Quality Initiative to Improve Antibiotic Duration and Outcomes in Patients Hospitalized With Uncomplicated Community-Acquired Pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. We aimed to improve antibiotic duration for CAP across 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). METHODS: This prospective collaborative quality initiative included patients hospitalized with uncomplicated CAP who qualified for a 5-day antibiotic duration. Between 23 February 2017 and 5 February 2020, HMS targeted appropriate 5-day antibiotic treatment through benchmarking, sharing best practices, and pay-for-performance incentives. Changes in outcomes, including appropriate receipt of 5 ± 1-day antibiotic treatment and 30-day postdischarge composite adverse events (ie, deaths, readmissions, urgent visits, and antibiotic-associated adverse events), were assessed over time (per 3-month quarter), using logistic regression and controlling for hospital clustering. RESULTS: A total of 41 hospitals and 6553 patients were included. The percentage of patients treated with an appropriate 5 ±â€…1-day duration increased from 22.1% (predicted probability, 20.9% [95% confidence interval: 17.2%-25.0%]) to 45.9% (predicted probability, 43.9% [36.8%-51.2%]; adjusted odds ratio [aOR] per quarter, 1.10 [1.07-1.14]). Thirty-day composite adverse events occurred in 18.5% of patients (1166 of 6319) and decreased over time (aOR per quarter, 0.98 [95% confidence interval: .96-.99]) owing to a decrease in antibiotic-associated adverse events (aOR per quarter, 0.91 [.87-.95]). CONCLUSIONS: Across diverse hospitals, HMS participation was associated with more appropriate use of short-course therapy and fewer adverse events in hospitalized patients with uncomplicated CAP. Establishment of national or regional collaborative quality initiatives with data collection and benchmarking, sharing of best practices, and pay-for-performance incentives may improve antibiotic use and outcomes for patients hospitalized with uncomplicated CAP.

Antibiotic Overuse After Hospital Discharge: A Multi-hospital Cohort Study.

BACKGROUND: Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions. METHODS: In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017-30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI. RESULTS: Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%-24.6%] to 80.6% [95% confidence interval, 69.4%-88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P < .001). CONCLUSIONS: Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge.

Syndromic diagnostic testing: a new way to approach patient care in the treatment of infectious diseases.

Advanced microbiology technologies such as multiplex molecular assays (i.e. syndromic diagnostic tests) are a novel approach to the rapid diagnosis of common infectious diseases. As the global burden of antimicrobial resistance continues to rise, the judicious use of antimicrobials is of utmost importance. Syndromic panels are now being recognized in some clinical practice guidelines as a 'game-changer' in the diagnosis of infectious diseases. These syndromic panels, if implemented thoughtfully and interpreted carefully, have the potential to improve patient outcomes through improved clinical decision making, optimized laboratory workflow, and enhanced antimicrobial stewardship. This paper reviews the potential benefits of and considerations regarding various infectious diseases syndromic panels, and highlights how to maximize impact through collaboration between clinical microbiology laboratory and antimicrobial stewardship programmes.

Impact of a Pharmacist-Driven MRSA Nasal PCR Protocol on Pneumonia Therapy.

Background:Methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) testing can rapidly detect MRSA colonization via nasopharyngeal swab. With a high negative predictive value for MRSA pneumonia, this test may help minimize the duration of anti-MRSA therapy and associated adverse drug events. Objective: This study aimed to evaluate the impact of a pharmacist-initiated MRSA nasal PCR protocol on pneumonia therapy. Methods: This retrospective, quasi-experimental study evaluated adult patients with pneumonia before and after the implementation of a pharmacist-initiated MRSA nasal PCR protocol. The primary outcome of this study was to compare duration of anti-MRSA therapy between the Pre-PCR group and PCR group. Secondary comparisons included duration of antipseudomonal therapy, time from intravenous (IV) to oral interchange, and clinical outcomes. Results: In total, 210 patients (Pre-PCR: n = 138, PCR: n = 72) were included. The MRSA nasal PCR result was negative for 63 patients (87.5%), and 56 (88.9%) vancomycin orders were discontinued within 24 hours of the negative result. The mean duration of vancomycin therapy was significantly shorter in the PCR group (2.5 vs 1.4 days, P < .001) as well as duration of IV therapy (5 vs 3.9 days, P = .003). There was no difference between groups in duration of antipseudomonal therapy (P = .425), acute kidney injury (AKI; P = .332), 30-day readmission (P = .137), or 30-day mortality (P = .179). Conclusion and Relevance: A pharmacist-driven MRSA nasal PCR protocol significantly decreased the duration of anti-MRSA therapy and IV antibiotics in patients with pneumonia. These findings add to the relatively small body of literature supporting pharmacist-initiated rapid diagnostic testing and follow-up.

Implementing outpatient antimicrobial stewardship in a primary care office through ambulatory care pharmacist-led audit and feedback.

OBJECTIVES: This study aimed to determine the impact of a pharmacist-led antimicrobial stewardship program (ASP) intervention on outpatient antibiotic prescribing for upper respiratory tract infections (URIs) and urinary tract infections (UTIs) in a primary care office. The primary outcome of this study was to characterize antibiotic prescribing over time. Secondary outcomes included describing ambulatory care pharmacist (ACP) workload and types of feedback given. METHODS: A retrospective pilot study was conducted within a primary care office. The office included a 0.6 full-time equivalent ACP and is part of a health system supported by a pharmacist and a physician co-led ASP. Education and guidelines were provided by the ACP and ASP leads before the intervention period August 2017-February 2018. The ACP provided bi-weekly audit of all URI and UTI prescriptions and written feedback to prescribers. RESULTS: During the 7-month intervention period, 1107 prescriptions were audited by the ACP, 825 URI and 282 UTI. The most common reasons for feedback included inappropriate agent (26.3%) or prolonged duration of therapy (24.3%). Guideline-concordant agent prescribed for a UTI increased from 20% at baseline to a median of 69.2%, whereas duration increased from 55% to 70.4%. Guideline-concordant agent prescribed for a URI increased from 43.3% to 86.8%, whereas the median duration of therapy decreased from 10 to 7 days. CONCLUSION: An ACP-led ASP intervention within a primary care office incorporating audit and feedback improved antibiotic prescribing for URIs and UTIs, including prescribing antibiotics when indicated, guideline-concordant antibiotic selection, and duration of therapy. Pharmacists practicing in ambulatory care settings may serve a vital role in leading successful outpatient ASP interventions.

Impact of an emergency medicine pharmacist on empiric antibiotic prescribing for pneumonia and intra-abdominal infections.

PURPOSE: It is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and intra-abdominal infections (CA-IAI). METHODS: A retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early-ASP vs. established-ASP. RESULTS: 320 patients were included in the study (EMP n = 185, no-EMP n = 135). Overall empiric antibiotic prescribing was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, p = 0.001); this was true for both the CAP (95% vs. 79%, p = 0.005) and CA-IAI subgroups (62% vs. 44%, p = 0.025). Total guideline-concordant prescribing significantly increased between the early-ASP and established-ASP (60% vs. 82.5%, p < 0.001) and was more likely when an EMP was present (early-ASP: 68.3% vs. 45.8%, p = 0.005; established-ASP: 90.5% vs. 73.7%, p = 0.005). Patients receiving guideline-concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p < 0.001). CONCLUSION: The presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI in both an early and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED.

Implementation of Rapid Diagnostic Testing without Active Stewardship Team Notification for Gram-Positive Blood Cultures in a Community Teaching Hospital.

In community hospitals, antimicrobial stewardship team notification of rapid diagnostic testing (RDT) results may not be feasible. A retrospective quasi-experimental study was conducted evaluating 252 adult inpatients with blood cultures positive for Gram-positive cocci in clusters (pre-RDT, n = 143; post-RDT, n = 109). The median time to appropriate therapy was significantly shorter in the post-RDT group (15 versus 0 h, P < 0.001), and the mean length of stay for patients with coagulase-negative staphylococcus was significantly shorter (10.5 versus 7.7 days; P = 0.015).

Outcomes of Aminopenicillin Therapy for Vancomycin-Resistant Enterococcal Urinary Tract Infections.

Vancomycin-resistant urinary tract infections are often challenging to treat. This retrospective cohort study compared outcomes between patients treated for vancomycin-resistant enterococcal urinary tract infection with an aminopenicillin and those treated with a non-ß-lactam antibiotic. Inpatients treated with an enterococcus-active agent for their first symptomatic vancomycin-resistant enterococcal urinary tract infection between 1 January 2012 and 31 December 2013 were considered for inclusion. Patients with colonization, on hospice, or receiving comfort care only were excluded. The primary endpoint of clinical cure was defined as resolution of clinical symptoms, or symptom improvement to the extent that no additional antibacterial drug therapy was necessary, and lack of microbiologic persistence. Secondary endpoints of 30-day readmission or retreatment and 30-day all-cause mortality were also compared. A total of 316 urinary isolates were screened, and 61 patients with symptomatic urinary tract infection were included. Twenty (35%) of the 57 isolates tested were ampicillin susceptible. Thirty-one patients received an aminopenicillin, and 30 received a non-ß-lactam. Rates of clinical cure for aminopenicillin versus non-ß-lactam treatment were 26/31 (83.9%) and 22/30 (73.3%) (P = 0.315), respectively. Rates of 30-day readmission (6/31, or 19.4%, versus 9/30, or 30%, respectively; P = 0.334), 30-day retreatment (4/31, or 12.9%, versus 4/30, 13.3%, respectively; P = 0.960), and 30-day all-cause mortality (2/31, or 6.5%, versus 1/30, or 3.3%, respectively; P = 0.573) were also not significantly different between groups. Aminopenicillins may be a viable option for treating vancomycin-resistant urinary tract infection regardless of the organism's ampicillin susceptibility. Prospective validation with larger cohorts of patients should be considered.

Perceptions of PGY1 pharmacy resident research, final projects, and associated publication outcomes.

PURPOSE: To describe the publication rate and the research landscape of postgraduate year 1 (PGY1) pharmacy residency programs within the Great Lakes Pharmacy Resident Conference (GLPRC) region. METHODS: This study was comprised of two elements. The first was a retrospective cohort evaluation of previously presented GLPRC research abstracts and publication rates. The second was a 45-question survey of current GLPRC PGY1 residency program directors (RPDs). The primary objective of this study was to evaluate publication rates of PGY1 abstracts submitted to the GLPRC. Secondary objectives included describing RPD perceptions of the value of research, identifying perceived barriers to research completion, and characterizing current and ideal components of residency research programs. RESULTS: A total of 447 PGY1 abstracts were reviewed; 47 (10.5%) resulted in manuscript publication within a peer-reviewed journal. There was no significant difference in publication rates between years (9.5% in 2013 vs 13.8% in 2016 vs 7.4% in 2019, P = 0.166). One hundred ten PGY1 RPDs in the GLPRC region were invited to participate in the survey, with 33 (30%) responses received. The majority of programs (94%) required manuscript submission to the RPD prior to graduation; however, only 12% required submission for peer-reviewed publication. Major barriers to research completion included lack of preceptor time and knowledge regarding the research and publication process, as well as lack of resident interest and knowledge of the process. CONCLUSION: The current publication rate of PGY1 research abstracts presented at the GLPRC remains at approximately 10%, which is unchanged from a previous investigation. RPD perceptions of the research process and barriers also remain largely unchanged or less favorable.

Full-dose challenge of moderate, severe, and unknown beta-lactam allergies in the emergency department.

OBJECTIVE: This study aims to assess the outcome of challenging documented moderate, severe, or unknown beta-lactam allergies with full dose administration of a beta-lactam antibiotic in emergency department (ED) patients admitted for acute bacterial infection. METHODS: A single-center, retrospective, descriptive study of adult patients challenged with a full dose of beta-lactam in the ED from January 2021 to December 2022 was conducted. Included patients had at least one documented moderate, severe, or unknown beta-lactam allergy in the electronic medical record (EMR) without documentation of prior tolerance. Patient demographics, prior beta-lactam antibiotic reaction, beta-lactam administered in the ED, inpatient beta-lactam continuation, adverse drug reactions, and updates to allergy profiles were collected. Descriptive statistics for data analysis were performed using SPSS Version 22. RESULTS: Of the 184 ED encounters with full-dose beta-lactam challenges, five (2.7%) patients with documented moderate, severe, or unknown beta-lactam allergies experienced an allergic reaction after the challenge; one (0.5%) patient had an allergic reaction in the ED, and the remaining four (2.2%) occurred after admission. No anaphylactic reactions occurred. All allergic reactions were limited to mild rash or itching. Most patients (98.9%) were challenged with a cephalosporin. A beta-lactam was continued in 86.4% of cases, and the allergy profile was updated for future utilization in 73.4% of patients. CONCLUSIONS: This study suggests that full-dose challenge of moderate, severe, or unknown beta-lactam allergies can be safely accomplished in the ED. This approach avoids unnecessary penicillin allergy skin testing and reduces utilization of suboptimal alternative antibiotic regimens.

Antimicrobial Stewardship at Transitions of Care.

Antimicrobial stewardship interventions have historically been siloed in different care settings; recently, a need for stewardship interventions at care transitions has arisen as inappropriate prescribing at care transitions may result in patient harm. There are several care areas that should be considered for optimizing antibiotic prescribing. Interventions can be difficult to implement as they often require the efforts of a multidisciplinary team and are resource intensive. Antimicrobial stewardship programs should prioritize interventions at transitions of care to improve prescribing and patient outcomes.

Outcomes of high-dose oral beta-lactam definitive therapy compared to fluoroquinolone or trimethoprim-sulfamethoxazole oral therapy for bacteremia secondary to a urinary tract infection.

Objective: Compare outcomes of patients receiving high-dose oral beta-lactam versus standard oral therapy for Enterobacterales bacteremia from a urinary tract infection (UTI). Design: Retrospective, multicenter, observational cohort. Setting: Three Michigan community teaching hospitals. Patients: Adult patients admitted between February 1, 2020, and October 1, 2022, with gram-negative bacteremia from a urinary source were evaluated. Patients receiving active empiric intravenous (IV) antibiotics and transitioned to appropriately dosed oral cephalexin, amoxicillin, fluoroquinolone (FQ), or trimethoprim/sulfamethoxazole (TMP/SMX) were included. Patients receiving less than 72 hours of oral therapy, diagnosed with renal abscess, lobar nephronia, or expired during admission were excluded. Methods: Standard oral therapy was defined as FQ or TMP/SMX. The primary outcome compared the composite of recurrent bacteremia or mortality within 30 days of therapy between groups. Secondary outcomes compared recurrent UTI, emergency department or hospital readmission, and Clostridioides difficile within 30 days. Results: 194 patients were included (beta-lactam, n = 75 vs standard therapy, n =119). Patients in both groups were treated for a median of 11 days, with 4 days IV and 7 days oral therapy. There was no difference in the primary outcome between groups (beta-lactam 1.3% vs standard therapy 1.7%, OR 1.27 [95% CI 0.11-14.2]). No patients experienced C. difficile in either group (p = 1.0). Infectious disease consultation was independently associated with standard therapy prescribing (OR 4.4 [95% CI 2.24-8.26]). Conclusion: High-dose oral beta-lactams were as safe and effective as oral FQ or TMP/SMX for the treatment of bacteremia from a urinary source. Most patients received 8-10 days of therapy in both groups.

Feasibility evaluation to expand a collaborative practice agreement and discontinue antibiotics after an emergency department or urgent care visit.

PURPOSE: The impact of pharmacist-led culture follow-up programs for positive cultures is well established. The benefits and feasibility of evaluating negative cultures and deprescribing unnecessary antibiotics after emergency department (ED) and urgent care (UC) visits are unknown; therefore, this evaluation characterized the burden of negative urine cultures and chlamydia tests and estimated how many potential antibiotic days could be saved with deprescribing. METHODS: This retrospective, descriptive study evaluated patients discharged from an ED or UC location with a pharmacist-led culture follow-up program. The primary objective was to characterize the proportion of patients with a negative urine culture or chlamydia test where an opportunity would exist to deprescribe antibiotics at follow-up. Secondary endpoints included estimating the number of potential antibiotic days that could be saved, postvisit healthcare utilization, and documented adverse drug reactions (ADRs). RESULTS: For a 1-month period, pharmacists reviewed 398 cultures, of which 208 (52%) were urine cultures or chlamydia tests with negative results. Fifty patients (24%) with negative results had been prescribed empiric antibiotics. The median duration of antibiotic treatment was 7 days (interquartile range [IQR], 5-7 days), while the median time to culture finalization was 2 days (IQR, 1-2 days). There was an opportunity to save a median of 5 antibiotic days per patient. Thirty-two patients (15.3%) followed up with their primary care physician within 7 days; of these patients, 1 (0.05%) had their antibiotic prescription discontinued by the primary care physician. There were no documented ADRs. CONCLUSION: Expansion of pharmacist-led culture follow-up programs to deprescribe antibiotics for patients with negative cultures has the potential to save significant antibiotic exposure.

Two Times Versus Four Times Daily Cephalexin Dosing for the Treatment of Uncomplicated Urinary Tract Infections in Females.

Background: The current treatment guidelines of the Infectious Diseases Society of America recommend ß-lactam antibiotics as alternative rather than first-line agents for the treatment of uncomplicated urinary tract infection (uUTI). Cephalexin is a commonly prescribed first-generation cephalosporin with excellent bioavailability and urinary penetration; however, little data exist to support optimal dosing for uUTI. Methods: This retrospective multicenter cohort study included adult female patients who received 5 to 7 days of cephalexin for symptomatic uUTI with a cefazolin-susceptible urine culture. The primary objective was to compare uUTI treatment failure (eg, continued or recurrent symptoms within 30 days) between patients treated with cephalexin 500 mg twice daily (BID group) and 500 mg 4 times daily (QID group) in the outpatient setting. Secondary outcomes included time to treatment failure, reported adverse events within 7 days of treatment, and occurrence of Clostridioides difficile within 30 days of treatment. Results: A total of 261 patients were included (BID, n = 173; QID, n = 88). Baseline characteristics were similar between the groups. Escherichia coli was the most commonly isolated pathogen (85.4%). There was no difference in treatment failure observed between the groups (BID 12.7% vs QID 17%, P = .343), including failure while undergoing therapy (BID 2.3% vs QID 5.7%, P = .438) or recurrence within 30 days (BID 10.4% vs QID 11.3%, P = .438). No differences in reported adverse events (BID 4.6% vs QID 5.6%, P = .103) were observed between groups. Conclusions: Twice-daily cephalexin is as effective as 4-times-daily dosing for uUTI. A twice-daily dosing strategy may improve patient adherence.

Evaluation of appropriate transmission-based precautions for non-SARS-CoV-2 respiratory viruses.

Appropriateness of transmission-based precautions after positive result for a non-SARS-CoV-2 virus was evaluated. Most patients (77.2%) lacked appropriate precautions within 3 hours of virus detection; 36.9% remained without appropriate precautions during their stay. With recent cessation of universal masking, adherence to infection control best practices is needed to optimize safety.