Assessing mortality outcomes of beta-lactam-allergic patients presenting with sepsis.

OBJECTIVE: To determine the impact of reported beta-lactam allergies on in-hospital mortality and other clinical outcomes in patients who presented with severe sepsis or septic shock. METHODS: This single-center, retrospective cohort study was performed at a 35-bed emergency department in central Kentucky. Patients presenting with sepsis, aged 18years or older, were identified between October 2016 and June 2017. RESULTS: 438 patients with severe sepsis and/or septic shock were identified. Rates of the combined endpoint of in-hospital mortality or transfer to hospice were similar in patients with a beta-lactam allergy (7.2%) versus those with no reported beta-lactam allergy (10.4%) (p=0.41). Time to initiation of antibiotic therapy was slightly longer in the beta-lactam allergic group (2.2h) versus those with no reported beta-lactam allergy (2.15h), but the difference was not statistically significant (p=0.993). Patients were 20.9% more likely to receive an appropriate empiric antibiotic, based off of retrospective culture review, if they did not report a beta-lactam allergy (p=0.009). This led to a delay in effective therapy of 1.59h in the reported beta-lactam allergy arm (p=0.037). CONCLUSIONS: Adequate documentation of beta-lactam allergies is vital to ensure timely and appropriate treatment in patients presenting with severe sepsis and septic shock. Choosing alternative treatment options results in increased time to effective antibiotics, reduced likelihood of covering cultures with first antibiotic, and increased total hospital and variable direct cost.

Implementation of an adult code sepsis protocol and its impact on SEP-1 core measure perfect score attainment in the ED.

INTRODUCTION: Timely management of sepsis has become an urgent concern among most hospitals. Institutions have been searching for unique ways to increase the quality of care and timely adherence to proven therapies. The objective of this study was to determine the impact of an Adult Code Sepsis Protocol on the rate of SEP-1 perfect score attainment (PSA) among patients who presented to the emergency department (ED) with severe sepsis or septic shock, as defined by the Centers for Medicare and Medicaid Services (CMS). METHODS: This was a retrospective, observational cohort study in a 35-bed tertiary care hospital ED from December 2016 to February 2018. Adults (≥18 years of age) who met the CMS-case definition of severe sepsis or septic shock presenting to the ED either prior to or after implementation of an Adult Code Sepsis Protocol were included. RESULTS: The primary outcome of SEP-1 PSA, which was abstracted in an all-or-none fashion, increased from 30.7% to 71.3% (p < 0.001). Inpatient mortality was reduced from 4% to 0% (p = 0.011) after protocol implementation. Protocol initiation also resulted in a significant reduction in both time to initiation of appropriate, empiric and effective antimicrobial therapy, based on culture results by 48 and 111 min, respectively (p < 0.001). There were no significant differences in other secondary outcomes including ICU length-of-stay, readmission, or economic outcome measures. CONCLUSIONS: The addition of an Adult Code Sepsis Protocol in the ED significantly increased the rate of SEP-1 PSA, reduced inpatient mortality, and improved the time to initiation of effective antimicrobial therapy.

Impact of real-time notification of Clostridium difficile test results and early initiation of effective antimicrobial therapy.

BACKGROUND: Clostridium difficile is a prominent nosocomial pathogen and is the most common causative organism of health care-associated diarrhea. To our knowledge, no studies have investigated the impact of real-time notification of culture results with rapid antimicrobial stewardship program (ASP) intervention in the setting of C difficile infection (CDI). The purpose of this study was to assess the impact of real-time notification of detection of toxigenic C difficile by DNA amplification results in patients with confirmed CDI. METHODS: This is a single-center, retrospective cohort study at a 433-bed tertiary medical center in central Kentucky. The study consisted of 2 arms: patients treated for CDI prior to implementation of real-time provider notification and patients postimplementation. The primary outcome was time to initiation of effective antimicrobial therapy. RESULTS: The median time to initiation of effective antimicrobial therapy decreased from 5.75 hours in the preimplementation cohort to 2.05 hours in the postimplementation cohort (P = .001). ASP intervention also resulted in a shorter time from detection of CDI to order entry of effective antimicrobial therapy in the patient's electronic medical record (3.0 vs 0.6 hours; P = .001). CONCLUSIONS: The implementation of a real-time notification system to alert a pharmacist-led ASP of toxigenic CDI resulted in statistically significant shorter times to order entry and subsequent initiation of effective antimicrobial therapy and contact precautions.

Retrospective review of ceftriaxone versus levofloxacin for treatment of E. coli urinary tract infections.

Background Urinary tract infections (UTIs) are among the most common bacterial infections. Options for initial treatment of pyelonephritis or UTI requiring hospitalization include levofloxacin (LVF) or extended-spectrum cephalosporins. Globally, uropathogenic Escherichia coli resistance rates to fluoroquinolones have increased in recent years. Objective To compare clinical outcomes of patients receiving ceftriaxone (CTX) to those who received LVF empirically for the treatment of E. coli UTI. Setting 433-bed community hospital in Lexington, KY. Methods Retrospective, single center, cohort study of adults with a urine culture positive for E. coli who received either IV LVF or CTX empirically for the treatment of UTI. Main outcome measure The primary outcome was hospital length of stay. Secondary outcomes include time to susceptible therapy (TsT), hospital cost, and susceptibility to empiric therapy. Results There was no statistically significant difference in LOS or hospital cost. Subgroup analysis compared patients that received concordant CTX treatment and patients that received discordant LVF treatment. Patients that received concordant CTX treatment had a nonsignificant shorter median LOS (4.16 vs. 6.34 days). Median hospital cost was lower ($4345 vs. $8462, p = 0.004) and median TsT was shorter (5.83 vs. 64.46 h, p < 0.001) in the concordant CTX group. Conclusion Choice of empiric antibiotic therapy should be based on local antibiogram data. For patients with UTI requiring hospitalization, CTX seems to be an effective empiric therapy for most patients. More data is required to examine the effectiveness of local and source specific antibiograms on clinical outcomes when guiding treatment of patients with UTI.

Clinical and economic impact of meropenem resistance in Pseudomonas aeruginosa-infected patients.

BACKGROUND: The emergence of carbapenem resistance has had a significant impact on both clinical and economic outcomes. METHODS: A retrospective, observational cohort study was performed in a 433-bed tertiary care medical center. The cohort was established from all inpatients with Pseudomonas aeruginosa-positive cultures over a 3-year period. Two multivariate models were developed: a logistic regression model to evaluate the primary outcome of in-hospital mortality and a linear regression model to evaluate the secondary outcome of total hospital cost. RESULTS: The adjusted odds ratio for in-hospital mortality among patients with meropenem-resistant isolates was 2.89 (95% confidence interval [CI], 1.15-7.28). There were significantly more deaths in the meropenem-resistant group (28.1% vs 8.9%, P = .003). Patients with meropenem-resistant P aeruginosa experienced a 4-day increase in median length of stay versus those in the meropenem-susceptible group (14 vs 9 days, P = .004). Likewise, the percentage of patients who required intensive care unit (ICU) admission increased from 42% to 81.3% (P <.001). Meropenem resistance was also associated with a significant increase in total hospital cost by a factor of 1.42 among patients who were not admitted to the ICU (95% CI, 1.03-1.95). CONCLUSIONS: Our results demonstrate that meropenem resistance was a significant predictor of in-hospital mortality. Carbapenem resistance also resulted in a significant increase in hospital cost, but only among patients who were not admitted to the ICU.

Evaluation of an alternative extended-infusion piperacillin-tazobactam dosing strategy for the treatment of gram-negative infections.

Introduction To enhance the probability of pharmacodynamic target attainment, piperacillin-tazobactam can be administered as either a continuous or extended-infusion dosage regimen for the treatment of gram-negative infections. Four hour extended-infusions of piperacillin-tazobactam 3.375 g administered intravenously (IV) every 8 h have been widely studied as an alternative to conventional, intermittent dosage regimens with largely favorable outcomes. Objective To assess the clinical and economic impact of a novel 3-h extended-infusion piperacillin-tazobactam dosing strategy for the treatment of gram-negative infections. Setting 433-bed community hospital in Lexington, KY. Methods Retrospective cohort study before and after the implementation of an alternative dosing protocol using a 3-h infusion of piperacillin-tazobactam 3.375 g IV every 6 h. Main outcome measures The primary outcome was in-hospital mortality. Secondary outcomes include length of stay, ICU length of stay, 30-day all-cause hospital readmissions, total cost per admission, complications, and a composite of in-hospital mortality and readmission within 30 days of discharge. Results Readmission within 30 days of hospital discharge was significantly reduced in the extended-infusion arm (1.2 vs. 13.7 %, P = 0.002). A composite endpoint of death or readmission was lower among patients who received the extended-infusion dosing regimen [ORadj 0.20; 95 % CI (0.07-0.57)]. However this was likely driven by reductions in readmission. Conclusion An alternative regimen of extended-infusion piperacillin-tazobactam resulted in a significant reduction in 30-day all-cause hospital readmission. These results indicate that 3-h infusions of piperacillin-tazobactam 3.375 g IV every 6 h may represent a clinically effective alternative to other commonly used regimens and results in fewer readmissions within 30 days.

Clinical and economic impact of a quality improvement initiative to enhance early recognition and treatment of sepsis.

BACKGROUND: Studies evaluating the clinical effectiveness of sepsis screening tools and methods to improve the time from diagnosis to antibiotic administration are needed to improve sepsis-related outcomes. OBJECTIVE: To evaluate the clinical and economic impact of a sepsis quality improvement initiative to improve early recognition and treatment of sepsis. METHODS: A retrospective observational study of adults with sepsis was performed in a 433-bed tertiary medical center. Baseline data were collected for 181 patients with sepsis diagnosis-related group (DRG) coding assignments from July through September 2013. The intervnetion group included 216 patients from October through December 2013. A First-Dose STAT Antibiotic policy was developed, and nurses were instructed to complete an electronic sepsis screening tool once per shift. Primary outcomes included in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Secondary outcomes included overall LOS and cost per case. RESULTS: Nonsignificant decreases in overall LOS (7.43 ± 5.68 days vs 6.77 ± 5 days; P = 0.138) and in-hospital mortality (13.8% vs 8.8%; P = 0.113) were observed in patients with sepsis DRGs. Early recognition and treatment contributed to significant reductions in ICU LOS (5.85 ± 4.38 days vs 4.21 ± 3.64 days; P = 0.003) and total cost per case ($14 378 vs $12 311; P = 0.033). The percentage of highest disease-severity DRG coding assignments decreased from 7.9% to 0%. CONCLUSIONS: Strategies to improve early recognition and treatment of sepsis, including routine use of an electronic sepsis screening tool and implementation of a First-Dose STAT Antibiotic policy, contributed to significant reductions in ICU LOS and cost per case.

Postexposure prophylaxis: a guide for prevention of human immunodeficiency virus transmission in orthopedic surgery.

Approximately half of orthopedic surgeons reported operating on at least 1 patient with known HIV infection. Knowledge of postexposure prophylaxis guidelines may prevent HIV transmission and avert unnecessary exposure to antiretroviral agents.