A Multicenter Evaluation of Prolonged Empiric Antibiotic Therapy in Adult ICUs in the United States.

OBJECTIVE: The purpose of this study is to determine the rate of prolonged empiric antibiotic therapy in adult ICUs in the United States. Our secondary objective is to examine the relationship between the prolonged empiric antibiotic therapy rate and certain ICU characteristics. DESIGN: Multicenter, prospective, observational, 72-hour snapshot study. SETTING: Sixty-seven ICUs from 32 hospitals in the United States. PATIENTS: Nine hundred ninety-eight patients admitted to the ICU between midnight on June 20, 2011, and June 21, 2011, were included in the study. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Antibiotic orders were categorized as prophylactic, definitive, empiric, or prolonged empiric antibiotic therapy. Prolonged empiric antibiotic therapy was defined as empiric antibiotics that continued for at least 72 hours in the absence of adjudicated infection. Standard definitions from the Centers for Disease Control and Prevention were used to determine infection. Prolonged empiric antibiotic therapy rate was determined as the ratio of the total number of empiric antibiotics continued for at least 72 hours divided by the total number of empiric antibiotics. Univariate analysis of factors associated with the ICU prolonged empiric antibiotic therapy rate was conducted using Student t test. A total of 660 unique antibiotics were prescribed as empiric therapy to 364 patients. Of the empiric antibiotics, 333 of 660 (50%) were continued for at least 72 hours in instances where Centers for Disease Control and Prevention infection criteria were not met. Suspected pneumonia accounted for approximately 60% of empiric antibiotic use. The most frequently prescribed empiric antibiotics were vancomycin and piperacillin/tazobactam. ICUs that utilized invasive techniques for the diagnosis of ventilator-associated pneumonia had lower rates of prolonged empiric antibiotic therapy than those that did not, 45.1% versus 59.5% (p = 0.03). No other institutional factor was significantly associated with prolonged empiric antibiotic therapy rate. CONCLUSIONS: Half of all empiric antibiotics ordered in critically ill patients are continued for at least 72 hours in absence of adjudicated infection. Additional studies are needed to confirm these findings and determine the risks and benefits of prolonged empiric therapy in the critically ill.

Correlates and Economic and Clinical Outcomes of an Adult IV to PO Antimicrobial Conversion Program at an Academic Medical Center in Midwest United States.

The study objectives were to evaluate the correlates and outcomes of a parenteral (IV) to oral (PO) antimicrobial conversion program at a Midwest US Academic Medical Center with the hypothesis that it will be associated with reduced drug costs. Patient-level data (n = 237; sex, race, admission source, admission status, admission severity, risk of mortality [relative expected, admission], and early death) were extracted from the Clinical Data Base/Resource Manager. Medication-level, drug-encounter data (n = 317; antibiotic/dose/route/frequency/duration, conversion status, 10-day IV/PO switch-eligibility criteria) were extracted from patient's hospital medical records. Univariate analyses using chi-square or Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables showed patients not converted (n = 149) versus converted (n = 88) at some point from IV to PO were more likely to be of white race and had higher risk of relative expected mortality. By applying the unit drug cost (derived from 2010 Thomson Reuters RED BOOK(TM)) and labor costs for IV/PO administration, both per dose, the overall 1-month drug cost-saving estimates in 2010 in US dollars were US$5242 from converting and US$8805 savings missed from not converting 518 and 1387 switch-eligible antibiotic doses, respectively. Despite sample-size limitations, this study demonstrated correlates and missed opportunities to convert antimicrobials from IV to PO, which warrants providers' attention.

Correlates and economic outcomes of proton pump inhibitor use by routes in intensive care unit patients.

Objectives were to evaluate correlates, and economic outcomes of proton pump inhibitor (PPI) use by route in the intensive care unit from an institutional-payer perspective. A 13-month retrospective study of electronic medical records was conducted of 534 adult (≥19 year-old) intensive care unit patients receiving a PPI (39% enteral-only, 34% parenteral-only, 27% both-route) in a Midwest USA academic medical center. Possible cost-savings with sensitivity analysis were estimated as differences in drug costs (US dollars) between switch eligible parenteral and alternate enteral-PPI medication doses. In multivariate logistic-regression of switch criteria (any oral-medication, orogastric-tube, nothing by oral route), significant correlate for enteral versus parenteral PPI-use was any oral-medication use but not orogastric-tube. Using enteral esomeprazole/lansoprazole instead of parenteral (esomeprazole/pantoprazole) PPI (in 37% i.e. 696 of 1895 switch-eligible doses) would have saved US$2384.17 or US$3564.86, respectively. By switching eligible patients on oral-medications or on orogastric-tube from parenteral- to enteral-PPI, institutions can realize significant drug cost-savings.

Rurality and other factors associated with adherence to immunosuppressant medications in community-dwelling solid-organ transplant recipients.

BACKGROUND: Data on immunosuppressant adherence of community-dwelling adult solid-organ transplant recipients (SOTRs) from rural populations in the United States are limited. Therefore, understanding the association of rurality and other factors of immunosuppressant adherence will help providers design and deliver patient-centered adherence enhancing interventions. OBJECTIVES: The objective was to examine factors associated with a previously validated 4-item Immunosuppressant Therapy Adherence Scale (ITAS) score in community-dwelling adult SOTRs who received a transplant from an academic center in the Midwestern United States. METHODS: For this observational study, cross-sectional survey data (patient demographic, medical condition, immunosuppressant therapy, and self-reported ITAS) received from adult SOTRs aged 19 years or older with other data from an academic transplant center's database were merged. Using multivariate logistic regression, significant SOTR characteristics associated with being adherent (ITAS score=12) versus nonadherent (ITAS score <12) were examined. RESULTS: The survey response rate was 30% (n=556/1827). Those SOTRs responding (n=556) had a kidney (48%), liver (47%), or other (4.5%) transplant. They were more likely to be 50- to 64-year olds (52%), men (55%), white (90%), metroresident (59%), with an annual income less than $55,000. The SOTRs were living with a transplant for 6.3 years (median), reported excellent-to-good health status (77%), and received different immunosuppressant regimens. More than half of the SOTRs (58%) were adherent. In multivariate analyses, compared with patients aged 65 years or older, younger patients, nonmetro rural- versus metroresident, and those having more (≥6) versus less (<6) comorbidities were significantly less likely to report adherence. SOTRs receiving tacrolimus-based combination immunosuppressant versus tacrolimus alone were more likely to report adherence. CONCLUSIONS: When designing and delivering patient care-centered interventions including those that use technology to increase immunosuppressant adherence, providers need to consider rural residence besides other well-established patient factors (younger age, immunosuppressant drug, and comorbidities) of nonadherence.