Missed Antimicrobial Stewardship Opportunities for Hospitalized Patients with Urinary Tract Infections Receiving Ceftriaxone.

Background: Ceftriaxone is a commonly utilized antibiotic for the treatment of urinary tract infections (UTI) despite the limited literature supporting its use. Opportunities for antimicrobial stewardship (ASP), including IV-to-PO conversions and de-escalation of therapy, are often missed in the hospital setting. Objective: The study reported here describes the utilization of ceftriaxone in patients admitted to the hospital and treated for UTIs in a large health system, focusing on opportunities for IV-to-PO conversion of antibiotic therapy. Methods: This was a multi-center, retrospective, descriptive study conducted in a large health system. Patients admitted from January 2019 to July 2019 were included for analysis if they were 18 years or older at admission, diagnosed with acute cystitis, acute pyelonephritis, or unspecified UTI, and received two or more doses of ceftriaxone. The primary outcome was to evaluate the percentage of patients who were eligible for conversion from IV ceftriaxone to oral antibiotics while admitted to the hospital based on the defined criteria for automatic pharmacist conversion in the health system. Percentage of urine cultures with susceptibility to cefazolin, the duration of antibiotic therapy in the hospital, and an evaluation of oral antibiotics prescribed at discharge were also recorded. Results: A total of 300 patients were included; 88% met the pre-specified criteria for IV-to-PO conversion, but only 12% were converted from IV-to-PO antibiotics during hospitalization. Approximately 65% of patients remained on IV ceftriaxone until discharge, at which time they were converted to a PO antibiotic, most commonly fluoroquinolones followed by third-generation cephalosporins. Conclusion: Patients admitted to the hospital and receiving treatment with ceftriaxone for UTI were infrequently converted to oral therapy prior to discharge despite meeting criteria for automatic pharmacist IV-to-PO conversion. Findings highlight opportunities to contribute to antimicrobial stewardship initiatives across the health system and the importance of tracking and reporting results to frontline providers.

Leveling Up: Evaluation of IV v. PO Linezolid Utilization and Cost after an Antimicrobial Stewardship Program Revision of IV to PO Conversion Criteria within a Healthcare System.

The CDC's Core Elements of an Antimicrobial Stewardship Program (ASP) lists intravenous (IV) to oral (PO) conversion as an important pharmacy-based intervention. However, despite the existence of a pharmacist-driven IV to PO conversion protocol, conversion rates within our healthcare system remained low. We aimed to evaluate the impact of a revision to the current conversion protocol on conversion rates, using linezolid as a marker due to its high PO bioavailability and high IV cost. This retrospective, observational study was conducted within a healthcare system composed of five adult acute care facilities. The conversion eligibility criteria were evaluated and revised on 30 November 2021. The pre-intervention period started February 2021 and ended November 2021. The post-intervention period was December 2021 to March 2022. The primary objective of this study was to establish if there was a difference in PO linezolid utilization reported as days of therapy per 1000 days present (DOT/1000 DP) between the pre- and post-intervention periods. IV linezolid utilization and cost savings were investigated as secondary objectives. The average DOT/1000 DP for IV linezolid decreased from 52.1 to 35.4 in the pre- and post-intervention periods, respectively (p < 0.01). Inversely, the average DOT/1000 DP for PO linezolid increased from 38.9 in the pre-intervention to 58.8 for the post-intervention period, p < 0.01. This mirrored an increase in the average percentage of PO use from 42.9 to 62.4% for the pre- and post-intervention periods, respectively (p < 0.01). A system-wide cost savings analysis showed projected total annual cost savings of USD 85,096.09 for the system, with monthly post-intervention savings of USD 7091.34. The pre-intervention average monthly spend on IV linezolid at the academic flagship hospital was USD 17,008.10, which decreased to USD 11,623.57 post-intervention; a 32% reduction. PO linezolid spend pre-intervention was USD 664.97 and increased to USD 965.20 post-intervention. The average monthly spend on IV linezolid for the four non-academic hospitals was USD 946.36 pre-intervention, which decreased to USD 348.99 post-intervention; a 63.1% reduction (p < 0.01). Simultaneously, the average monthly spend for PO linezolid was USD 45.66 pre-intervention and increased to USD 71.19 post-intervention (p = 0.03) This study shows the significant impact that an ASP intervention had on IV to PO conversion rates and subsequent spend. By revising criteria for IV to PO conversion, tracking and reporting results, and educating pharmacists, this led to significantly more PO linezolid use and reduced the overall cost in a large healthcare system.

Underutilization of Aldosterone Antagonists in Heart Failure.

Background: Treatment with an aldosterone antagonist (AA) has been shown in multiple trials to reduce heart failure (HF)-related morbidity, mortality, and hospital readmission. American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) treatment guidelines recommend the use of an AA in all HF patients with an ejection fraction ≤35% and no known contraindication. Several studies have documented underuse of AA. Objectives: To determine the proportion of patients who received AA therapy consistent with the ACCF/AHA guidelines. Secondary objectives included determining the proportion of patients who received an AA inconsistent with guidelines and 30- and 90-day readmission rates. Methods: A retrospective chart review was conducted of patients admitted to an inner city academic medical center with a diagnosis of HF between August 16, 2011, and June 5, 2013. Results: A total of 346 HF admissions (87.6% African American) were evaluated. Use of an AA at discharge was consistent with guidelines in 31% of patients. A total of 121 patients (35%) were discharged on an AA. Among the remaining 225 patients who were not discharged on an AA, 170 (75.6%) had no contraindication to therapy. Sixty-one patients were readmitted within 30 days, and a total of 108 patients were readmitted within 90 days. There were no significant differences in readmission rates between patients who were discharged on AA therapy and those who were not. Conclusion: AAs are still underutilized in the treatment of HF.

Should Pharmacies Be Included in Medication Reconciliation? A Report of Recurrent Valproic Acid Toxicity.

Including outpatient pharmacies in the medication reconciliation process upon hospital discharge is not commonly performed. This case highlights the consequences of a patient refilling a discontinued prescription for valproic acid (VPA). We present a 32-year old male found unresponsive after ingesting delayed release divalproex sodium. Cerebral edema was visualized on magnetic resonance imaging. Hemodialysis and levo-carnitine treatment led to improved mental status, and VPA was discontinued. The same patient presented with VPA overdose eight months later after he continued to fill an outdated prescription. This case highlights consequences of VPA toxicity; it also demonstrates an opportunity to improve patient safety and high-value care by collaborating with outpatient pharmacies in the medication reconciliation process upon hospital discharge.

Action plans to reduce hospitalizations for chronic obstructive pulmonary disease exacerbations: focus on oral corticosteroids.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is associated with a huge burden of suffering and healthcare expenditures. Patients hospitalized due to COPD have increased risk of death. Starting in 2015, reimbursements by the Centers for Medicaid Medicare Services will be significantly reduced to hospitals with excess 30 day readmissions for COPD. Oral corticosteroid (OCS) therapy is established in improving outcomes in COPD patients treated in the emergency department and hospital. The objective of this article is to review the evidence evaluating home OCS treatment of COPD exacerbations as part of a comprehensive self-management action plan. METHODS: We reviewed the English literature via PubMed, Embase, and Scopus using the search terms: chronic obstructive pulmonary disease exacerbations AND: oral corticosteroids, prednisone, prednisolone, methylprednisolone, treatment, self-management, disease management, written action plans. When pertinent articles were found, we reviewed the relevant articles cited. FINDINGS: Two randomized trials enrolling 933 patients provide evidence of reduced rates of hospitalization by using comprehensive COPD action plans, including OCS therapy. Three trials with 790 patients enrolled did not reveal reduced rates of hospitalization. Among all five trials together, there were no differences in deaths (76 in the intervention groups [home action plans]; 81 in the usual care groups). Additional studies not assessing hospitalizations have found home use of OCSs increases time to the next exacerbation and decreases recovery time. CONCLUSION: Further randomized trials are needed to establish that home use of OCS therapy, as part of a comprehensive action plan, reduces the rate of hospitalizations. Such action plans should include structured patient education, early initiation of OCSs, oral antibiotics, and frequent telephone reinforcement and support from case management.

Incorrect use of peak flow meters: are you observing your patients?

BACKGROUND: Monitoring peak expiratory flow (PEF) values is one option as part of asthma action plans per national guidelines. PEF assessment is also recommended in emergency department and hospitalized patients. Incorrect use of peak flow meters (PFM) has obvious implications for appropriate decisions by patients and clinicians. METHODS: We searched the English literature via PubMed and SCOPUS using the following search terms: PEF maneuver; incorrect use of PFM. When pertinent articles were found, we assessed publications cited in those papers. All studies related to incorrect use of PFM in patients with asthma were included. RESULTS: Nine studies have reported errors in performing the PEF maneuver, including three pediatric and six adult studies. Errors were found at most steps of the maneuver, and inability to perform all steps correctly was common in these investigations. Examples of errors included failure to inhale fully or give maximum effort on exhalation, accelerating air with the tongue and buccal musculature, and performing only one attempt versus three. Gender differences in correct use of PFM are suggested by three adult studies. One study described falsifying PEF values by manipulating the PFM indicator, and another investigation assessed the PEF maneuver in two positions in bed versus the correct posture of standing. CONCLUSION: Many pediatric and adult patients do not use PFM correctly. Clinicians should regularly observe patients use PFM to detect errors and help ensure correct use and accurate PEF measurements.