Early antibiotic discontinuation in patients with clinically suspected ventilator-associated pneumonia and negative quantitative bronchoscopy cultures.

OBJECTIVES: Preliminary data suggest that antibiotic discontinuation in patients with negative quantitative bronchoscopy and symptom resolution will not increase mortality. Because our hospital algorithm for antibiotic discontinuation rules out ventilator-associated pneumonia in the setting of negative quantitative bronchoscopy cultures, we compared antibiotic utilization and mortality in empirically treated, culture-negative ventilator-associated pneumonia patients whose antibiotic discontinuation was early versus late. DESIGN: Retrospective, observational cohort study. SETTING: Eight hundred sixty-seven bed, tertiary care, teaching hospital in Hartford, CT. PATIENTS: Eighty-nine patients with clinically suspected ventilator-associated pneumonia and a negative (<10 colony forming units/mL) quantitative bronchoscopy culture between January 2009 and March 2012. Early discontinuation patients (n = 40) were defined as those who had all antibiotic therapy stopped within one day of final negative culture report, whereas late discontinuation patients (n = 49) had antibiotics stopped later than one day. MEASUREMENTS: Univariate analyses assessed mortality, antibiotic duration, and frequency of superinfections. Multivariate logistic regression was performed to assess the effect of early discontinuation on hospital mortality. RESULTS: Patients had a mean ± SD Acute Physiology and Chronic Health Evaluation II score of 26.0 ± 6.0. Mortality was not different between early discontinuation (25.0%) and late discontinuation (30.6%) patients (p = 0.642). Antibiotic duration (days) was also not different for patients who died vs. those who survived (Median [interquartile range]: 3 [1-7.5] vs. 3 [1.75-6.25], respectively, p = 0.87), and when controlling for baseline characteristics and symptom resolution, only Acute Physiology and Chronic Health Evaluation II score was associated with hospital mortality on multivariate analyses. There were fewer superinfections (22.5% vs. 42.9%, p = 0.008), respiratory superinfections (10.0% vs. 28.6%, p = 0.036), and multidrug resistant superinfections (7.5% vs. 35.7%, p = 0.003), in early discontinuation compared with late discontinuation patients. CONCLUSIONS: In this severely ill population with clinically suspected ventilator-associated pneumonia and negative quantitative bronchoalveolar lavage cultures, early discontinuation of antibiotics did not affect mortality and was associated with a lower frequency of MDR superinfections.

Addressing challenges in bar-code scanning of large-volume infusion bags.

PURPOSE: A hospital pharmacy's efforts to identify and address challenges with bedside scanning of bar codes on large-volume parenteral (LVP) infusion bags are described. SUMMARY: Bar-code-assisted medication administration (BCMA) has been shown to reduce medication errors and improve patient safety. After the pilot implementation of a BCMA system and point-of-care scanning procedures at a medical center's intensive care unit, it was noted that nurses' attempted bedside scans of certain LVP bags for product identification purposes often were not successful. An investigation and root-cause analysis, including observation of nurses' scanning technique by a multidisciplinary team, determined that the scanning failures stemmed from the placement of two bar-code imprints-one with the product identification code and another, larger imprint with the expiration date and lot number-adjacently on the LVP bags. The nursing staff was educated on a modified scanning technique, which resulted in significantly improved success rates in the scanning of the most commonly used LVP bags. Representatives of the LVP bag manufacturer met with hospital staff to discuss the problem and corrective measures. As part of a subsequent infusion bag redesign, the manufacturer discontinued the use of the bar-code imprint implicated in the scanning failures. CONCLUSION: Failures in scanning LVP bags were traced to problematic placement of bar-code imprints on the bags. Interdisciplinary collaboration, consultation with the bag manufacturer, and education of the nursing and pharmacy staff resulted in a reduction in scanning failures and the manufacturer's removal of one of the bar codes from its LVP bags.