1041. Staphylococcus aureus Bacteremia Bundle Adherence Pre- and Post-Implementation of Mandatory Infectious Diseases Consultation and Antimicrobial Stewardship Pharmacist Intervention

Staphylococcus aureus bacteraemia (SAB) carries high rates of morbidity and mortality. Antimicrobial stewardship programmes (ASPs) are well situated to promote adherence to quality performance measures in order to optimize the management of SAB and associated clinical outcomes. This uncontrolled pre-post quasi-experimental study evaluated compliance with an ASP-driven comprehensive care bundle and associated clinical outcomes for patients with SAB. The ASP provided recommendations to prescribers to promote adherence with quality performance measures, which included: initiate effective antibiotics within 24 h of Gram's stain; achieve therapeutic vancomycin trough concentration; provide β-lactam therapy if MSSA; obtain repeat blood cultures every 48 h until clearance; complete appropriate treatment duration; eliminate or debride foci of infection; and obtain an echocardiogram for complicated bacteraemia. One hundred and seventy patients with SAB were included: 82 patients in the pre-intervention group and 88 patients in the ASP-intervention group. Overall bundle adherence to quality performance measures improved from 56.1% (46/82) in the pre-intervention group to 84.1% (74/88) in the ASP-intervention group (P < 0.001), which was associated with a reduction in 30 day readmission with SAB [9 patients (11.0%) versus 1 patient (1.1%), P = 0.008]. The 30 day mortality was numerically lower in the ASP-intervention group, but the difference was not statistically significant [16 patients (19.5%) versus 10 patients (11.4%), P = 0.2]. Implementation of an ASP-driven comprehensive care bundle for SAB improved adherence with performance measures and was associated with a decrease in hospital readmission for SAB.

BackgroundAntimicrobial stewardship programs (ASPs) improve Staphylococcus aureus bacteremia (SAB) management. The objective of the current study was to evaluate the effect of unsolicited prospective audit and feedback (PAF) using a standardized SAB bundle form on the management of SAB.MethodsMulticenter, pre-post quasi-experimental study of inpatients with SAB. The ASP developed an evidence-based SAB management bundle that included recommendations for infectious diseases consultation, blood culture clearance, appropriate empiric and definitive therapy, echocardiography, adequate treatment duration, and source control where applicable. ASP pharmacists performed PAF using a standardized form outlining bundle components. The primary outcome was bundle component adherence. Secondary outcomes were length of stay, 30-day readmission rate, and in-hospital and 30-day mortality rates.ResultsA total of 199 patients were included (preintervention group, 62; intervention group, 137). Bundle implementation with PAF resulted in significant improvements in infectious diseases consultation (56.5% in preintervention vs 93.4% in intervention group), appropriate definitive antibiotic therapy (83.9% vs 99.3%), ordering echocardiography (72.6% vs 95.6%), and adequate treatment duration (87.0% vs 100%) (all P < .001). Overall bundle adherence increased by 43.8% (P < .001). Readmission and 30-day mortality rates decreased, but this difference did not reach statistical significance.ConclusionsUnsolicited PAF using a standardized SAB management bundle significantly improved adherence to evidence-based recommendations. This simple yet effective ASP-driven intervention can ensure consistent management of a highly morbid infection.

Standardized diagnostic criteria for malnutrition were developed by the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) in 2012. The criteria as a whole has had little validation, and the effect of underlying condition on the impact of malnutrition has not been well studied. We measured the association between severe malnutrition and hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality among critically ill inpatients. We analyzed hospital records from 5606 patients whose admission included an ICU stay. Associations between severe malnutrition and LOS and mortality were examined by multivariable linear and logistic regression. Thirteen percent were diagnosed with severe malnutrition. These had significantly longer hospital LOS (18 [interquartile range 10-35] days vs 8 [5-14] days), total ICU LOS (7 [3-15] days vs 3 [1-6] days) and in-hospital mortality (odds ratio [OR] 2.78, 95% confidence interval [CI] 2.33-3.31), compared with those without severe malnutrition. After adjusting for demographics, we found significant interactions between severe malnutrition and ICU location. Patients with malnutrition in the cardiothoracic surgery ICU experienced the largest increases in hospital LOS (21.10 days, 95% CI 18.58-23.61), ICU LOS (12.14 days, 95% CI 10.41-13.87), and in-hospital mortality (OR 8.78, 95% CI 5.11-15.07). Critically ill patients diagnosed with severe malnutrition based on the AND/ASPEN diagnostic characteristics experienced longer hospital and ICU LOS and increased mortality. The magnitude of effect of malnutrition was modified by ICU location, underscoring the need to identify the major comorbidities associated with malnutrition.

Comparison of knowledge to antimicrobial stewardship institution policies targeting Staphylococcus aureus bacteremia and candidemia between medical doctors and pharmacists in an academic teaching hospital in Japan.

BackgroundClostridium difficile remains a pathogen of importance as global infections steadily rise. While traditionally thought of as a nosocomial infection, C. difficile prevalence is increasing in the community. This may be due partly to asymptomatic gastrointestinal colonization with C. difficile. Disruption of the gut microbiome in colonized patients (patients) through the use of antibiotics (ABX) and acid-suppressive therapy (AST) may lead to active colitis. In an effort to prevent progression to active disease, a novel vertical antimicrobial stewardship (AMS) intervention was initiated at our hospital on May 1, 2017. This study aims to describe our experience with this intervention.MethodsThis single-center, descriptive study evaluated the impact of a vertical AMS intervention for patients colonized with C. difficile as identified by surveillance nucleic acid amplification test (NAAT) upon hospital admission. Between May 1 and December 10, 2017, patients on five units [two hematology/oncology (HO), solid-organ transplant (SOT), intensive care unit (ICU), medicine ward (MED)] were screened, with surveillance results reported to the AMS team. Positive results prompted the AMS pharmacists to evaluate patients for potential ABX and AST de-escalation interventions (INTV) daily until discharge.ResultsOf the 37 patients who developed active colitis, ABX INTVs were made on 6 (16%) with 33% acceptance and AST INTVs were made on 10 (27%) with 50% acceptance.Hospital UnitTotal Patients no.Patients on ABX no. (%)ABX INTV no. (%)ABX INTV Accepted no. (%)Patients on AST no. (%)AST INTV no. (%)AST INTV Accepted no. (%)Patients that Developed Active Colitis no. (%)*SOT5036 (72)4 (11)3 (75)35 (70)8 (23)6 (75)6 (12)HO10686 (81)15 (17)9 (60)84 (79)23 (27)16 (70)18 (17)MED4827 (56)7 (26)5 (71)29 (60)8 (28)7 (88)6 (13)ICU6144 (72)7 (16)6 (86)42 (69)10 (24)5 (50)7 (11)ALL Patients265193 (73)33 (17)23 (70)190 (72)49 (26)34 (69)37 (14)*Active colitis: (NAAT+/Enzyme Immunoassay [EIA]+) or NAAT+/EIA– with symptoms.ConclusionThe rate of progression from colonization to colitis was low in all patient populations studied, despite high rates of ABX and AST use. Further research into what causes progression from colonization to colitis is needed.DisclosuresAll authors: No reported disclosures.

Corresponding Author: Zachary Howe: 705 Riley Hospital Drive SFT Room W6111, Indianapolis, IN 46228, 317-948-9562, zhowe@iuhealth.org No conflicts of interest. Background Staphylococcus aureus bacteremia (SAB) has the potential to cause severe complications including septic shock, endovascular infection, and disseminated infection. In the setting of a high-inoculum infection (such as endocarditis), heightened production of the BlaZ beta lactamase may increase the effective minimum inhibitory concentration (MIC) at the site of infection, potentially reducing the efficacy of cefazolin. The majority of studies comparing anti-staphylococcal penicillins (ASPCNs) versus cefazolin in methicillin-susceptible S. aureus (MSSA) bacteremia are in adult patients finding that cefazolin is non- inferior to ASPCNs and is associated with fewer adverse effects. Given the significant differences in pathogenesis of infection and rates of complications in children compared to adults with SAB, studies in pediatric cohorts are needed. Thus, we sought to compare safety and efficacy of ASPCNs versus cefazolin for the treatment of MSSA bacteremia in children. Methods A retrospective cohort study was conducted to compare the safety and efficacy of ASPCNs (nafcillin and oxacillin) versus cefazolin in pediatric patients with SAB due to MSSA. The primary endpoint was a composite of treatment failure defined as: mortality due to SAB, recurrence of MSSA bacteremia within 1 year of original SAB, or clinical failure, defined as a blood culture positive for MSSA within a 14-day period following 2 consecutive negative cultures. Secondarily, antibiotic associated adverse effects were compared between groups. Patients with infection of the central nervous system or experiencing mortality within 48 hours of starting antimicrobials were excluded. Results Of 174 patients screened, 127 met inclusion criteria. Of these patients, 64 (50%) received cefazolin and 63 (50%) received an ASPCN (16 oxacillin [12.6%], 37 nafcillin [37.4%]). Patients received a median of 18.5 days of therapy (IQR 19 days). No difference in PRISM score was observed between groups (median 2 vs 3, p=0.267). For the primary endpoint, a statistically significant difference was not observed with cefazolin as compared to ASPCNs (4.7% vs 12.7%, p=0.11). A similar incidence of treatment failure was observed in the ASPCN group across subgroup analyses, including in patients with or without prosthetic material, with or without endocarditis, with full, partial, or no source control, and when comparing cefazolin to nafcillin and oxacillin separately. No differences in incidence of acute kidney injury (17.2% vs 19%, p=0.79) or hepatoxicity (0% vs 3.2%, p=0.24) were observed. Conclusion The current study did not observe an association between use of cefazolin and poorer clinical outcomes as compared to ASPCNs for the treatment of MSSA bacteremia in pediatric patients. ASPCNs have historically been thought to be more likely to lead to clinical success compared to cefazolin for high inoculum infections. In this study, cefazolin was associated with a lower rate of composite mortality, treatment failure, or recurrence in patients with prosthetic material with or without endocarditis, including those without source control. However, as BlaZ genotypic testing is not available for use in clinical practice, it is difficult to determine if such a phenotype was present in a significant proportion of included cases. Future studies would ideally be prospective in nature and have a sample size of patients with infections associated with a high inoculum of bacteria (ex: endocarditis) sufficiently large to determine if a significant improvement in outcomes can be seen with ASPCNs as compared to cefazolin. Should rapid diagnostic testing for BlaZ production become commercially available, studies could also utilize this testing to determine if a difference in clinical outcomes can be observed specifically with infections due to such strains of MSSA.

Background: In recent years there has been an increase in cardiac device-related infections and the need for transvenous lead extraction (TLE). Limited data exist on secular trends in baseline characteristics and outcome measures among patients undergoing this high-risk procedure. Objective: To examine secular trends in baseline characteristics and outcomes for patients undergoing lead extraction procedure at our institution. Methods: We conducted a retrospective chart review of patients undergoing TLE from 2010 to 2021, at a tertiary academic institution. Patients were divided into three epochs (2010-2013, 2014-2017 and 2018-2021). Baseline characteristics in hospital length of stay (LOS) and survival were compared between groups. Results: A total of 794 patients, with a mean age of 64±16 years, were analyzed. 481 (60%) patients had infection as the indication for TLE. On average, 2 ± 1 leads were extracted per patient. The longest lead dwell time was 6.5 ± 4.8 years. Significant progressive increase in baseline comorbidity over time is noted (Table 1). A concomitant increase in infection indication versus lead management was also noted. There was a significant increase in the median hospital LOS across epochs; 3.88 IQR (1.26-10.06) for epoch 1 vs 7.34 IQR (2.25-13.35) for epoch 2, vs 9.06 IQR (5.78-14.05) for epoch 3 (P &lt; 0.0001). While there was no difference in long term survival curves (log rank p =0.4), between group analysis showed higher risk for 30 day [RR 2.24(1.08-4.66) p=0.0306] and 1 year mortality [RR 1.44 (1.004-2.05) p=0.0478] between epoch 3 vs epoch 1. Conclusion: Across epochs, the number of TLE procedures performed decreased while patient morbidity increased with a notable increase in infection indication for the procedure. This corresponded to a progressive increase in hospital LOS and an emergent signal toward increased near-term mortality.

Incidences of Staphylococcus aureus bacteraemia (SAB) in Israeli children are unknown. The characteristics of SAB in children have not been evaluated. SAB from children aged ≤18years old, admitted to a tertiary hospital in Israel during 2002-2015, were included. The proportional rate of SAB was calculated per 1000 admissions. SAB were classified as community acquired (CA), hospital acquired (HA) and healthcare related (HCR). Patients' characteristics, antibiotic susceptibility and outcomes were assessed in each group. The rate of SAB was stable, 1.48 per 1000 admissions. HA, CA and HCR-SAB comprised 53%, 25% and 22%, respectively. Only 27/185 (14.6%) were caused by methicillin-resistant Saureus (MRSA): 22%, 6% and 5% of HA, CA and HCR-SAB, respectively. Central venous catheter, recent surgery, immunodeficiency and age <6years were the main risk factors for HA and HCR-SAB (adjusted OR: 68.9, 7.5, 5.8 and 5.5, respectively). Treatment duration for CA was >21days: and for HA and HCR, 14-20days. All-cause in-hospital mortality and 30-day mortality were documented in 10 (5%) and 3 (2%) episodes, respectively. The rate of SAB; the proportions of CA, HA and HCR-SAB; and the proportion of MRSA was stable over the years. MRSA was mainly in HA-SAB. Thirty-day mortality was rare.

BackgroundWe aimed to improve the prognosis, treatment, and management of Staphylococcus aureus bacteremia (SAB) by evaluating the association between adherence to quality indicators (QIs) and clinical outcomes in patients with their clinical outcomes.MethodsWe retrospectively collected clinical and microbiological data on hospitalized patients with SAB from 14 hospitals (three with > 600, two with 401–600, five with 201–400, and four with ≤ 200 beds) in Japan from January to December 2022. The SAB management quality was evaluated using the SAB-QI score (ranging from 0 to 13 points), which consists of 13 QIs (grouped into five categories) based on previous literature.ResultsOf the 4,448 positive blood culture episodes, 289 patients with SAB (6.5%) were enrolled. The SAB-QI scores ranged from 3 to 13, with a median score of 9 points. The SAB-QI score was highest in middle-sized hospitals with 401–600 beds. Adherence to each of the four QI categories (blood culture, echocardiography, source control, and antibiotic treatment) was significantly higher in survived cases than in fatal cases. Kaplan–Meier curves with log-rank tests demonstrated that higher adherence to SAB-QIs indicated a better prognosis. Logistic regression analysis revealed that age, methicillin resistance, multiple comorbidities (≥ 2), and low SAB-QI score were significantly associated with 30-day mortality in patients with SAB.ConclusionsOur study highlights that greater adherence to the SAB-QIs correlates with improved patient outcomes. Management of patients with SAB should follow these recommended indicators to maintain the quality of care, especially for patients with poor prognosticators.Supplementary InformationThe online version contains supplementary material available at 10.1007/s15010-024-02284-z.

Staphylococcus aureus is the second-most-common pathogen among bloodstream infections. Due to a high hospital mortality rate (15 - 40%), frequent complications and recurrences the clinical management of Staphylococcus aureus bacteremia (SAB) is distinct from bacteremia from other pathogens. A literature search was performed using PubMed. Guidelines and best practice expert recommendations were included. The detection of S. aureus in blood culture should always be considered clinically relevant. The drug of choice for treatment of a bloodstream infection with methicillin-sensitive S. aureus is flucloxacillin (8 - 12 g i. v./d). In a bloodstream infection with methicillin-resistant S. aureus (MRSA) vancomycin or daptomycin (the latter not in pneumonic focus) are recommended. Follow-up blood cultures, source identification, including transoesophageal echocardiography in patients with risk profile, and rapid source control are important measures. The duration of therapy is at least 14 days with uncomplicated SAB, whereby the entire therapy should be carried out intravenously. In case of complicated SAB, a total therapy duration of at least 4 - 6 weeks is recommended. Adherence to this set of measures can reduce mortality by up to 50%. SAB is associated with high morbidity and mortality. Clinical management is complex. By adhering to diagnostic and therapeutic measures, the prognosis can be improved.

The effect of age and infection on outcome after trauma is unknown. We evaluated the incidence and impact that nosocomial infection (NI) and age have on morbidity and mortality. Several risk factors were identified and analyzed for correlation with infection. Prospective data were collected on patients admitted for > or = 3 days over a 2-year period. Each patient was followed by an infectious disease specialist throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection. Of the 3,254 patients admitted, 88% were < 65 and 12% were > or = 65 years of age. Injury Severity Score was not significantly different (older vs. younger). Five hundred one (17.4%) of the younger patients developed an NI with a significantly higher hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality compared with the noninfected group. One hundred forty-seven (39%) of the older group developed an NI and also had significant increases in hospital LOS, ICU LOS, and mortality. Older infected patients had the highest hospital LOS, ICU LOS, and mortality. The greatest relative risk of mortality was demonstrated with the combination of increased age and NI. Once infected, however, younger patients with penetrating trauma had a greater relative risk of mortality in the group-specific comparison. Many risk factors were associated with infection. Only chronic obstructive pulmonary disease in elderly trauma patients was a significant independent risk factor for infection. NI significantly increases hospital LOS, ICU LOS, and mortality after injury. Age increases risk of infection matched for injury severity, with a significantly higher hospital LOS, ICU LOS, and mortality. Once infected, however, younger patients with penetrating trauma have the greatest risk of mortality. Chronic obstructive pulmonary disease in elderly trauma patients was found to be an independent predictor of infection.

Antimicrobial Stewardship (AS) is crucial for delivering high-quality care to patients, minimizing adverse effects and outcomes, mitigating antimicrobial resistance, and generating cost savings for the healthcare system and patients. Successful AS programs are often multi-disciplinary, with infectious diseases and antimicrobial stewardship pharmacists (ID/ASP) playing a key role in the implementation and coordination of care. This study evaluated the documentation of stewardship interventions following the implementation of an ID/ASP-led stewardship program in a large Midwestern academic medical center. This quasi-experimental study evaluated the impact of hiring an ID/ASP with subsequent AS education and feedback and updated documentation methods. It was conducted from January 2023 to September 2023 (pre-intervention) and October 2023 to December 2024 (post-intervention), and compared the impact of an ID/ASP pharmacist on the documentation of key AS interventions by non-ID pharmacists. The number and type of interventions and drugs used in interventions were assessed for adult and pediatric patients before and after the ID/ASP pharmacist was hired. The primary outcome was the average number of interventions documented by non-ID pharmacists per month in the pre-intervention period compared to the post-intervention period. A p-value < 0.05 was considered statistically significant. A total of 5606 non-ID pharmacist interventions occurred throughout the study. There was a statistically significant increase in average monthly documented interventions by non-ID pharmacists after the intervention compared to before (283 ± 102 vs. 152 ± 49, respectively; p = 0.002). Furthermore, the ID/ASP pharmacist contributed an additional average of 104 interventions per month and was able to perform high-impact AS interventions. This study demonstrated a positive impact of an ID/ASP pharmacist-led AS program in a large academic medical center. The number of documented AS interventions significantly increased in the post-intervention period. These data underscore the importance of ID/ASP in advancing the shared goal of antimicrobial stewardship.

Persistent Staphylococcus aureus bacteremia (SAB) has been associated with increased mortality. Enhanced microbial detection with new blood culture technology may improve detection of S. aureus in patients with SAB. We performed a 24-month retrospective study of hospitalized adults with SAB and an infectious diseases consult comparing two time periods pre- (January to December 2018) and postimplementation (January to December 2019) in which the VersaTREK and BacT/Alert Virtuo blood culture systems were used, respectively. Measurements included SAB duration, time to positivity, source of bacteremia, antimicrobial therapy, and mortality. A total of 416 episodes of SAB occurred during the study period: 176 (42%) pre- and 240 (58%) postimplementation. Patients in both periods had similar clinical characteristics; however, patients in the postimplementation period were more likely to have intermediate (3 to 6 days; 23% versus 40%; P < 0.001) and prolonged SAB duration (>7 days; 4% versus 14%; P < 0.001). Combination antistaphylococcal therapy was more frequent postimplementation (6.3% pre- versus 15.8% postimplementation; P = 0.003), and the median time to source control was shorter (4 versus 2 days; P = 0.02). Median time to positivity for the index blood culture was shorter postimplementation (17.8 h pre- versus 13.3 h postimplementation; P < 0.001). There was no difference in 90-day all-cause readmissions (51% versus 44%; P = 0.11) or mortality (32% versus 32%; P = 0.95). An increased frequency of prolonged SAB with increased use of combination antistaphylococcal therapy was noted with implementation of a new blood culture system, likely secondary to the blood culture media; however, no differences on adverse outcomes were noted.

Background: A point prevalence survey (PPS) conducted at Singapore General Hospital (SGH) in 2021 demonstrated that 60.6% of surgical inpatients were prescribed with antibiotics, of which 46.1% received extended-course (&amp;gt;24 hours) surgical antibiotic prophylaxis (SAP). Hence, SGH antimicrobial stewardship (AMS) program implemented a series of targeted AMS strategies among surgical departments, namely 1) data-driven feedback with pay-for-performance; 2) targeted education and capacity building; 3) engaging surgeons as partners in AMS; 4) digital stewardship tools; and 5) national collaborations. In this study, we aim to evaluate the impact of these multi-pronged AMS strategies on the change in antibiotic prescribing patterns in surgical inpatients using serial PPS findings. Methods: The PPS were conducted annually by AMS pharmacists at SGH between 2021 to 2024, with methodology in accordance with Global-PPS protocol. Data collected included proportion of surgical inpatients prescribed with antibiotic, SAP duration, compliance to antibiotic guidelines, and documentation of antibiotic indication and stop/review date. Results: In the study period, the proportion of surgical inpatients prescribed with antibiotics decreased from 60.6% to 54.5%. Proportion of patients with extended-course SAP improved from 46.1% (2021) to 37.6% (2023), before increasing to 44.0% (2024) based on PPS-defined SAP duration. Documentation of indication improved from 69.8% to 80.9% and antibiotic stop/review date increased from 42.6% to 52.7%. Compliance with antibiotic guidelines for antibiotic choice remained high (&amp;gt;80%) throughout. Conclusion: PPS is a useful tool to identify gaps in antibiotic prescribing and evaluate the effectiveness of AMS strategies. We demonstrated that targeted multi-pronged AMS strategies, tailored to different prescribing cultures among surgeons, reduce the proportion of patients prescribed with antibiotics and extended-course SAP. Continued efforts are necessary to sustain improvements and address persistent barriers.

This chapter describes the roles (and responsibilities) of the whole pharmacy department in an effective ASP and summarizes the potential pharmacy-driven antimicrobial stewardship interventions that can be implemented. Additionally, the chapter describes formal and non-formal training opportunities for pharmacists practicing antimicrobial stewardship. Finally, it discusses the roles and responsibilities of the pharmacist as an antimicrobial stewardship leader/champion in developing, implementing, and maintaining an effective ASP.