INFECTIOUS DISEASES

Resident Jessica Acosta (jessica.acosta@baycare.org)

Co-Authors Mitchell Purse, Jenifer Wheeler

Practice Site St. Joseph's Hospital North

Abstract Title Evaluating the incidence of surgical site infections in patients undergoing gastrointestinal

surgeries while receiving antimicrobials for existing infections

Background

Surgical site infections (SSIs) occur within 30 days after an operation and are usually related to surgical techniques or inappropriate prophylactic antimicrobial use. Appropriate antimicrobials

should have activity against the most common surgical pathogens and should be administered at such a time to provide adequate tissue concentrations. Current guidelines recommend

administering an additional dose of an antimicrobial before surgery in patients receiving antimicrobials for existing infections; however, there are limited studies evaluating the safety and

effectiveness of an additional antimicrobial dose before surgery in patients receiving antimicrobials for existing infections. This study evaluated the effectiveness of a preoperative

antimicrobial dose in patients currently receiving antimicrobials for existing infections.

Methodology

This was a single-site, retrospective chart review of patients who underwent gastrointestinal surgeries from November 2019 to October 2019 and were receiving antimicrobials for existing

infections. The control group was comprised of patients undergoing gastrointestinal procedures and were on antimicrobials for an existing infection who do not receive an additional

antimicrobial for the purpose of surgical prophylaxis. The treatment group was comprised of patients undergoing gastrointestinal procedures and were on antimicrobials for an existing

infection who received an additional antimicrobial for the purpose of surgical prophylaxis within 120 minutes prior to surgery. The primary objective was to evaluate the effectiveness of a preoperative antimicrobial dose in patients currently receiving antimicrobials for existing

infections by measuring the incidence of SSIs. Secondary objectives included development of post-operative acute kidney injury (AKI) as defined by the KDIGO guidelines and Clostridium

difficile infections (CDI) during hospitalization. Data was collected from an electronic medical record system and maintained on a de-identified data collection form which included all

measurable outcomes.

Results

A total of three patients in the control group developed an SSI during the study period and no patients developed an SSI in the treatment group (p= 0.074; 95% CI [-0.06-0.131]). A total of two patients in the control group and two patients in the treatment group developed post-operative AKI (4% vs 4%; p=0.983; 95% CI [ -0.082-0.080)]. CDI did not occur in any of the patients during

the study period.

Conclusions

In this study, an additional preoperative antimicrobial dose for the purpose of surgical prophylaxis did not reduce the incidence of SSIs or increase the risk of acute kidney injury and C.

difficile infections. An adequately powered studied focused on patients currently on antimicrobials for existing infections that will be undergoing a surgical procedure and receiving

antimicrobial prophylaxis may provide additional support to the current guideline recommendations.

Resident Greter Acosta Pena (gacostapena@browardhealth.org)

Co-Authors Jonathan Richardson

Practice Site Broward Health Medical Center

Abstract Title Effect of meropenem restriction on antibiotic use and clinical outcomes

Background

Meropenem, a broad-spectrum beta-lactam antibiotic, is indicated for empiric and definitive treatment of multi-drug resistant organisms (MDRO). However, broad-spectrum antibiotic use is often

unnecessary or inappropriate and can lead to the emergence of antibiotic-resistant bacteria. Literature has shown an association between decreased antimicrobial usage with an improvement in

pathogen susceptibilities. Broward Health Medical Center recently implemented a meropenem restriction policy in which all meropenem utilization is restricted to infectious disease (ID),

pulmonology, trauma, and pediatric intensive care. The purpose of this study was to assess the impact of this restriction on inpatient antibiotic use and clinical outcomes.

Methodology

A retrospective, single-centered chart review of hospitalized adults receiving at least twenty-four hours of meropenem was conducted from May to July 2019 for the pre-implementation group and

July to October 2019 for the post-implementation group. Exclusion criteria were pregnancy and mortality within twenty-four hours of meropenem initiation. Baseline demographics included

admission diagnosis, history of antimicrobial exposure within the past three months, co-morbidities, antibiotic regimen, duration, indication, and length of stay. The primary outcome was antibiotic de-escalation within 96 hours of meropenem initiation. Antibiotic de-escalation was defined as use of

narrower spectrum antibiotics or discontinuation of antibiotics. Secondary outcomes included thirty-day readmission rate, re-initiation of broad-spectrum antibiotics, length of stay, and inpatient mortality. The primary outcome was analyzed with chi-square test with an alpha level of 0.05.

Results

Data was collected for a total of 100 patients, 50 patients in the pre-implementation group and 50 patients in the post-implementation group. Patient age ranged from 19 to 91 years with a median age of 59 years. The most common documented indications for meropenem therapy were pneumonia and urinary tract infections. Antibiotic regimen with meropenem was de-escalated in 34% (n=17) and 30%

(n=15) of the patients in the pre and post-intervention groups, respectively (P=0.67). The most common reasons for not de-escalating were absence of conclusive microbiology, clinical worsening

despite appropriate antibiotic therapy, and definitive therapy for MDRO infections. In our study, extended-spectrum beta-lactamase (ESBL) producing organisms were detected in 14% (n=7) and 26% (n=13) of the patients in the pre and post-implementation groups, respectively (P=0.13). Thirty-day

readmission rates (pre group 24% vs post group 12%, P=0.12) and inpatient mortality rates (pre group 12% vs post group 6%, P=0.3) were lower among patients in the post-implementation group

compared to patients in the pre-implementation group; however, the difference was not statistically significant. There was no difference in re-initiation of broad-spectrum antibiotics (pre group 16% vs

post group 18%, P=0.79) and median length of stay (pre group 15 vs post group 12, P=0.35) between the groups.

Conclusions

The meropenem restriction policy was not associated with lower rates of meropenem de-escalation. In this study, no difference in practice patterns were observed between the study groups of the medical disciplines ordering meropenem. Another important observation was that de-escalation

sometimes occurred past 96 hours due to delay of interpretation of culture and susceptibilities. Our findings indicate that there is a need for additional implementation of prospective antibiotic

stewardship interventions through real-time audit and feedback provided by clinical pharmacists.

Resident Viktoria Andonova (VAndonova@brrh.com)

Co-Authors Kristin Boyar

Practice Site Boca Raton Regional Hospital

Abstract Title Risk of acute kidney injury in patients receiving vancomycin and piperacillin-tazobactam

compared to vancomycin and cefepime

Background

Vancomycin is one of the most commonly used antibiotics to cover methicillin-resistant Staphylococcus aureus (MRSA). As such it is often used in combination with broad-spectrum

antibiotics such as piperacillin-tazobactam or cefepime for empiric therapy in commonly encountered hospital infections. Previous studies have shown that concomitant use of

vancomycin plus piperacillin-tazobactam may put patients at an increased risk for acute kidney injury compared to vancomycin plus cefepime. This research project aimed to investigate the incidence of acute kidney injury in patients receiving vancomycin plus piperacillin-tazobactam

compared to vancomycin plus cefepime.

Methodology

This was a prospective, single center observational study conducted at Boca Raton Regional Hospital, a 400 bed advanced academic medical center. A computer-generated report through Discern Analytics was used to identify eligible patients during the period of January 1, 2019 to

December 31, 2019. Patients who met the inclusion criteria and received vancomycin in combination with either piperacillin-tazobactam or cefepime for at least 48 hours were analyzed. The primary outcome was the incidence of acute kidney injury in patients receiving vancomycin

plus piperacillin-tazobactam compared to vancomycin plus cefepime.

Results

In total, 1087 patients were reviewed and 147 met the inclusion criteria (75 received vancomycin plus piperacillin-tazobactam and 72 received vancomycin plus cefepime). Patients were

evaluated and the incidence of acute kidney injury was significantly higher in the vancomycin plus piperacillin-tazobactam group compared to the vancomycin plus cefepime group, 29.3% versus

15.3%, respectively (P value 0.04).

Conclusions The combination of vancomycin plus piperacillin-tazobactam is associated with an increased risk of acute kidney injury compared to vancomycin plus cefepime. Clinicians should be aware of this

risk and be cautious when prescribing this regimen.

Resident Megan Barber (megan.barber@baycare.org)

Co-Authors Lynne Krop, Joseph Hong, Christopher Fronczek, Jonathan Grey

Practice Site Morton Plant Hospital

Abstract Title Validation of a proposed vancomycin clearance equation for initial dosing in the obese population

Background

Lack of antibiotic dosing guidance within the obese population is associated with higher reported rates of adverse drug events, development of drug-resistant pathogens, and clinical failure. Initial

dosing is based on estimated values of vancomycin clearance (VanCL), with subsequent dosing derived from calculated pharmacokinetic parameters following two post distribution

measurements and target AUC. A previous study with AUC monitoring at our facility in obese patients lead to the development of a novel vancomycin clearance formula. This study aims to

validate this newly derived formula in the obese population.

Methodology

IRB approved, retrospective, multicenter, pharmacokinetic evaluation in adult obese patients. Evaluable patients received vancomycin therapy and had two steady state post distribution

concentrations (peak and trough) collected to calculate patient specific VanCL and other pharmacokinetic parameters, used for subsequent dosing to achieve the therapeutic AUC target. Estimated VanCL was calculated using the new and standard equation and compared to the same

patient specific VanCL obtained from two post distribution concentrations. Comparison of previously estimated vancomycin clearance method with the new equation will be analyzed using

least square regression method with corresponding regression coefficient.

Results 225 patients were evaluated. Linear regression analysis for the new and the standard VanCL

equation was preformed and compared to the true VanCL. The regression coefficient for the new and the standard equation was R² = 0.455 and R² = 0.392 respectively.

Conclusions The new VanCL equation had a better predictive value to the patients true VanCL compared to

the currently used standard VanCL equation.

Resident John Boulos (jbou0003@shands.ufl.edu)

Co-Authors Barbara Santevecchi, Kathryn DeSear, Catherine Vu, Bethany Shoulders, Megan Logan, Veena Venugopalan

Practice Site UF Health Shands

Abstract Title Measuring the impact of allowing 72-hours of empiric linezolid on ICU consumption of intravenous gram-

positive antibiotics

Background

The Centers for Disease Control have proposed antibiotic timeout (ATO) policies as one method to reduce the unnecessary use of antibiotics. Many studies demonstrate the benefits of this strategy, including cost

savings, reductions in inappropriate antibiotic use, and decreased duration of therapy. At UF Health Shands Hospital, several broad-spectrum antimicrobials require pre-approval before dispensation, including

linezolid. In January 2018, an ATO policy was implemented for IV linezolid in the Intensive Care Unit (ICU) to allow 72 hours of use without pre-approval. To meet criteria, patients must not have received greater than or equal to 72 hours of MRSA-targeted therapy with vancomycin or linezolid before the ordering date. This

study aims to measure the impact of allowing 72 hours of empiric IV linezolid on ICU consumption of IV gram-positive antibiotics (IVGP-AB).

Methodology

A single-center, quasi-experimental, pre- and post-intervention study was conducted to evaluate the change in restriction criteria for linezolid in the ICU setting at UF Health Shands Hospital. Subjects were

divided into groups by pre-implementation (July 1, 2016 to June 30, 2017) and post-implementation (July 1, 2018 to June 30, 2019) periods. A 6-month washout period was implemented to account for the transition of policy into practice. The primary outcome was days of therapy (DOT) per patient of IVGP-AB (specifically

vancomycin and linezolid). Secondary outcomes included in-hospital length of stay (LOS), ICU LOS, in-hospital mortality, 30-day readmission, and adverse events such as acute kidney injury (AKI) and initiation

of renal replacement therapy (RRT). AKI was determined by ICD-10 codes upon discharge. Univariate differences between cohorts were assessed using equal variance, two sample t-tests for continuous

variables, and Chi-squared or Fisher’s exact test for categorical variables as appropriate. Multivariate linear regression modeling was performed to determine the impact of confounding for each baseline

characteristic on the primary outcome. Independent variables significantly associated with the primary outcome and the group assignment were included in the multivariate model. Statistical significance for

univariate and multivariate analyses was determined using a threshold of α < 0.05.

Results

2718 patients met the criteria for inclusion in the study. 1091 patients were included in the pre-intervention group, and 1627 patients were included in the post-intervention group. Baseline

characteristics were well matched between the two groups and demonstrated no statistically significant difference among age, sex, race, time from ICU admission to first antibiotic order, or mechanical

ventilation. The pre-intervention group had a higher percentage of patients with an ID consult. There was a statistically significant reduction in the total DOT of IVGP-AB from pre- to- post-implementation periods (4.97 vs. 4.36 days, p<0.01), with an absolute difference of 0.61 days. Secondary outcomes of in-hospital

LOS, ICU LOS, and in-hospital mortality did not vary significantly between the two groups. 30-day readmission was found to be lower in the post-intervention group (12.9% vs. 3.9%, p<0.01). A multivariate analysis showed that, while controlling for confounders, the post-intervention group reduced the DOT of

IVGP-AB by 0.24 days compared to the pre-intervention group (p< 0.01), which is consistent with our univariate analysis. Patients that had an ID consult ordered resulted in a 1.53 DOT increase in IVGP-AB than

those who did not (p<0.01).

Conclusions

We assessed the impact of an ATO policy allowing 72 hours of empiric IV linezolid in the ICU. We found a statistically significant reduction in days of therapy of IVGP-AB without differences in in-hospital LOS, ICU

LOS, in-hospital mortality, and incidence of AKI. The small margin of difference in the primary outcome could have been attributed to this policy. There were several limitations identified in this study. These

include the definition of AKI, which was determined by ICD-10 codes upon discharge, rather than a more objective description such as KDIGO criteria. Also, the single-center sample of this study limits the external validity of these results. Future directions may include evaluating antibiotic indications to focus initiatives

on optimizing duration of therapy for the most common indication(s), performing antibiotic time-outs more frequently, involving multidisciplinary efforts (i.e. nursing support, etc.), and evaluating expenditure with

antibiotic use.

Resident Alexander Branton (alexander.branton@va.gov)

Co-Authors Samuel Solone, Joseph Hong, Victoria Koenig, Peter Pasek

Practice Site Bay Pines VA Healthcare System - Bay Pines

Abstract Title Impact of area under the concentration-time curve (AUC) targeted vancomycin dosing on

nephrotoxicity

Background

Vancomycin has been a mainstay for the treatment of Methicillin-resistant Staphylococcus aureus (MRSA) infections since the late 1960's. Current guidelines have associated an area under the concentration-time curve over minimum inhibitory concentration (AUC/MIC) greater than or

equal to 400 as the pharmacodynamic target for clinical success in the treatment of MRSA. Due to the variability in vancomycin elimination rate, and , high variability in vancomycin volume of distribution (0.388 to 2.040 L/kg), the use of trough concentrations as a surrogate marker may

not be as reliable as once predicted. As such, trough concentrations may not accurately predict a patient's true vancomycin exposure and may unknowingly increase their risk of nephrotoxicity.

This purpose of this study is to evaluate the incidence of nephrotoxicity between a trough-based vancomycin dosing method and a revised two-point sampling dosing protocol for AUC-targeted

calculations.

Methodology

The trough-based (pre-intervention) group will be comprised of patients who received an inpatient vancomycin order from October, 2017 to September, 2018 while the AUC-targeted

calculations (post-intervention) group will be comprised of patients who received an inpatient vancomycin order from October, 2018 to September, 2019. The primary outcome of the study

will be the incidence of nephrotoxicity. Achievement of therapeutic target, total daily vancomycin dose, vancomycin duration of therapy, 30-day readmission, duration of ICU admission (if

applicable), and total inpatient duration of hospitalization will also be compared between the two groups.

Results Pending

Conclusions Pending

Resident Kayla Brice (kabrice@mhs.net)

Co-Authors Corey Frederick, Sara Eltaki, Angel Maldonado

Practice Site Memorial Regional Hospital

Abstract Title Assessment of a mandatory treatment algorithm on Clostridioides difficile infection recurrence

rates

Background

In 2017, the Infectious Diseases Society of America (IDSA) updated guidelines for the treatment of Clostridioides difficile infections (CDI) and recommends either vancomycin or fidaxomicin as first-

line therapy. Metronidazole was removed as a first-line treatment option. At our institution, readmission rates for CDI were high and a standard of care based on the updated guidelines

needed to be established. This study aims to evaluate the implementation of an IDSA guideline-based adult CDI protocol’s effect on readmission rates.

Methodology

This study was a retrospective chart review. Electronic medical records were reviewed to identify patients before and after implementation of an Adult CDI Protocol. Data analysis included patient

demographics, diagnostic laboratory values and CDI treatment regimens. We hypothesized no difference in readmission rates for CDI cases following implementation of a mandatory treatment

algorithm. Secondary outcomes of this study determined physician adherence to the 2017 CDI guidelines, any single metronidazole orders that were not clinically indicated and assessed the

resolution of infection. Nominal data was used to evaluate outcomes.

Results

Data was analyzed for 70 patients in the pre-implementation and 52 patients in the post-implementation group. The null hypothesis was accepted as a statistical significance between

groups was not found; 12.9% and 9% in the pre/post implementation group respectively (p=0.7913). Physician adherence to guidelines was 70% and 69.2% in the pre/post

implementation group respectively (p=0.9203). Single metronidazole orders that were not clinically indicated was 45.7% and 17.3% in the pre/post implementation group respectively

(p=0.002). Resolution of infection was 91.4% and 88.5% in the pre/post implementation group respectively (p=0.4237).

Conclusions Implementation of the MHS Adult CDI Protocol provided a standard of care for initial episodes of CDI based on the latest IDSA guidelines and significantly decreased single metronidazole orders

that were not clinically indicated.

Resident Sarena Bumbarger (sarena-bumbarger@smh.com)

Co-Authors Jamie Kisgen, Megan Seddon

Practice Site Sarasota Memorial Hospital

Abstract Title Impact of a multimodal stewardship bundle on antibiotic prescribing in urgent care patients with

acute respiratory tract infections

Background

Recent studies suggest upwards of 50 percent of antibiotic prescriptions for acute respiratory illnesses in the urgent care setting are unnecessary. In an effort to improve prescribing practices, The Joint Commission has recently implemented new antimicrobial stewardship requirements for accredited ambulatory health care organizations beginning January 1, 2020. The objective of this

study is to determine the influence of a multimodal antimicrobial stewardship bundle on prescribing patterns for ARTIs in the outpatient urgent care setting.

Methodology

This retrospective, quasi-experimental pre/post study includes patients 18 years and older presenting to an urgent care facility with an International Statistical Classification of Disease 10th Revision (ICD-10) diagnosis code of acute bronchitis, pharyngitis, or acute rhinosinusitis. The pre-group includes patients presenting from March through April 2019 and post-group is from March

through April 2020. Exclusion criteria include diagnoses with other infections which require antibiotic therapy. Study interventions include: 1) Development and implementation of organization-specific treatment guidelines; 2) Education to urgent care providers; and 3)

Prospective audit and feedback through monthly de-identified prescribing reports. The primary outcome is percentage of visits with an ARTI primary diagnosis for which an antibiotic was

prescribed. Secondary outcomes include rate of antibiotic prescribing stratified by ARTI diagnosis; usage of rapid diagnostic tests; and total duration of antibiotic therapy. Descriptive and

inferential statistics will be used to analyze primary and secondary outcomes. This study was Institutional Review Board approved.

Results

Between March – April 2019 there were a total of 3810 urgent care visits with the pre-specified primary diagnosis codes for an ARTI compared with 2054 visits from March – April 2020. Of these visits, approximately 47% resulted in an antimicrobial prescription in the pre-group vs. 45% in the

post-group. The most frequently diagnosed ARTI was bronchitis (62% vs 65%), and the most commonly prescribed antimicrobial was azithromycin (43% vs 39%). In the pre-group,

approximately 40% bronchitis, 63% sinusitis, 46% non-Strep pharyngitis, and 77% Strep pharyngitis-visits received antimicrobials, compared to approximately 37%, 62%, 48%, and 69% of

visits in the post-group.

Conclusions

While overall antimicrobial prescribing rates did not change between pre- and post-intervention groups, consideration must be given to the confounding factors affecting prescribing rates during

the COVID-19 pandemic. In order to determine the true effect of interventions implemented, repeat studies may be warranted during a more controlled period of time.

Resident Angela Chen (Angela.Chen3@va.gov)

Co-Authors

Practice Site Bay Pines VA Healthcare System - Bay Pines

Abstract Title Impact of a procalcitonin algorithm on antibiotic therapy duration in lower respiratory tract

infections

Background

Acute respiratory tract illnesses are associated with antibiotic overuse despite more than 40% of respiratory infections being attributable to viral cause. Procalcitonin is a calcitonin-related gene product that is expressed in bacterial infections and downregulated in viral infections. Studies have shown that concentrations fall rapidly during recovery from acute bacterial infections;

therefore, it has been proposed as an adjunct to guide antibiotic prescribing. Several trials have reported significant reduction in antibiotic exposure and duration of treatment when procalcitonin was used to guide therapy. There is also some evidence to suggest that

procalcitonin-guided antibiotic therapy can reduce mortality. Bay Pines Veterans Affairs Healthcare System (BPVAHCS) has implemented a procalcitonin algorithm, however, data is

limited regarding its impact.

Methodology

This was a retrospective chart review conducted at BPVAHCS. Subjects were divided into pre-procalcitonin and post-procalcitonin algorithm implementation groups. Data was obtained from

October 2018 through January 2019 and October 2019 through January 2020 for the pre- and post- groups, respectively. Subjects that met the requirements for the study were obtained from

the electronic medical record. The primary outcome was to evaluate the difference in days of antibiotic therapy between the two groups. Secondary outcomes included differences in adverse

events, length of stay, and 30-day readmission rates.

Results Pending

Conclusions Pending

Resident Brianna Choyce (brianna.choyce@adventhealth.com)

Co-Authors Michael Kirsch, Melissa Ruble

Practice Site AdventHealth Tampa

Abstract Title Retrospective comparison of outcomes in patients receiving vancomycin and cefepime versus

cefazolin for prophylaxis in procedures by neurosurgeons at AdventHealth, Tampa

Background

The North American Spine Society (NASS) offers guidance for neurosurgical antimicrobial prophylaxis (PPX) based on the type of surgery and patient risk factors. Despite this guidance, utilization trends at AdventHealth, Tampa (AHT) reveal use of broad-spectrum coverage for

extended durations in this setting. Prolonged antibiotic courses and compulsory use of broad-spectrum agents increase rates of antimicrobial resistance, as well as incidence of antibiotic-

related adverse effects. Initiatives that encourage judicious use of broad-spectrum agents are at the core of AHT antimicrobial stewardship program.

Methodology

A single-center retrospective chart review was conducted on patients at AHT who underwent spinal surgical procedures from January2019-March 2019. Patients age 18-90 years were included

if they received one of the following antimicrobial PPX regimens: vancomycin/cefepime or cefazolin. Patients who had an infection at the time of surgery or if surgery was considered

contaminated/dirty were excluded. A comparison was made between the two PPX regimens. The primary outcome of interest was 60-day rehospitalization with surgical site and/or post-surgical

infection.

Results

A total of 74 patients met criteria for review. Cefazolin therapy was used for surgical PPX in 55% (n=41) of patients, while a combination of vancomycin/cefepime was used in 45% (n=33). The

average duration of PPX was 2.6 days and 4.2 days respectively. There was no statistically significant difference in incidence of rehospitalization due to surgical site or post-surgical

infection between the two groups (n=2 in the cefazolin group and n=0 in the vancomycin/cefepime group; P= 0.499).

Conclusions In this study, there was no observed clinical benefit from use of vancomycin/cefepime nor

extended duration.

Resident Lisa Dang (lidang@mhs.net)

Co-Authors Deborah Fernandez, Shalonda Barnes-Warren, Sandra Adeife, Carolina Gutierrez

Practice Site Memorial Hospital Pembroke

Abstract Title Evaluation of Procalcitonin Levels in Managing Antimicrobial Therapy in Sepsis Patients at a

Community-Based Acute Care Hospital

Background

The Infectious Diseases Society of America (IDSA) guidelines for implementing an Antibiotic Stewardship Program (ASP) recognize that utilizing serial procalcitonin measurements can

decrease antibiotic use. The goal of this program evaluation is to optimize use of procalcitonin monitoring through the expansion of antimicrobial stewardship services at Memorial Hospital

Pembroke.

Methodology

This is a program evaluation that will compare the impact made before and after the expansion of pharmacy monitoring services to the ASP at Memorial Hospital Pembroke. The primary objective

is to optimize the use of obtaining and monitoring procalcitonin levels in sepsis patients. The secondary objective is to evaluate optimization of procalcitonin use through pharmacy initiated

antimicrobial stewardship interventions. The services provided will be an expansion of pharmacy monitoring services currently provided at Memorial Hospital Pembroke, including procalcitonin

ordering and assessment. An analysis will be done to determine the impact of these antimicrobial stewardship interventions provided in sepsis patients.

Results

A total of 60 patients were reviewed from November 2019 to March 2020. In forty-two (70%) patients, antibiotic regimens remained unchanged despite procalcitonin levels. This may have

been due to the critical status of the patient. The remaining eighteen (30%) patients had an opportunity for de-escalation or escalation of antibiotic therapy based upon serial procalcitonin levels. Of the 18 patients eligible for intervention, the recommendation was accepted in twelve

(67%) patients and rejected in six (33%) patients.

Conclusions The optimization of ordering and monitoring procalcitonin levels in sepsis patients may be

beneficial through pharmacist-initiated ASP interventions. This benefit may be most impactful when correlating with the overall clinical status of the patient.

Resident Brandon Dittmar (brandon.dittmar@bhcpns.org)

Co-Authors Shelby Gaudet

Practice Site Baptist Hospital – Pensacola

Abstract Title Effect of procalcitonin assay values on antibiotic prescribing practices at a community health system

Background

Procalcitonin is a peptide precursor of calcitonin released in response to bacterial toxins. Its blood concentration fluctuates in direct correlation with the severity of bacterial burden, making it a valuable tool that can be used

along with other clinical indicators to differentiate bacterial infections from nonbacterial etiologies and to assess antibiotic effectiveness. Baptist Health Care began using procalcitonin assays in January 2018 in response to several controlled clinical studies supporting its use in practice. This study seeks to assess how procalcitonin assay values have since contributed to the initiation, continuation, escalation, and de-escalation of antibiotic

therapies.

Methodology

The Institutional Review Board of Baptist Hospital approved this study. The first one hundred procalcitonin assay values were selected from computer-generated reports each month between January 2019 and June 2019. Assay values were then analyzed in conjunction with physician documentation within the electronic medical record. Inclusion criteria encompassed all adult patients with initial and repeated procalcitonin assay values.

There were no exclusion criteria. Data collected included patient age, sex, diagnosis, length of stay, department ordering the procalcitonin assay, involvement of an infectious disease physician, initial antibiotic regimen, initial

procalcitonin assay value, repeat procalcitonin assay values, and change(s) in antibiotic regimen following procalcitonin results. Values obtained in the emergency department were further assessed for impact on

patient admission. The primary outcome was modification to an antibiotic regimen pursuant to procalcitonin assay value(s). In order for the primary outcome to be achieved, the provider had to expressly document

procalcitonin as a contributing factor in the electronic medical record.

Results

Two hundred ninety three patients were ultimately included in this study with a total of 600 procalcitonin assay values analyzed. One hundred thirty four (45.7%) of these patients were male. The average and median lengths of stay were 10.4 days and 7 days, respectively. The average patient age was 64.5 years, with a range of 19 to

103 years. The most common diagnoses in descending order of occurrence were: respiratory illness, sepsis/suspected sepsis, skin and soft tissue infection, urinary tract infection, and intraabdominal infection. Of the 293 patients included in this study, 230 (78.4%) were admitted on an initial antibiotic regimen prior to the first procalcitonin assay result while 63 patients were not on antibiotics prior to the initial procalcitonin assay

result. Seventeen of the 63 patients (27%) who were not on initial antibiotics were then initiated on an antibiotic regimen while the remaining 46 patients were not. Procalcitonin was a documented factor in initiating

antibiotics for 10 of these 17 patients (58.8%), while it was documented as a justification to not initiate antibiotics in 11 of the remaining 46 patients (23.9%). Additionally, of the 230 patients started on an antibiotic

regimen prior to the procalcitonin assay result, 65 patients (28.2%) saw antibiotic adjustments following the initial procalcitonin result while 165 patients did not. Provider documentation indicated procalcitonin was a

factor in 25 of these 65 patients (38.5%) whose regimens were modified, while it was documented as a factor to not adjust antibiotics in 21 of the 165 patients (12.7%) whose regimens were not modified. Of the 600 values

sampled over the six month study period, procalcitonin assay values were documented as justification to expand antibiotics 27 times, narrow antibiotics 25 times, and continue the current antibiotic regimen 53 times. In the emergency department, 89 of 93 patients (95.7%) with a procalcitonin assay ordered were admitted. Of

those admitted, 45 patients (50.5%) had an initial procalcitonin assay result of 0.25 ng/mL or greater.

Conclusions

These data indicate that procalcitonin assay values play a role in adjusting antibiotic regimens and assessing antibiotic appropriateness. These data further suggest that providers are using procalcitonin assay values as

evidence to initiate antimicrobial agents in patients with elevated values. However, this study comes with several limitations. Primarily, the study design required express documentation of procalcitonin values as evidence for adjusting an antibiotic regimen. The detail of provider documentation varied widely between

practitioners. Robust pharmacy antimicrobial stewardship activities including a review of procalcitonin assay results occur daily. The lack of documentation beyond order adjustments by clinical pharmacists may have led to a sizeable underestimation of procalcitonin utility. During the study period, clinical pharmacist documented 1114 interventions in regards to antibiotic therapy adjustments. Further research is needed to fully determine

the contribution of procalcitonin assay values to clinical practice.

Resident Alyssa M. Dungca (alyssa.dungca@leehealth.org)

Co-Authors Ryan Hire, Ashley Cubillos, Robert Castro, John A. Armitstead

Practice Site Lee Health

Abstract Title Utility of methicillin-resistant staphylococcus aureus nasal polymerase chain reaction testing for

antibiotic de-escalation in a community health system

Background

In the hospital setting, most patients diagnosed with pneumonia will be initiated on broad-spectrum antibiotic coverage, where the goal of therapy is to streamline to a narrower

therapeutic option once culture results are available. The timing and quality of respiratory cultures limit their ability to be used as a reliable parameter for early de-escalation. MRSA nasal

Polymerase Chain Reaction (PCR)-based testing has demonstrated a high negative predictive value (NPV) for detecting MRSA pneumonia and can assist with rapid discontinuation of anti-MRSA therapy for pneumonia. In March 2018, Lee Health implemented a pharmacist-driven MRSA PCR ordering protocol. This protocol allows pharmacists to order MRSA PCR tests in

patients who are receiving vancomycin, linezolid, or tedizolid for pneumonia. The goals of the initiative are to promote appropriate anti-MRSA antibiotic utilization, improve patient safety, and

drive cost-effectiveness of antimicrobial therapy.

Methodology

This multi-center, retrospective, observational analysis included hospitalized patients 18 years and older, who received vancomycin, linezolid, or tedizolid for community-acquired, hospital-acquired, or aspiration pneumonia. Data will be analyzed for a time period before (January 1 – March 1, 2018) and after (January 1 – March 1, 2019) the introduction of pharmacist-ordered

MRSA PCR testing to assess its effect on the utilization of anti-MRSA antibiotics, with the primary outcome examining its effect on anti-MRSA antibiotic days of therapy.

Results

Patients in the post-protocol group had approximately 16 hours less antibiotic therapy duration, however this difference did not reach statistical significance (57.7 hours vs. 41.5 hours, p=0.45).

Comparing the pre- and post-protocol groups, there was a difference in the distribution of patients (p=0.04) with community acquired (27 vs. 64 patients), hospital acquired (64 vs. 47), or

aspiration pneumonia (9 vs. 10 patients). More patients were also mechanically ventilated in the post-protocol group (11 vs. 23, p=0.02). With the 90 negative MRSA Nasal PCR tests in the post-

protocol group, only 47% had documented pharmacist interventions and those actions led to the de-escalation of anti-MRSA antibiotics for 85.7% of those patients. Additionally, there was

decrease in 30-day all cause readmissions in the post-protocol group (12 vs. 23, p=0.04). This study had a 100% specificity with the MRSA nasal PCR test.

Conclusions

Overall, this study reflects the need to optimize the utilization of this diagnostic test, as only 20% of patients had de-escalation of their anti-MRSA antibiotics within 24 hours of a negative MRSA PCR test. The post-protocol group may have had more critical patients who were mechanically

ventilated, which may have reduced the demonstrated impact of MRSA PCR results on de-escalation. Importantly, a high rate of de-escalation was noted in patients who had pharmacist intervention on negative MRSA PCR results. Overall, it is important to continue to encourage

pharmacist intervention on negative MRSA Nasal PCRs to promote early discontinuation of anti-MRSA antibiotics as part of antimicrobial stewardship.

Resident Nicole Dziewiatkowski (Nicole.Dziewiatkowski@martinhealth.org)

Co-Authors Aileen Martinez

Practice Site Cleveland Clinic Martin Health

Abstract Title Evaluate the utilization of the FilmArray® respiratory viral panel and its effects on antimicrobial

stewardship in a community based health-system

Background

Respiratory infections account for millions of missed work days every year. They are associated with significant morbidity and mortality, especially when diagnosis is delayed. Various diagnostic

tests are available to assist confirmation of a respiratory infection. Given the expense of the upper respiratory panel by polymerase chain reaction (PCR), it is typically reserved for

immunocompromised patients who are hospitalized. Currently, this institution does not have a standardized criterion for ordering the respiratory panel. The purpose of this study is to evaluate

the percentage of patients who had a discontinuation of antibiotic therapy in relation to the upper respiratory panel results.

Methodology

A single-center retrospective chart review was conducted on 150 adult patients who received an upper respiratory panel by PCR between October 1, 2018 and March 31, 2019. The electronic

medical records of patients who received the test was reviewed. Data collected included antimicrobials prescribed, antibiotic days of therapy, chest imaging, procalcitonin levels,

infectious disease consults, viral pathogen detected, patient demographics, admission and discharge dates as well as the ordering provider of the PCR. The primary outcome of this study is

to assess the percentage of patients who had a discontinuation of antimicrobial therapy in relation to the upper respiratory panel results. Secondary endpoints include chest imaging

results, procalcitonin levels and infectious disease consults. This data will then be utilized to identify areas for improvement in the prescribing of antimicrobials and usage of the upper

respiratory panel by PCR at the institution.

Results Pending

Conclusions Pending

Resident Katie Farris (katie.farris@ascension.org)

Co-Authors Sasha Premraj, Alyssa Simpson

Practice Site Sacred Heart Health System

Abstract Title Effect of formulary management and education on antimicrobial stewardship in the emergency

department

Background

Antimicrobial resistance is an escalating public health concern and the prevalence has expanded from the inpatient setting to the community. Inappropriate antimicrobial use has been described

as the most important preventable cause of drug resistance in both hospital and community settings. Targeting areas of antibiotic overuse is key to combating resistance and improving

patient outcomes through appropriate antibiotic prescribing. Antibiotic therapy typically begins in the emergency department (ED) where providers treat a variety of different disease states under

time constraints and with little definitive information. The ED lies at the transition between inpatient and outpatient settings and ED practitioners have the unique opportunity to impact

antimicrobial stewardship in both settings.

Methodology

This is a Quasi-experimental study conducted at a community teaching hospital. The primary intervention is education of providers and removal of criteria for use antimicrobials from

automatic dispensing cabinets. Patients included are adults admitted to the ED during a specified time frame before and after intervention. The primary outcome is percentage of meropenem,

levofloxacin, and ciprofloxacin orders meeting criteria for use pre- and post- intervention. Secondary outcomes include number of orders pre- and post- intervention, percentage of orders

not meeting criteria for use continued inpatient, percentage of accurate responses on ciprofloxacin and levofloxacin power forms pre- and post- intervention, and percentage of orders

meeting criteria for use when an ED pharmacist is on duty vs. not on duty.

Results Pending

Conclusions Pending

Resident Michael Finnick (michael.finnick@ascension.org)

Co-Authors Bryan Allen, Abdel Bello, Chad Cannon

Practice Site St. Vincent's Healthcare

Abstract Title Evaluation of risk scores for multidrug resistant organisms in community acquired pneumonia

Background

Multidrug resistant organisms (MDROs) are one of the largest threats to global health which lead to longer hospital stays, higher medical costs, and increased mortality. MDROs are not commonly

identified as the causative pathogen in community acquired pneumonia (CAP). However, early identification is crucial for targeted therapy and treatment success. While multiple risk scores

have been developed to predict MDROs in CAP, no one tool has been recommended by infectious disease guidelines to guide empiric therapy. This study was performed to evaluate the utility of

risk scores for MDROs in CAP.

Methodology

This study was a multi-centered, IRB-approved, retrospective observational cohort study. Subjects admitted to one of the three Ascension St. Vincent's facilities from January 1, 2013 to

October 31, 2019 were eligible for evaluation. Subjects were identified using a CAP orderset and included if they were > 18 years old, had imaging with suspected pneumonia within 48 hours of admission, and had microbiologically evaluable respiratory or blood cultures without another

source of infection. Subjects were randomized using a random number generator and screened for inclusion and evaluated based on information in the first encounter assessed after

randomization. The primary outcome was the overall accuracy of four risk scores used to predict MDROs in CAP - DRIP score, HCAP definition, 2019 CAP guideline recommendations, and Ascension's local guideline. Sensitivity, specificity, negative predictive value, and positive

predictive values were also assessed.

Results Pending

Conclusions Pending

Resident David Fiumara (David.Fiumara@baycare.org)

Co-Authors William Braun, Kristen Hollingworth, Tammy Pham

Practice Site St. Anthony's Hospital

Abstract Title Antimicrobial stewardship in diabetic ketoacidosis: an evaluation of appropriate use of

antimicrobials in diabetic ketoacidosis patients

Background

Use of broad-spectrum empiric antimicrobial therapy is vital for patients with severe infections. Overuse of these agents leads to resistance, increased health care expenses, and drug toxicities.

The objective of this study is to assess the appropriateness of antimicrobial use in patients presenting with diabetic ketoacidosis through assessment of patients with clear radiographic or

culture-driven confirmation of acute bacterial infection.

Methodology

This retrospective study was approved by the Institutional Review Board. The electronic medical record of patients who were admitted to a community hospital between March 2018 and August 2019 with a diagnosis of diabetic ketoacidosis were reviewed. Patients were excluded if less than

18 years of age, currently receiving chemotherapy or transplant therapy, or did not meet the predefined criteria for diabetic ketoacidosis. The primary outcome was incidence of confirmed infection as defined by positive culture(s), imaging, respiratory panel, or documented cellulitis. Secondary outcomes included source of infection, days to de-escalation, duration of therapy,

length of stay, and incidence of adverse drug reactions.

Results

In total, 169 cases of diabetic ketoacidosis in 120 patients were evaluated. The incidence of confirmed infection was 44/169 (26.0%) cases, while the use of antibiotics was 82/169 (48.5%).

Pneumonia, cellulitis, and urinary tract infection were the most common type of confirmed infections. The incidence of acute kidney injury was significantly higher in those treated with

antimicrobials versus no antimicrobials (23 vs 11, p=0.02).

Conclusions

Infection is a well-recognized trigger of diabetic ketoacidosis; this study demonstrates the incidence of co-infection with diabetic ketoacidosis to be 26%. Further research is needed to

evaluate possible tools for early diagnosis of infection in patients presenting with diabetic ketoacidosis to help reduce antimicrobial use in this population.

Resident Leslie Gallardo (lxg864@miami.edu)

Co-Authors Jennifer Quevedo, Anthony D. Anderson

Practice Site University of Miami Hospital (U of Miami Health System)

Abstract Title Evaluation of a pharmacy-driven vancomycin AUC/MIC-based dosing at an acute care hospital

Background

Vancomycin efficacy against staphylococcus aureus is best achieved using area under the curve/minimum inhibitory (AUC/MIC) concentrations with a target ratio of ≥400, as

recommended by the Infectious Diseases Society of America (IDSA) guidelines. In order to achieve target AUC/MIC, the recommendations have been to target a trough of 15-20 mcg/mL. However, troughs above 15 mcg/mL have been associated with an increased risk of nephrotoxicity, without clearly associated improved outcomes. The aim of the study is to evaluate if implementation of

vancomycin AUC/MIC dosing protocol, with a target ratio of ≥400, is associated with trough levels below 15 mcg/mL.

Methodology

A prospective study was conducted of patients hospitalized in our institution who received intravenous vancomycin during the month of April 2020, with a pharmacy-to dose consult. AUC/

MIC dosing protocol was implemented with the use of a spreadsheet-based calculator, using first-order pharmacokinetics equations and two steady-state serum vancomycin concentrations.

Patients were excluded if they were identified as positive or rule-out for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); as well as patients requiring dialysis. The primary

outcome was the percentage of patients achieving target AUC/MIC ratio ≥400 and trough levels below 15 mcg/mL. Secondary outcomes included total percent of target AUC/MIC ratio reached

at steady state, and incidence of nephrotoxicity due to vancomycin therapy.

Results

A total of sixteen patients met inclusion criteria. Eight patients were included in the analysis as these patients had two appropriately collected serum vancomycin concentrations. The mean age was 69 years, and 50% (n=4/8) were males. Seventy-five percent of patients (n=6/8) achieved a target AUC/MIC ratio ≥400 at steady state. All patients who met the AUC/MIC goal had a trough

below 15 mcg/mL. Patients who met AUC/MIC goal had an average AUC/MIC of 459, with an average trough of 9.1 mg/L. Nephrotoxicity occurred in one patient; the onset was 3 days after

discontinuation of vancomycin, however, it is unclear if related to vancomycin therapy.

Conclusions

The implementation of a vancomycin AUC/MIC dosing protocol was associated with the majority of patients obtaining target AUC/MIC goals while maintaining troughs below 15 mg/L, indicating a

potential decreased risk of nephrotoxicity. A major limitation of the study was a small sample size, as well as increased workload due to frequent nursing and laboratory staff education and

process monitoring. Further research needs to be conducted in order to validate the pharmacy-driven vancomycin AUC/MIC dosing protocol.

Resident Amanda Gibbs (gibbs.amanda@mayo.edu)

Co-Authors Kevin Epps, Vanessa Toncray, Daniel Jackson, Senka Runjaic

Practice Site Mayo Clinic Florida

Abstract Title Electronic health system based best practice advisory to enhance the time to de-escalation of

vancomycin for respiratory indications

Background

Multiple studies have demonstrated a high negative predictive value (> 95%) for methicillin-resistant Staphylococcus aureus (MRSA) recovered from lower respiratory sources. Based on

these results, MRSA pneumonia is highly unlikely when MRSA nasal swab results are negative and vancomycin use can be de-escalated. Lack of clear de-escalation guidelines leads to longer

duration of vancomycin therapy, increased risk of adverse events, and increased resources for vancomycin (cost, nursing administration, therapeutic drug monitoring, etc.). Given the limited guidance surrounding prompt de-escalation, this study will evaluate the impact of a MRSA nasal

screen best practice advisory (BPA) on vancomycin length of therapy for respiratory indications at Mayo Clinic in Jacksonville, Florida.

Methodology

A retrospective single-center, pre-post cohort study was conducted to assess the time to de-escalation of vancomycin before and after implementation of an electronic prompt. A chart review of patients on vancomycin empirically for the treatment of suspected or confirmed

respiratory infections during January to April 2019 (before implementation of the MRSA screen BPA) and October to January 2020 (after implementation) was conducted. The primary endpoint

evaluated was the time from prescribing to de-escalation of vancomycin in hours.

Results

After review of 433 charts, 61 patients met inclusion criteria for the pre-BPA cohort and 59 patients for the post-BPA cohort. No statistical difference was noted for demographics or length of hospital stay. Time to de-escalation was found to be statistically significant between the pre-BPA cohort and post-BPA cohort with a median of 76 hours (IQR = 52-109) and 42 hours (IQR =

37-61), respectively (p = 0.002). Accuracy of the BPA was confirmed with the alert documented as triggered or MRSA nasal swab previously ordered by the provider. Acute kidney injury occurred in

18% of the pre-BPA cohort versus 5% of the post-BPA cohort (p = 0.01; NNT = 8).

Conclusions Implementation of a methicillin-resistant Staphylococcus aureus nasal screen best-practice

advisory is useful in further minimizing the time to de-escalation of vancomycin.

Resident Kristen R. Glover (Kristen.glover@adventhealth.com)

Co-Authors Amy Carr, Bibidh Subedi, Joanna Longueira, Jose Alexander

Practice Site AdventHealth Orlando

Abstract Title Impact of Verigene + Direct BC on time to targeted antibiotic therapy (TTAT) for patients with

gram negative bloodstream infections

Background

Time to antibiotic susceptibility via conventional microbiologic methods is often 48 to 72 hours. In our health system, a novel technique to directly test for organism identification and antimicrobial

susceptibilities from blood culture has reduced time to full susceptibilities to 20 hours for monomicrobial Gram negative bloodstream infections. This study aimed to evaluate the clinical

impact of the novel technique (Verigene BC-GN plus direct blood culture) across a healthcare system.

Methodology

This multisite, retrospective study compared patients with Gram negative bloodstream infection processed via novel technique (Verigene BC-GN plus direct blood culture) to patients with Gram negative bloodstream infection processed via Verigene BC-GN plus conventional microbiologic

methods. Primary outcome was time to targeted antibiotic therapy (TTAT) defined as time from initial positive blood culture collection to culture-driven adjustment in antibiotic regimen.

Secondary outcomes included duration of antibiotic therapy, hospital and ICU length of stay, infection-related readmission rate, in-hospital mortality, antibiotic-related hospitalization cost,

and total cost of hospitalization.

Results Pending

Conclusions Pending

Resident Amanda Haddad (amanda.haddad@hcahealthcare.com)

Co-Authors Abigail Antigua, Kathryn Hernando, Kayihura Manigaba

Practice Site North Florida Regional Medical Center

Abstract Title Impact of required electronic prompts for antibiotic indication and duration on length of

treatment in hospitalized patients with pneumonia

Background

The CDC Core Elements of Hospital Antibiotic Stewardship Programs recommends implementing policies to support optimal antibiotic prescribing including documentation of dose, duration, and indication. The study institution implemented new physician order entry screens in the electronic health record requiring indication and duration on all antibiotic orders. The objective of this study

is to determine if implementation of mandatory indication and duration prompts for antibiotic orders decreases antibiotic duration of therapy in hospitalized patients with pneumonia.

Methodology

This was a retrospective, pre-post, time-interrupted, quasi-experimental study. The pre-implementation study period included patients from March 1st, 2015 to November 30th, 2016,

and the post-implementation period included patients from March 1st, 2017 to November 30th, 2018. This study was determined to be Institutional Review Board (IRB) exempt after it was

submitted through the Centralized Algorithms for Research Rules on Exemption (CARRIE) system. Patients were identified using the clinical surveillance platform, and patient charts were reviewed in the electronic health record. Adult patients over 18 years of age with bacterial pneumonia who received antibiotic therapy for at least 48 hours were included. The Wilcoxon signed rank test will be used to measure continuous data. The primary endpoint was length of antimicrobial therapy for treatment of pneumonia. Secondary endpoints were 30-day all-cause in-hospital mortality, length of hospital stay, length of intensive care unit (ICU) stay, 30-day in-hospital readmission,

Clostridium difficile infection, antimicrobial resistance.

Results Pending

Conclusions Pending

Resident Kristin Hand (kristin.hand2@adventhealth.com)

Co-Authors

Practice Site AdventHealth Orlando

Abstract Title Appropriateness of choice and duration of antibiotics on discharge

Background

Patients will often have antibiotics initiated and completed when they are admitted. Data from literature studies in the time frame of 2006-2012 showed that at least 1 dose of antibiotic was given to 55% of hospitalized patients and about 75% of all hospital days involved antibiotics.

However, while transitioning to home antimicrobial therapy, some patients will be prescribed an unnecessarily long duration of antimicrobials compared to guideline recommendations upon discharge. Studies have shown that longer durations of antimicrobial therapy do not lead to

increased survival, reduced admissions, or repeated emergency department visits. In addition, longer durations can lead to higher resistance rates and significantly more adverse effects. The

purpose of this study is to illustrate the need for pharmacist intervention in the choice and duration of antimicrobials prescribed on discharge.

Methodology

Study design is a retrospective chart review of 7 campuses of AdventHealth Central Florida. Patients were included if they were at least 18 years of age, received a course of antibiotics while

in patient, were discharged on antibiotics and were diagnosed with one of the following infections: uncomplicated cystitis, uncomplicated pyelonephritis, community-acquired

pneumonia, hospital-acquired pneumonia, and Clostridioides difficile. Patients were excluded if they have an infectious diseases consult, were immunocompromised with HIV/AIDS, cancer, transplant, inherited diseases that affect the immune system, diabetes, or malnutrition, had

chronic kidney disease, were pregnant or if they did not clinically improve with the initial duration of antibiotics prescribed (febrile, elevated white blood cell count, or signs and symptoms of

infection still present despite antimicrobial therapy).

Results Pending

Conclusions Pending

Resident Kirstyn Hill (Kirstyn.Hill@LeeHealth.org)

Co-Authors Ashley Cubillos, Elisabeth Caulder, Catherine Guglielmo, Suzanne Turner

Practice Site Lee Health

Abstract Title Implementation of vancomycin dose adjustment by area under the curve (AUC) monitoring within a

291-bed community hospital

Background

An area under the curve to minimum inhibitory concentration (AUC/MIC) ratio of 400 to 600 mg-hr/L is associated with clinical efficacy and decreased rates of nephrotoxicity in Staphylococcus aureus and

Enterococcus species infections. The implementation of AUC-based monitoring requires a practice change from traditional trough-based monitoring and multidisciplinary education. The objective of

this project was to optimize safety and efficacy by implementing a vancomycin dosing by AUC monitoring program within a community hospital.

Methodology

Implementation of vancomycin dosing by AUC monitoring was a multi-step, pharmacy-driven initiative at a 291-bed hospital within a multi-site community health system. Project development tasks included obtaining buy-in and approval from several key stakeholders, including pharmacists

and infectious diseases physicians; the creation and validation of a spreadsheet-based dosing calculator; creation and delivery of education materials to pharmacy, nursing, phlebotomy, and

providers; and updates to the system-wide pharmacokinetic protocol. Outcomes and characteristics of patients dosed by AUC-based monitoring were then evaluated after program implementation.

Results Of 32 total patients, 20 (63%) had a therapeutic AUC on the first occurrence of pharmacokinetic drug monitoring. Sixteen of these 20 patients (80%) were able to avoid a vancomycin dose increase that

would have been required with trough-only monitoring. No patients experienced acute kidney injury.

Conclusions The transition from trough to AUC vancomycin monitoring is a multi-step process with many key

stakeholders and potential barriers.

Resident Vanessa Huffman (vhuffman@mhs.net)

Co-Authors Diana Carolina Andrade, Kyle Brown, Jared Ham, Alejandro Lopez Cohen, Leon Melnitsky

Practice Site Memorial Hospital West

Abstract Title Impact of nasal swabs on empiric treatment of respiratory tract infections (INSERT-RTI)

Background

Methicillin resistant staphylococcus aureus (MRSA) polymerase chain reaction nasal swabs (PCRNS) are a rapid diagnostic tool with a high negative predictive value. Infectious Disease

Society of America and American Thoracic Society guidelines state that a negative PCRNS suggests MRSA pneumonia is unlikely and anti-MRSA coverage unnecessary. Antimicrobial Stewardship Programs (ASP) utilizing PCRNS demonstrated reduced anti-MRSA antibiotic

exposure, length of stay (LOS), and cost without increased mortality.

Methodology

An ASP plus PCRNS bundle was implemented to educate clinicians on the utility of PCRNS for anti-MRSA therapy de-escalation in respiratory tract infections (RTI). A retrospective study was

conducted comparing adult patients diagnosed with RTI before and after "bundle"• implementation. The study included patients started on vancomycin/linezolid with a PCRNS

order. Pre and post groups were defined as 3 months before and after bundle implementation with a one month washout in-between. The primary objective was the difference in duration of anti-MRSA therapy (DOT) for RTI after bundle implementation. Secondary objectives included

hospital LOS, 30-day readmission, hospital mortality, and cost.

Results

62 of 110 patients analyzed were included, 20 in the pre-intervention and 42 in the post-intervention arms. Baseline characteristics were similar among groups. DOT decreased after

bundle implementation from 90 to 59.7 hours (p= 0.039); DOT for patients with a negative PCRNS decreased from 96.2 to 56.5 hours (p= 0.014). Median cost was lower after intervention [$51.69

versus $75.30 (p <0.01)].

Conclusions No significant difference in LOS, mortality, or readmission found. The implementation of an ASP

"bundle"• decreased vancomycin/linezolid exposure and cost without negatively impacting outcomes.

Resident Kortney Kelly (kortney.kelly@baycare.org)

Co-Authors Steve Nelson, Karin Thatcher, Jovino Hernandez

Practice Site Winter Haven Hospital

Abstract Title Reducing broad spectrum antibiotic utilization: impact of weekly pharmacist-led antimicrobial

stewardship meetings

Background

Antibiotic-resistant organisms are responsible for at least 23,000 deaths and 2 million infections annually in the United States. These infections are difficult to treat and typically require longer hospital stays, more expensive antibiotics and additional follow-up for the patient. The rise in

antibiotic resistance and need for diligent use of antimicrobial agents have urged for implementation of antimicrobial stewardship programs (ASPs). The Center for Disease Control

and Prevention (CDC) currently estimates that 30% of prescribed inpatient antibiotics are unnecessary although ASPs are customary in healthcare systems. The goal of this study was to

measure the additional impact of weekly pharmacist-led stewardship meetings on further reducing inappropriate antibiotic use in a healthcare setting with an established ASP.

Methodology

This single center, retrospective study included patients that were treated with a targeted broad-spectrum antibiotic. The targeted antibiotics included were intravenous vancomycin,

ciprofloxacin, levofloxacin, daptomycin, meropenem, linezolid, cefepime, ceftriaxone, and piperacillin/tazobactam. Weekly pharmacist-led antimicrobial stewardship meetings were

implemented to provide a forum for collaboration between pharmacists and infectious disease providers. Matched 6-month time periods prior to and following meeting implementation were analyzed. The primary outcome assessed was utilization of targeted broad-spectrum antibiotics

as measured by days of therapy (DOT) per 1000 patient days, prior to and following implementation of the meetings. Secondary outcomes included physician acceptance rate of

pharmacist recommendations and utilization of each individual targeted antibiotic prior to and following the intervention.

Results

Following meeting implementation, the monthly average utilization of targeted antibiotics was 754.64 DOT per 1000 patient days. This was a 15.1% increase from the pre-intervention average of 655.85 DOT per 1000 patient days. When comparing the two cohorts, a monthly increase of 98.8 DOT per 1000 patient days (95% CI 60.1 to 137.4, p-value 0.001) was observed. In terms of

each individual targeted antibiotic, utilization of cefepime, ceftriaxone, meropenem, and vancomycin increased (p-value 0.001, 0.036, 0.007, 0.039, respectively). Utilization of piperacillin-tazobactam decreased (p-value 0.043). Pharmacist antibiotic stewardship recommendations were accepted 95.52% of the time following the intervention, compared to 89.65% prior, a difference

of 5.88% (95% CI 3.18 to 8.57, p-value <0.001).

Conclusions

This study found that weekly, pharmacist-led antimicrobial stewardship meetings did not lead to a reduction in targeted broad-spectrum antibiotic utilization over a 6-month period. Following

implementation of the pharmacist-led meetings, provider acceptance rates of pharmacist recommendations were increased by 5.88%. Future studies should include addressing qualitative

measures of specific antibiotics and addressing appropriateness based on clinical context. Pharmacists should continue to be encouraged to make recommendations on antibiotic therapy

and increase prescriber awareness of pharmacy’s role in antimicrobial stewardship.

Resident Veronica Kim (minjung.kim@adventhealth.com)

Co-Authors Thang (Timmy) Do, Felix Sanchez

Practice Site AdventHealth East Orlando

Abstract Title 10 vs. 14 days of Clostridioides difficile infection treatment for first episode and impact on recurrence

Background

Clostridioides difficile infection (CDI) is a bacterial infection in the human intestinal tract that can occur after exposure to broad-spectrum antibiotics. Due to the spore-forming nature of the bacteria,

CDI is challenging to treat with high rates of recurrence. According to the 2017 Infectious Diseases Society of America guideline, first-line therapy for an initial episode of CDI is either vancomycin 125

mg orally four times per day or fidaxomicin 200 mg orally twice daily for 10 days. Treatment duration may extend to 14 days if patients have inadequate symptom resolution by day 10 of therapy. No

guideline recommendation is currently available on the duration of therapy in order to minimize the risk of first recurrence.

Methodology

The research design was a retrospective chart review study at 7 campuses of AdventHealth Central Florida. Patients age 18 years or older with first episode of CDI between January 1, 2017 and March 31, 2019 were assessed in this research. The primary objective was to compare the rate of 30-day

recurrence in patients who received oral vancomycin or fidaxomicin for 10 vs. 14 days. The secondary objectives were the rate of 60-day recurrence and the number of days to recurrence for up to 60 days

after the completion initial treatment.

Results

A total of 425 patients were evaluated and 67 patients met inclusion criteria. A total of 29 patients received vancomycin or fidaxomicin for 10 days, and 38 patients received therapy for 14 days. Between the two groups, there was no statistically significant difference in baseline

characteristics except for higher rates of cirrhosis in 10-day group. The 30-day recurrence was 1/29 (3.4%) in 10-day treatment group and 3/38 (7.9%) in 14-day treatment group. This data was

further analyzed using a two-tailed Fisher’s exact test, which showed no statistical significance with a p-value of 0.62. Recurrence between 31 to 60 days was 3.4% in 10-day group and 5.3% in 14-day

group. The average number of days to recurrence for up to 60 days was 17 days in 10-day group and 33 days in 14-day group. Although this study looked at both vancomycin and fidaxomicin therapy, 61/67 (91.0%) of patients received vancomycin as primary treatment regimen.

Conclusions

In conclusion, our findings suggest 30-day recurrence was not statistically significant in 10-day vs. 14-day therapy for patients with initial episode of CDI. We recommend determining the duration of therapy based on symptom resolution by day 10 of therapy and following the current guideline

recommendations.

Resident Brian Knott (brian.knott@adventhealth.com)

Co-Authors Dana Roth

Practice Site AdventHealth Altamonte Springs

Abstract Title Utilizing Verigene to optimize antibiotic selection in CTX-M and carbapenemase negative blood

cultures

Background

Due to the severity of bloodstream infections, the Verigene microarray platform is deployed to rapidly identify organisms and the potential mutations they harbor. Rapid identification can ensure appropriate antibiotic selection. CTX-M, the most common mutation which confers

extended-spectrum beta-lactamases (ESBL) in the organisms Proteus mirabilis, Escherichia coli, and Klebsiella pneumoniae, can be detected with Verigene. As other undetectable ESBL

mutations exist, questions remain regarding the safety of antimicrobial de-escalation if CTX-M is not detected. The evidence for utilization of Verigene for de-escalation of antibiotics prior to

susceptibilities is scarce and may not be generalizable to the local population. Current first-line therapy for ESBL-producing organisms are the broad-spectrum class of carbapenems. Selection of

the most narrowed-spectrum antimicrobial for treatment of bacteremia can reduce the development of resistance and reduce collateral damage. This analysis aims to identify the

percentage of non-CTX-M ESBL organisms and the negative predictive value of CTX-M detection by Verigene to gain insight into resistance patterns and guide prescribing of narrower spectrum

antibiotics at the initiation of therapy.

Methodology

This was a retrospective, single-center, seven-campus chart review. Adults (≥18 years old) with bloodstream infections caused by Proteus mirabilis, Klebsiella pneumoniae, and Escherichia coli

were included. Patient charts from January 1, 2019- June 1, 2019 were reviewed. A sample size of 200 patients was targeted. The primary outcome was the negative predictive value of Verigene

for the detection of CTX-M isolates. Secondary outcomes included the percentage of CTX-M, KPC, NDM, VIM, IMP, and OXA48 positive isolates and the potential number of days of anti-ESBL

therapy avoided.

Results

Of the 200 patients reviewed, 203 isolates of Proteus mirabilis, Klebsiella pneumoniae, and Escherichia coli were identified. The negative predictive value was 98.9%. Verigene was unable to detect resistant mutations in two isolates which demonstrated resistance to ceftriaxone. Overall the sensitivity, specificity, and positive predictive value were 92.3, 99.4%, 96% respectively. Of the 203 isolates, 25 (12.3%) were CTX-M positive, while one isolate demonstrated resistance to ceftriaxone without a detectable mutation. The remaining 177 (87.2%) isolates were ceftriaxone susceptible. No carbapenemase producing isolates were identified. 42 patients were included in

the secondary outcome for the potential number of days of anti-ESBL therapy avoided. The overall duration of anti-ESBL therapy that could have potentially been avoided was 34.0 days.

Conclusions

Among patients with bloodstream infections caused by the organisms Proteus mirabilis, Klebsiella pneumoniae, and Escherichia coli, Verigene was able to effectively identify ESBL-producing isolates. De-escalation of anti-ESBL antibiotics may be a feasible option upon organism and

mutation identification with the utilization of Verigene. Prospective studies are needed to fully assess the safety of this antimicrobial stewardship blueprint.

Resident Ashlan J. Kunz Coyne (ashlan.kunzcoyne@jax.ufl.edu)

Co-Authors Anthony M. Casapao, Carmen Isache, Yvette S. McCarter, James Morales, Christopher A. Jankowski

Practice Site UF Health Jacksonville

Abstract Title Influence of antimicrobial stewardship and molecular rapid diagnostic tests on optimal antimicrobial prescribing

for extended-spectrum beta-lactamase- and carbapenemase-producing bloodstream infections

Background

Molecular rapid diagnostic tests (mRDT) may help expedite the time to optimal antimicrobial therapy and lessen clinical and economic burdens related to extended-spectrum beta-lactamase (ESBL)- and carbapenemase-

producing bacteria. The greatest impact of mRDT appears to occur when the tests are implemented in combination with antimicrobial stewardship program (ASP) intervention. The purpose of this study was to

evaluate if the addition of mRDT to standard ASP practices (mRDT + ASP) decreased the time to optimal antimicrobial therapy for patients with ESBL- and carbapenemase-producing E.coli and K. pneumoniae BSI

compared to conventional microbiological methodologies and ASP intervention (CONV + ASP).

Methodology

Retrospective, parallel cohort study conducted at two academic medical centers from February 2012 through July 2019 evaluating the impact of an ASP with and without the presence of mRDT in hospitalized adult patients with ESBL- and carbapenemase-producing E.coli and K. pneumoniae BSI. Patients were included if they had a positive blood culture with E.coli or K. pneumoniae determined to be ESBL- or carbapenemase-producing by molecular

and/or traditional microbiology methods, and available susceptibility test results. Patients were excluded if they had a polymicrobial BSI, died before culture results, transferred–in from an outside facility with previously

identified positive blood cultures, were bone marrow/solid organ transplant recipients, or had cancer/febrile neutropenia. Primary outcome was time to optimal antimicrobial therapy defined as time from blood culture draw

to start of carbapenem therapy for ESBL-producing BSI and ceftazidime-avibactam or at least one drug active in-vitro that is the most-narrow spectrum for carbapenemase-producing BSI. Secondary outcomes include time to

microbial clearance defined as the time from index culture collection to the time of collection of the first negative blood culture or hospital discharge, all-cause hospital mortality, 30-, 60- and 90-day readmission rates, and

Clostridioides difficile rates. Descriptive statistics were performed between two ASP practices. Kaplan-Meier with log-rank for the primary outcome of time to optimal therapy and secondary outcome of time to microbial

clearance. Bivariate analysis with chi-square/Fisher’s exact test and Student t-test or Wilcoxon rank-sum for continuous variables, as appropriate. A p-value less than 0.05 was considered statistically significant.

Results

A total of 378 patients were included for evaluation. mRDT + ASP (n=164) and CONV + ASP (n=214) were balanced with respect to baseline characteristics: mean age (59.5 vs 62.9 years), female gender (43.3% vs 44.4%), presence

of beta lactam allergy (20.1% vs 16.4%), nursing home/long-term care residence (22% vs 19.2%), immunosuppressive medication (7.9% vs 6.1%) or surgical procedures within 30 days (20.7% vs 19.2%), gram-

negative infection within 6 months (48.2% vs 40.7%), history of ESBL or carbapenem-resistant Enterobacteriaceae infection (32.9% vs 29%), mean Pitt Bacteremia (3.1 vs 3.4), mean Charlson Comorbidity score (6.1 vs 5.5), and

incidence of hospital-acquired infection (51.2% vs 43.5%), respectively. Infectious diseases consults were significantly greater for CONV + ASP compared to mRDT + ASP (82.2% vs 34.8%; p<0.001). The most common BSI sources for mRDT + ASP and CONV + ASP were urinary (51.8% vs 45.8%) and intra-abdominal (12.6% vs 14.1%).

Overall, 89.7% of patients (339/378) received optimal antimicrobial therapy. When comparing mRDT + ASP (n=161) and CONV + ASP (n=178), there was a statistically significant decrease in both time to optimal

antimicrobial therapy (20.5 hrs [(IQR 17.0-42.2 hrs)] vs 50.1 hrs [(IQR 27.6-77.9 hrs)], respectively; p<0.001) (Graph 1) and time to microbial clearance (71.9 hrs [(IQR 54.1-108.5 hrs)] vs 91.2 hrs [(IQR 64.6-134.3 hrs)], respectively;

p=0.007) (Graph 2). No significant difference was detected for all-cause hospital mortality (8.0% vs 13.6%; p=0.088), 30-day (27.4% vs 20.1%; p=0.094), 60-day (36.6% vs 28.0%; p=0.093), 90-day (38.4% vs 31.8%; p=0.179)

readmission rates, or Clostridioides difficile rates (6.1% vs 3.3%; p=0.189).

Conclusions

Our study supports the clear benefit of mRDT + ASP intervention on shortening time to optimal antimicrobial therapy and microbial clearance in patients with ESBL- or carbapenemase-producing organisms in BSI compared to

CONV + ASP intervention. The use of mRDT + ASP was almost three times more likely to receive optimal antimicrobial therapy when compared to CONV + ASP. Limitations of this study include a retrospective design

lacking randomized data. Future studies should assess whether shorter time to microbial clearance translates to a shorter necessary duration of therapy, and a comparison of outcomes between carbapenem agents utilized as

optimal therapy for ESBL-producing organisms in BSI. ASPs can use these data to help justify the need for mRDT to quickly identify patients and promote optimal antimicrobial therapy in patients with ESBL- and carbapenemase-

producing E.coli and K. pneumoniae BSI.

Resident Kelsey Ladd (kladd@tgh.org)

Co-Authors Kristen Zeitler, Ripal Jariwala, Nicholas Piccicacco, Jose Montero

Practice Site Tampa General Hospital

Abstract Title Outcomes in Vancomycin-Resistant Enterococcus (VRE) Bacteremia with a Focus on Antibiotic

Therapy Choices at a Large Academic Medical Center

Background

Vancomycin-resistant Enterococcus (VRE) bacteremia is a life-threatening infection which is responsible for approximately 5,400 deaths annually in the United States. Due to limited

therapeutic options and high resistance rates, our study aimed to assess the clinical outcomes and antibiotic therapy strategies for this infection at our institution.

Methodology

This was a single-center, IRB-approved, retrospective study of patients with VRE bacteremia from January 2012 through December 2018 at an academic medical center. Patients with a diagnosis of

VRE bacteremia who received VRE-directed antibiotic therapy were included. Clinical outcomes including mortality, hospital and intensive care unit (ICU) length of stay, and rates of infection

recurrence were compared based on the VRE treatment agent utilized. Adverse effects warranting changes in antimicrobial therapy were also evaluated.

Results

The incidence of mortality in patients with VRE bacteremia was 32.5%, 23.1%, and 20% in those who received daptomycin, linezolid, and ampicillin, respectively (p = 0.574). Additional clinical outcomes including hospital and ICU length of stay, bacteremia duration, and rates of infection

recurrence were similar amongst treatment groups. Patients with Enterococcus faecium isolates had increased rates of ICU admission as well as higher daptomycin MIC values when compared to

other Enterococcus species.

Conclusions

No differences in clinical outcomes were seen among patients treated with daptomycin, linezolid, or ampicillin. While beta-lactam antibiotics may be an appropriate therapeutic option for

ampicillin-susceptible VRE isolates, Enterococcus faecium infections may warrant broader empiric antimicrobial therapy due to increasing rates of resistance.

Resident Jade Levy (levyj3@ccf.org)

Co-Authors Damien Alpizar, Khusbu Patel

Practice Site Cleveland Clinic Florida

Abstract Title Role of procalcitonin in the reduction of antibiotic days in hospitalized patients with pneumonia

Background

According to the CDC, one-third of antibiotic prescriptions in hospitals involve potential prescribing problems. Optimizing antibiotic use can be facilitated through the use of biomarkers

in a clinical infectious workup. The Infectious Disease Society of America (IDSA) currently recommends the use of procalcitonin (PCT) plus clinical criteria to guide the discontinuation of

antibiotics in hospital acquired pneumonia (HAP). For community acquired pneumonia (CAP), the 2019 IDSA guidelines do not provide recommendations on the use of PCT for the discontinuation of antibiotics. Several studies have demonstrated that incorporating PCT into decision making for

discontinuation of antibiotics resulted in reduced antibiotic exposure, without impacting treatment failure or mortality.

Methodology

This study is a single-center, chart review conducted on adult patients with hospital or community acquired pneumonia admitted between July 1, 2018 and July 31, 2019. Patients with

ventilator associated pneumonia, immunosuppressive therapies, and co-infections requiring prolonged antibiotic use were excluded. The study group includes those with two or more PCT

levels drawn during their stay, to assess for appropriate discontinuation of antibiotics. The control group consists of those who had zero or one PCT level ordered. The primary outcome is the mean

antibiotic duration in each group. Secondary outcomes include hospital length of stay, appropriateness of discontinuation of antibiotics based on PCT level trend, in-hospital mortality,

and readmission for a presumed respiratory tract infection diagnosis within 30 days.

Results

A total of 101 patients were included in the study, with 38 patients in the study group and 63 patients in the control group. Baseline characteristics were similar between the two groups. Approximately 87% of patients in each group had CAP, 6% had HAP, and 7% had aspiration

pneumonia. Of the comorbidities that affect PCT, the most common were acute kidney injury and chronic kidney disease in both groups. The primary outcome of mean antibiotic days was higher

in the study group (8.7 vs. 7.6 days; p=0.10). The median length of stay was significantly higher in the study group (6 vs. 3 days; p<0.0001). In-hospital mortality was numerically higher in the study group (7.9% vs. 1.6%; p=0.12). Lastly, readmission within 30 days for respiratory symptoms was

similar between the two groups (13.5% vs. 11%; p=0.72).

Conclusions

Patients with multiple PCT levels did not show a difference in duration of antibiotic therapy. This finding does not correlate with previous studies that demonstrate a shorter duration of therapy when PCT levels are incorporated into the clinical decision making process. However, it appears that those in the study group were more severely ill than the control group based on the higher rate of direct admission to the ICU and in-hospital mortality; this could have been a contributing factor to the numerically higher duration in the study group. Being a retrospective study, it was

assumed that the PCT levels were being used to guide the duration of antibiotic therapy. Overall, further education and research is required to determine the role PCT has in guiding antibiotic

therapy in pneumonia.

Resident Morgan Mannka (Morgan.Mannka@hcahealthcare.com)

Co-Authors Beatrice Armstrong, Joshua Gilmore, Steven Tran

Practice Site Putnam Community Medical Center

Abstract Title Impact of fluoroquinolone versus alternative monotherapy on treatment failure of urinary tract

infections at a small, rural community hospital

Background

Urinary tract infections (UTIs) are one of the most common bacterial infections encountered in both inpatient and outpatient settings, bringing them to the forefront of emerging antimicrobial

resistance. Fluoroquinolones have traditionally been an empiric regimen of choice amongst providers; however the overuse has contributed to high resistance rates. This study sought to observe if fluoroquinolone usage for UTIs versus alternative monotherapy negatively impact

patient readmission rates at a small, rural community hospital.

Methodology

This was a single-center, retrospective chart review conducted at Putnam Community Medical Center (PCMC). Subjects were randomized between two arms: levofloxacin monotherapy and

alternative agent monotherapy including nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin, and cephalosporins. Data was obtained from January 2016 to June 2019 using the

electronic medical record (eMAR) and diagnosis-related group (DRG) codes. The primary outcome of this study was to determine the effectiveness of levofloxacin versus alternative recommended

agents regarding treatment failure rates in non-intensive care (ICU) patients >18 years old diagnosed with a clinically-defined UTI. Patients were excluded if they were pregnant, had an indwelling catheter, recent urinary tract instrumentation three months prior to admission or

transferred to ICU within 24 hour of admission. Secondary outcomes include length of stay (LOS), antibiotic days of therapy (DOT) and days of intravenous (IV) antibiotics prior to de-escalation to

oral therapy.

Results Pending

Conclusions Pending

Resident Christina Marlowe (christina.marlowe@adventhealth.com)

Co-Authors Nam Vu, Issam McDoom

Practice Site AdventHealth Orlando

Abstract Title Daptomycin versus vancomycin for treatment of cellulitis in patients greater the 140 percent

ideal body weight

Background

The lipophilic properties of vancomycin allow for its accumulation in obese patients, making management in these patients more difficult. Serum vancomycin trough levels are more difficult

to predict, and the higher doses of vancomycin subject these patients to increased risk for adverse events such as nephrotoxicity. As there is limited evidence on daptomycin and

vancomycin in obese patients, this project seeks to determine which antimicrobial agent leads to greater clinical cure in patients >140% ideal body weight (IBW).

Methodology

Retrospective review of adult patients > 140% IBW being treated for cellulitis with either daptomycin or vancomycin using an electronic medical record report. Patients were excluded if they had ESRD on HD or PD, concomitant infection, line access issues, culture results positive for

pathogen known to be resistant, and known or suspected osteomyelitis or bacteremia. The primary endpoints of this study are clinical cure defined as resolution of signs/symptoms or

improvement such that no further antimicrobial therapy was necessary, and mg/kg dosing of daptomycin and vancomycin therapy. Secondary outcomes include microbiologic cure, adverse

events, trough levels, duration of therapy, change of antimicrobial agent, and readmission within 30 days. Baseline characteristics such as age, weight, height, percentage IBW, and concomitant

nephrotoxic medications were collected. All outcomes were reported using descriptive statistics. All study related information was collected and stored confidentially. No patient identifiers were

recorded.

Results Pending

Conclusions Pending

Resident Graciela Meshkalla (Graciela.Meshkalla@baycare.org)

Co-Authors William Braun, Tammy Pham, Kristen Hollingworth

Practice Site St. Anthony's Hospital

Abstract Title Comparison of vancomycin area-under-curve versus trough-based monitoring strategies: a

retrospective chart review

Background

Vancomycin is used empirically and for long-term treatment in patients with gram-positive infections, including those due to methicillin resistant Staphylococcus aureus (MRSA). Data shows

that area under the curve (AUC)-guided vancomycin monitoring has reported reduced drug exposure and nephrotoxicity when compared to traditional trough-based monitoring. In addition, due to the large amount of data supporting AUC-monitoring, guidelines are now recommending it

for serious MRSA infections. Vancomycin AUC-monitoring was implemented at St. Anthony’s Hospital in October 2019.

Methodology

This study is a retrospective chart review that evaluates patients admitted to St. Anthony’s hospital between January 1, 2019 and February 12, 2020, who were initiated on vancomycin

therapy before and after the implementation of AUC-guided vancomycin monitoring. The primary outcome is the time to therapeutic concentration of vancomycin indicated by a trough within

goal before the intervention and an AUC/MIC of 400-600 mg*hr/L post intervention. Secondary outcomes include differences in total daily dose of vancomycin, comparison of therapeutic

troughs, and incidence of acute kidney injury. Patients included were at least 18 years of age, treated with vancomycin for ≥ 48 hours, and had appropriately drawn levels. Patients were excluded if they received dialysis, were treated for cellulitis, or refused laboratory draws.

Results

The study included 97 patients in the trough-monitored group and 93 patients in the AUC-monitored group. The median time to therapeutic trough and AUC/MIC was 51.7 hours and 58.7 hours, respectively (p=0.965). The median total daily dose of vancomycin used was 2,500 mg for both groups (p=0.908). The median therapeutic trough was 16.9 in the trough-monitored group and 13.4 in the AUC-monitored group, (p<0.001). The median AUC in the AUC-monitored group

was 511. Acute kidney injury occurred in 14 patients in the trough-monitored group and 4 patients in the AUC-monitoring group (p=0.024).

Conclusions

This primary outcome of the study demonstrated there was no statistical difference in time to therapeutic concentration. The secondary outcomes showed there was no statistical difference in

total daily dosing but found AUC monitoring resulted in lower troughs and less acute kidney injury.

Resident Kevin Moore (Kevin.Moore2@baycare.org)

Co-Authors Jonathan Grey, Christopher Fronczek, Kerry Marr

Practice Site Mease Countryside Hospital

Abstract Title Impact of the BacT/Virtuo blood culture system on time to clearance of Staphylococcus aureus

bacteremia

Background

Blood stream infections (BSI) caused by Staphylococcus aureus correlate to high rates of morbidity and mortality. Current evidence demonstrates that timely diagnosis and treatment of BSI is critical to improving patient outcomes. Newer more sensitive culture mediums offer a shorter time to detection of organisms which can lead to patients receiving appropriate therapy sooner, however, their use may also lead to a longer time to blood culture clearance. If blood culture clearance time is increased due

to these more sensitive culture mediums and not a result of a persistent infection, this could inappropriately influence a prescriber's antibiotic selection and treatment duration. The purpose of this study is to determine if there is an increase in time to clearance Staphylococcal blood cultures

since implementing the resin based BacT/ALERT Virtuo within a large community health system compared to the charcoal based VersaTREK system used previously.

Methodology

This an IRB approved, retrospective cohort study. Patients admitted to Mease Countryside Hospital, Morton Plant Hospital or St. Joseph's Hospital from January 9th 2018-June 30th 2018 and from

January 9th 2019-June 30th 2019 that meet inclusion criteria were included in this study. The primary outcome was to determine if there was an increase in time to clearance for Staphylococcus aureus

bacteremia blood cultures after the implementation of the BacT/ALERT Virtuo blood culture system in comparison to the previous blood culture system, VersaTREK.

Results

371 patients were screened based on positive blood cultures for S. aureus, of which 277 met inclusion/exclusion criteria. There were 129 patients in the pre-implementation group and 148

patients in the post-implementation group that met inclusion/exclusion criteria and were analyzed per study protocol. Baseline characteristics in both groups were similar. The primary outcome (time to

blood culture clearance) was significantly longer in the post-implementation group compared to the pre-implementation group [median 3.95 (IQR 2.57 – 6.71) vs. median 2.18 (IQR 1.56 – 3.93) days, P <

0.001]. Length of stay was increased by a median of 2 days in the post-implementation group, although this difference was not statistically significant [median 12 (IQR 8 – 18.8) vs. median 10 (IQR 10 – 17.5) days, P = 0.25]. There was a statistically significant increase in therapy escalation for the

post-implementation group compared to the pre-implementation group [22.1% vs. 35.4%, P < 0.02]. Use of second line antibiotics for escalation in terms of days per 100 patient days was significantly

higher in the post-implementation group; ceftaroline by 11 days (P < 0.001), daptomycin by 10 days (P < 0.001), combination therapy by 12 days (P < 0.001). All-cause 30-day mortality was not statistically

significant between groups [10.2% vs. 6.1%, P = 0.22].

Conclusions

In conclusion, duration of Staphylococcus aureus bacteremia was 1.8 days longer when using a resin-based blood culture system (BacT/ALERT Virtuo blood culture system) compared to a charcoal-based

blood culture system (VersaTREK). This study also demonstrates that the duration of S. aureus bacteremia can impact length of stay and antibiotic selection. A patient’s clinical status should be considered before changing antibiotic therapy, rather than basing the decision to escalate therapy

solely on persistent blood culture results.

Resident Laila Najia (laila.najia@adventhealth.com)

Co-Authors Bibidh Subedi, Eric Pyles, Phillip Biddlecome

Practice Site AdventHealth Orlando

Abstract Title Anti-staphylococcal efficacy of cefepime, meropenem, and piperacillin-tazobactam in patients

with polymicrobial infections

Background

There is a paucity of literature describing de-escalation techniques in patients with polymicrobial infections or co-infection with one offending organism being methicillin-susceptible

Staphylococcus aureus (MSSA) treated with β-lactam monotherapy. Cefepime, meropenem, and piperacillin-tazobactam all represent later generation β-lactams that provide coverage to MSSA

and a wide spectrum of gram-negative organisms. The purpose of this study is to describe treatment outcomes for patients with polymicrobial infections with MSSA bacteremia or

pneumonia who are treated with cefepime, meropenem, or piperacillin-tazobactam.

Methodology

This is a retrospective cohort study including chart review of patients at a community teaching hospital system. Patients reviewed included those who had confirmed polymicrobial infections

including MSSA bacteremia or pneumonia and received definitive therapy with cefepime, meropenem, or piperacillin-tazobactam. The primary outcome is treatment success defined as

resolution of fever (initial measured temperature ≥ 100.4F) or hypothermia (≤ 95F), and leukocytosis (WBC >12,000 cells/mm3) or leukopenia (WBC <4,000 cells/mm3). Secondary

outcomes include duration of definitive therapy and if duration meets minimum standard from guidelines, in-hospital mortality, hospital and ICU length of stay, 30-day readmission rates for

presumed infectious causes, and hospital acquired Clostridioides difficile infection.

Results Pending

Conclusions Pending

Resident Julia Nash (julia.nash@tmh.org)

Co-Authors Kelly Rodrigue

Practice Site Tallahassee Memorial Healthcare

Abstract Title Efforts to reduce healthcare facility-onset Clostridioides difficile infections by a pharmacist-led

interdisciplinary team

Background

Clostridioides difficile infection (CDI) is the most common hospital-acquired infection in the United States, creating an estimated $4.8 billion in extra inpatient costs annually by increasing length of stay, morbidity, and mortality. Risk factors include antibiotic use, older age, recent GI

surgery, immunosuppression, and healthcare exposure. IDSA/SHEA’s 2018 CDI guidelines no longer recommend oral metronidazole for treatment of CDI, instead recommending oral

vancomycin or fidaxomicin first-line for any severity of infection. Antimicrobial stewardship, in addition to proper hand and environmental hygiene, is paramount in preventing healthcare

facility-onset CDI (HO-CDI), defined as a diagnosis after 48 hours of admission. TMH had 61 HO-CDI cases in 2018 (21.6% of total CDI cases) which increased to 74 cases in 2019 (29.3% of all CDI.)

The project’s purpose was to implement quality improvement practices identified from cases at TMH to reduce HO-CDI.

Methodology

This was a quasi-experimental quality improvement project conducted at Tallahassee Memorial HealthCare. Subjects included had a positive C. difficile PCR on or after day 3 of admission. Data

was obtained via the electronic medical record. Root-cause analyses were completed by a pharmacist, nurse, and infection preventionist for each case of HO-CDI. Multidisciplinary

meetings were held to discuss findings and consider interventions. The oral vancomycin order sentences in CPOE were updated to align with guideline recommended doses. The hospitalist group was inserviced highlighting the project’s findings and the importance of antimicrobial

stewardship in preventing these infections. The primary objective was to decrease the incidence of HO-CDI at TMH. A secondary objective was to optimize overall CDI management for all patients

at TMH.

Results

The proportion of total CDI cases that qualified as HO-CDI decreased slightly in the post-intervention period (24.3% vs. 27.1%). As a secondary outcome, the treatments used for HO-CDI were more likely to adhere to guideline recommendations in the post-intervention period (100% vs. 53.8%), duration of antibiotic therapy prior to CDI onset decreased (6.4 vs. 7.8 days), and the

overall length of stay for HO-CDI patients decreased (18.1 vs. 26.0 days).

Conclusions

Multidisciplinary efforts between pharmacy, nursing, and infection prevention appear to have been successful in decreasing the rate of HO-CDI and improving overall management of CDI in the

hospital setting. However, it should be noted that changes in the hospital census and infection prevention measures may have affected these results. Future interventions aim to include the

addition of electronic alerts regarding laxative administration or past C. difficile infection when C. difficile screens and broad-spectrum antibiotics are ordered, respectively.

Resident Mark Nazareno (nazareno.mark@mayo.edu)

Co-Authors Christine Lally, Kevin Epps, Wendelyn Bosch, Julio Mendez

Practice Site Mayo Clinic Florida

Abstract Title Risk factors and prevalence of drug resistant cytomegalovirus (CMV) infection in solid organ

transplant recipients

Background

Resistant cytomegalovirus (CMV) infection negatively impacts survival outcomes and increases the risk of both allograft rejection and death in transplant patients. Known risk factors for CMV infection include serological mismatch and intense immunosuppression. Valganciclovir (VGCV)

and ganciclovir (GCV) are foundational antiviral agents for CMV infection prophylaxis. Identifying potential risk factors for resistant CMV, including the emergence of new predisposing factors,

may assist in dose optimization of chemoprophylaxis and reduce initial treatment failure.

Methodology

This study was an IRB approved retrospective, observational chart review conducted at Mayo Clinic health systems that evaluated CMV infections occurring between 2008 and 2018. The primary patient list was generated using the CMV diagnosis codes and another report was created using lab codes utilized for resistant CMV testing. Resistant CMV was defined as a positive result on the resistance testing or treatment with high dose ganciclovir, foscarnet,

letermovir, cidofovir, or cytomegalovirus immune globulin after CMV diagnosis during the study period. Analysis of patient characteristics was completed to identify risk factors. Comparison of

the resistant CMV group with the total CMV group identified the incidence rate and prevalence of drug resistant CMV. The primary outcome was the association of individual risk factors or renal dose adjustments of prophylaxis and the development of resistant CMV. Secondary outcomes

include the incidence rate and prevalence of resistant CMV at Mayo Clinic sites.

Results

There were 1591 total CMV cases identified between the practice sites. The analysis identified 34 total resistant cases from these sites during the study period. The prevalence of resistant CMV

between all sites was 2.14% (34/1591). The calculated incidence rate of resistance was 3.4 cases per year. The most common transplanted organs in the resistant cases were kidney and lung. The transplanted kidney group was divided into deceased, living related or living unrelated categories and had 17 total kidneys among the sites. The Rochester site had the most resistant cases overall

(N=14). Arizona had 41.2% of all the resistant cases with a transplanted kidney. The resistant cases with lung transplants (N=9) accounted for 26.5% of the total and were exclusively from the

Florida site.

Conclusions

Resistant CMV remains a threat to solid organ transplant recipients despite a low prevalence and incidence rate. Potential factors which may increase resistant CMV risk include: lung or kidney

transplantation and renal dose adjustments of the CMV prophylaxis regimen. Additional research is warranted to validate these risk factors and optimize renal dose adjustments.

Resident Amber Newell (newell.amber@mayo.edu)

Co-Authors Susan Dodge

Practice Site Mayo Clinic Florida

Abstract Title Bacitracin irrigation prophylaxis to reduce surgical site infections in neurosurgery patients

Background

Antimicrobial stewardship programs (ASPs) have an increasing presence in the inpatient setting, as The Joint Commission (TJC) and Center of Medicare and Medicaid Services (CMS) mandates the

development of such programs. The use of antibiotics is often monitored due to the increasing resistance rates globally. Specifically highlighting the use of antibiotics utilized intraoperatively, many concerns in regard to appropriateness of use as well as sterilization of compounding may

warrant further investigation. Notably in surgical settings, antibiotic irrigations are used to distinctively control source of infection prior to closure of the surgical site. Often times the utilization of these antibiotics are unmonitored for efficacy and require little oversight for

immediate-use.

Methodology

This study was an Institutional Review Board approved retrospective, observational chart review of patients who underwent select neurology surgeries including laminectomy, discectomy, spinal

fusion, and craniotomy from 12/01/2018 to 4/1/2019. Electronic medical records of patients meeting all inclusion criteria were obtained from Mayo Clinic Jacksonville, FL. The primary

objective of this study was to compare the incidence of surgical site infections between patients after neurology surgery who received intraoperative bacitracin irrigation prophylaxis (bacitracin group) compared to those who did not (control group). Secondary outcomes included infection

rate comparisons of patients who received preoperative compounded bacitracin irrigation under USP 797 requirements versus immediate-use preoperative compounded bacitracin irrigation,

hospital length of stay, and rate of readmissions.

Results

After a retrospective observational review of patient charts from 12/01/2018 to 4/1/2019, 109 patients met inclusion criteria with 61 patients meeting criteria for the bacitracin irrigation group and 48 patients meeting criteria for no antibiotic irrigation group. There was 1 incident of surgical site infections (SSI) in the bacitracin group and no SSIs in the control group (p value 0.37). The one

documented incident of SSI in the bacitracin group was compounded under USP 797, and the non-USP compounded irrigation group did not have any documented SSIs (p value 0.79). Hospital length of stay for the bacitracin group was 2.9 ± 4.9 and 2.8 ± 2.955 in the control group (p value

0.90).

Conclusions

Bacitracin antibiotic irrigations in the setting of neurosurgery were not associated with a significant difference in SSIs. There is inadequate evidence to support routine use of topical or

local antimicrobial agents. With consideration of the uncertainty of trade-offs between the benefits and harms of intraoperative bacitracin irrigation, the FDA has concluded that there is no

use for bacitracin in the market.

Resident Damarys Padilla (Damarys.Padilla@nchmd.org)

Co-Authors Justin Immerman

Practice Site NCH Healthcare System

Abstract Title Timing and weight-based dosing assessment of preoperative antibiotic prophylaxis in a

community healthcare system

Background

The American Society of Health-System Pharmacists, Infectious Disease Society of America, Surgical Infection Society, and Society for Healthcare Epidemiology of America Clinical Practice

Guidelines for Antimicrobial Prophylaxis in Surgery define the appropriate timing of administration of preoperative antibiotics to prevent surgical site infection and related morbidity

and mortality. This quality improvement project reviewed the administration of preoperative antibiotic prophylaxis within a community hospital.

Methodology

Following IRB approval, approximately 200 patient charts from October through December 2019 were retrospectively reviewed to identify fallouts in preoperative antimicrobial administration. A fallout was defined as a lack of documented antimicrobial administration 30 to 60 minutes before

surgical incision. Additionally, pre-incision weight-based doses of antibiotics were collected to determine appropriateness. The primary endpoint was the total number of patients who were

considered fallouts relative to the total number of patients included in the analysis. The secondary endpoint was the assessment of weight-based dosing of preoperative antibiotics. An

educational tool and in-service were developed to improve preoperative antimicrobial management with regards to dose and administration time. Lastly, a pre- and post-survey were

administered to relevant stakeholders to assess knowledge of preoperative antimicrobial administration.

Results Pending

Conclusions Pending

Resident Kunal Patel (kunal.patel@hf.org)

Co-Authors Joseph Bratsch, Jay Pauly, Michael Sanchez

Practice Site Health First Holmes Regional Medical Center

Abstract Title Ciprofloxacin plus metronidazole compared to beta-lactam based regimens for complicated intra-

abdominal infections: a multi-center study

Background

Previous studies in the early 2000s report that ciprofloxacin plus metronidazole is equivalent to beta-lactam therapy in terms of clinical response in treating complicated intra-abdominal

infections. Due to the rising resistance rates of Escherichia coli to fluoroquinolones, the use of ciprofloxacin plus metronidazole compared to beta-lactam therapy needs to be reassessed. The

purpose of this study was to compare clinical response for the use of ciprofloxacin plus metronidazole versus beta-lactam therapy in patients with complicated intra-abdominal

infection.

Methodology

This multi-center, retrospective study included adult patients treated for complicated intra-abdominal infection in a health system consisting of three community hospitals and a tertiary

level II trauma center. Patients were included with all relevant ICD10 and DRG codes for complicated intra-abdominal infections. Chi-squared analyses, t-test, and multivariate logistic

regression were used to assess the primary outcome of clinical response between the two groups.

Results

Of the 961 patients assessed from May 2016 to May 2019, 224 patients met the inclusion criteria. Beta-lactam antibiotics were associated with statistically significant higher clinical cure rates than

ciprofloxacin plus metronidazole (97.3% vs. 90.2%; p<0.05). The average length of stay was statistically higher in beta-lactam therapy compared to ciprofloxacin plus metronidazole (5.03

days vs. 4.36 days; p<0.05).

Conclusions

Results from this study suggest that beta-lactam antibiotics may be superior to quinolone-based regimens for complicated intra-abdominal infections, in terms of clinical cure. Lower rates of clinical cure in quinolone-based regimens can be explained by increasing rates of quinolone-

resistant Escherichia coli.

Resident Srujay Patel (Srujay.Patel@orlandohealth.com)

Co-Authors Janessa Smith, Shauna Junco

Practice Site Orlando Health

Abstract Title Adherence to updated surgical site prophylaxis guidelines for colorectal surgery and association with

surgical site infection rates

Background

The surgical site infection (SSI) rate for colorectal procedures at Orlando Regional Medical Center (ORMC) was 4.71% in 2018, which was higher than the national average. In January 2019, ORMC changed the

recommended pre-operative prophylaxis regimen for colorectal procedures from cefoxitin to cefazolin plus metronidazole, the latter of which was recommended to be given as a 10-minute infusion. The goal of this

study is to assess adherence to the updated guidelines and whether adherence is associated with lower rates of SSI.

Methodology

This is a retrospective chart review of adults identified by ICD-10 codes for colorectal surgery at an 800-bed teaching hospital from March through December 2019 who did not receive antibiotic treatment for an

infection before or within 24 hours of surgery. The primary outcome is percentage of colorectal surgery cases adherent to ORMC's antibiotic prophylaxis guidelines as defined by a composite of adherence to the

choice of agent, dose, and time of administration prior to incision. Secondary outcomes include SSI rate among cases adherent versus non-adherent with the composite and individual components of adherence, among cases that did and did not receive redosing during the procedure, among cases that did and did not

receive post-procedure prophylaxis, association of reported allergies to selection of prophylaxis agents, and to assess adverse effects attributed to metronidazole infusions. Logistic regression analysis will be

performed, with SSI being the dependent variable, to identify risk factors with strong correlation to presence of SSI.

Results

This study screened 319 colorectal cases; 206 met inclusion criteria and six (2.9%) reported SSI within 30 days of procedure. Twenty cases had reported allergies to penicillin with most (90%) non IgE-mediated. All cases had available data to assess adherence to IV prophylaxis. Only 63 cases were able to be assessed for

adherence to composite prophylaxis since oral prophylaxis is given for 24 hours prior to surgery and outpatient medication history was not completed for all patients. Of these, 48 cases were able to be

assessed for adherence to oral prophylaxis and 15 emergent cases were unable to receive oral prophylaxis. For the primary outcome, 34/63 (54%) evaluable cases were adherent to all components of antibiotic

prophylaxis. Adherence to oral prophylaxis was 35/48 (72%). Adherence to all aspects of IV prophylaxis was 117/206 (57%), with adherence to individual components higher: agent choice 172 (83%), dose 193

(94%), and time of administration 135 (66%). No statistical difference in SSI rate was found for cases adherent vs. non-adherent to composite prophylaxis (p=0.922), oral prophylaxis (p=0.276), IV prophylaxis

(p=0.733), intra-operative redosing (p=0.155), or cases receiving post-operative prophylaxis (p=0.310). There were no reported adverse events related to metronidazole infusion rate. Non-adherence to

preferred regimen of cefazolin plus metronidazole was 65% in cases with reported penicillin allergies vs. 11.4% in cases without reported penicillin allergy (p=<0.0001). Logistical regression analysis identified pre-operative hyperglycemia (BG > 180mg/dL) (OR 19.56, 95% CI: 2.00-191.25, p= 0.011) and surgical wound

class IV (dirty) (OR 18.09, 95% CI 1.60 – 205.13, p= 0.019), but not adherence to IV prophylaxis, to be significant predictors of SSI.

Conclusions

Time of administration was the most common reason for non-adherence to guideline recommendations at our institution and reported penicillin allergy was associated with a significantly higher use of agents other than cefazolin plus metronidazole. This study failed to identify a difference in SSI rate in cases adherent vs.

non-adherent to several aspects of recommended prophylaxis; however, this study was likely underpowered to find a difference as SSI rates were lower after implementation of the new guideline.

Findings from this study will allow for targeted monitoring and education to improve adherence to time of prophylaxis administration prior to procedure, appropriate prophylaxis agent selection for cases with

reported penicillin allergies, and management of pre-operative hyperglycemia, all of which are modifiable or potentially modifiable risk factors that have been shown to decrease risk of SSI in adequately powered

studies.

Resident Tu Phan (Tu.Phan@baycare.org)

Co-Authors Somer Slappey, Jovino Hernandez

Practice Site Winter Haven Hospital

Abstract Title Optimization of antibiotic therapy for acute bacterial skin and skin structure infections through pharmacist-

driven rapid MRSA PCR testing

Background

Methicillin-resistant Staphylococcus aureus (MRSA) is identified as the most frequent cause of acute bacterial skin and skin structure infections (ABSSSIs) among patients presenting to emergency departments

in the US. The most common pathogen causing purulent ABSSSIs is Staphylococcus aureus, either methicillin-susceptible (MSSA) or MRSA. 90% of the patients hospitalized with ABSSSIs were treated with anti-MRSA

agents empirically. Of these, only 43% had positive MRSA cultures. The objective of this study was to evaluate the effectiveness of pharmacist-driven MRSA/SA (MRSA/MSSA) wound PCR testing in decreasing

the use of anti-MRSA antibiotics and providing targeted initial antimicrobial therapy in patients with purulent ABSSSIs.

Methodology

This was a single-center, retrospective and prospective study conducted at a community hospital. Eligible participants were patients who were at least 18 years of age and admitted with a diagnosis of a purulent ABSSSI. The key exclusion criteria included patients with admission to the intensive care unit, history of

severe beta lactam allergy, presence of an additional site of infection requiring treatment (eg, pneumonia), presence of recurrent abscess(es) which was treated medically or surgically prior to admission, history of a

surgical site or post-procedural infection, and history of MRSA. In the retrospective control group, screening was conducted in reverse chronological order from August 1st, 2018 to July 31st, 2019 to include an equal number of patients in each arm. The prospective intervention group were patients with MRSA/SA wound PCR results admitted from September 1st, 2019 to February 29th, 2020. The intervention of the study was

the pharmacist-led MRSA/SA wound PCR testing which began in August 2019. Data collection was performed through systematic review of electronic medical records of patients with purulent ABSSSI in order to obtain patient demographic data and to evaluate eligibility for inclusion. The primary outcome was the duration of anti-MRSA antibiotic use for purulent ABSSSI. The secondary outcomes were the proportion of discordant antibiotic use, duration of antibiotics, hospital length of stay, 30-day hospital readmission rates, and the

incidence of antibiotic-associated adverse events. A sample size of 26 in each arm was calculated based on an 80% power, with a two-sided alpha level of less than or equal to 0.05 to detect a 40-hour difference in the

primary endpoint. The Mann-Whitney test with a p-value of 0.05 was utilized to evaluate the median duration of anti-MRSA antibiotics between the retrospective control and prospective intervention groups.

Baseline demographics and other outcomes were analyzed using the Mann-Whitney test for continuous data and the Fisher’s exact test were utilized for discreet data.

Results

A total of 1042 patients were assessed, and 54 patients were included (27 in each group). Baseline demographics were similar between groups. The median duration of anti-MRSA antibiotics was 23.5 hours

less in the prospective intervention group vs the retrospective control group (50 hours vs 73.5 hours, p=0.013). The proportion of discordant antibiotic use was less in the prospective intervention group vs the

retrospective control group (51.8% to 81.5%, p=0.039), with all patients positive for MRSA receiving appropriate antibiotics. The median duration of all antibiotics was reduced by 2 days in the prospective intervention group vs the retrospective control group (p=0.018). Hospital length of stay was significantly

reduced from 5 days to 4 days (p=0.032) in the prospective intervention group. 30-day readmission rates and antibiotic-associated adverse events were similar between the two groups. The strengths of this study include similarities between groups in type and severity of ABSSSIs and other baseline demographics.

Another strength is that a washout period of 1 month was included to affirm the effects seen were attributable to the intervention. There are a few limitations that must be considered when evaluating the

results of this study. First, this is a single-site with a small sample size, thus limiting its generalizability. Second, there is potential for physician reluctance to discontinue anti-MRSA antibiotics despite PCR results. Third, there is variation in frequency and timing of PCR ordering among pharmacists as they are required to actively identify all patients with purulent wounds and ensure PCR tests are ordered. Lastly, there was no

assurance of appropriate wound PCR collection technique, which could affect the accuracy of the test.

Conclusions Duration of anti-MRSA antibiotics and the proportion of discordant antibiotic use for purulent ABSSSIs were

significantly improved through pharmacist-driven rapid MRSA PCR testing.

Resident Sarah R. Piccuirro (sarah.piccuirro@jax.ufl.edu)

Co-Authors Christopher Jankowski, Alyssa Claudio, Carmen Isache, Anthony Casapao

Practice Site UF Health Jacksonville

Abstract Title Comparison of acute kidney injury in patients prescribed vancomycin in combination with

piperacillin-tazobactam or cefepime for diabetic foot infections

Background

Although recent studies have concluded that concomitant therapy with vancomycin (VAN) and piperacillin-tazobactam (PTZ) may be associated with higher rates of acute kidney injury (AKI)

compared to other beta-lactam combinations, diabetic patients may be more susceptible to AKI due to many factors. The purpose of this study is to determine whether an empiric regimen of PTZ and VAN or cefepime (CFP) and VAN would be favored in patients treated for diabetic foot

infections (DFI) based on incidence of AKI.

Methodology

This was an observational, retrospective, cohort study conducted at UF Health Jacksonville between February 1, 2012 and November 30, 2019. The primary endpoint was the incidence of

AKI in patients receiving VAN + PTZ compared to VAN + CFP for the treatment of DFIs. Secondary endpoints include time to AKI from antibiotic initiation, severity of AKI, requirement of dialysis,

length of stay, readmission due to AKI, and total hospital charges.

Results

Among 356 patients screened for inclusion, 210 were analyzed. 49 of 140 patients (35%) in the VAN + PTZ group and 5 of 70 patients (7.14%) developed AKI according to the AKIN criteria (odds

ratio, 7.00 [95% CI, 2.64 to 18.53], P < 0.0001). After adjusting for potential sources of bias through logistic regression, VAN + PTZ was an independent predictor of AKI (odds ratio, 6.37 [95%

CI, 2.38 to 17.07], P < 0.0001).

Conclusions VAN + PTZ was associated with an increased rate of AKI compared to VAN + CFP in patients

treated for DFI.

Resident Naomi N. Pierre (pierren@ccf.org)

Co-Authors Nina Joiner, Jillian Dietz

Practice Site Cleveland Clinic Florida

Abstract Title Effectiveness of low dose valganciclovir for cytomegalovirus prophylaxis in liver transplant

recipients

Background

Solid-organ transplant recipients are at an increased risk for opportunistic infections due to the use of potent immunosuppressants to reduce the risk of rejection. Guidelines recommend a

target dose of valganciclovir 900 mg daily for cytomegalovirus (CMV) prophylaxis. Some centers use a reduced dose of 450 mg daily in liver transplant patients, as they are thought to be at a

lower risk of infections due to a lower utilization of induction therapy and with decreased immunosuppression dosing. Evidence supporting reduced dose of valganciclovir is limited. At

Cleveland Clinic Weston (CCW), liver transplant recipients received the standard-dose of 900 mg daily (adjusted for renal function) from program inception in 2013 until 2018, where the protocol was implemented to target a low-dose of 450 mg daily (adjusted for renal function). The objective

of this study was to compare the rates of CMV viremia in liver transplant patients who receive standard-dose compared to low-dose of valganciclovir.

Methodology

A retrospective chart review was conducted on liver transplant recipients at CCW. The study included all patients who received valganciclovir for CMV prophylaxis from January 2013 to

January 2019. Patients who received other agents for antiviral prophylaxis, those who underwent multi-organ transplants, or those who underwent retransplants were excluded. The primary

efficacy outcome was the incidence of CMV viremia within 12 months. The primary safety outcome was the incidence of leukopenia between 1 and 6 months post-transplant.

Results

A total of 188 patients were included in this study; 140 received a standard-dose of valganciclovir (900 mg, adjusted for renal function) and 48 received a low-dose of valganciclovir (450 mg,

adjusted for renal function). Patients in the low-dose group received prophylaxis therapy for approximately one month less than patients in the standard-dose group. In addition, they were

more likely to have received induction therapy and had lower kidney function. The primary outcome of CMV viremia was 5.7% and 16.7% in the standard-dose group and low-dose group

respectively (p = 0.02). A subgroup analysis revealed that 37.5% of patients with the outcome of CMV viremia received induction therapy in the standard-dose group, compared to 0% in

standard-dose group. The incidence of leukopenia was similar in both groups at 72.9% and 81.9% respectively (p = 0.25). The incidence of other opportunistic infections was lower in the standard-

dose group than in the low-dose group, at 12.1% and 27.1% respectively (p = 0.01). All other secondary outcomes including incidence of thrombocytopenia (mild and severe), allograft loss within 6 and 12 months, mortality at 6 and 12 months, and death-censored allograft survival,

were all similar in both groups.

Conclusions

This study shows that the use of low-dose valganciclovir in liver transplant patients may not be as effective in preventing CMV viremia compared to standard-dose, and that there is no benefit in

terms of risk for leukopenia. However, patients in the low-dose group experienced a higher incidence of opportunistic infections. The current data suggests that an institutional protocol

change to standard-dose valganciclovir may be necessary for centers like CCW, where the low-dose of valganciclovir is used for CMV prophylaxis in liver transplant patients. Limitations of this

study includes retrospective design, mismatched sample sizes, inability to collect patient compliance information, and inconsistent frequency of laboratory monitoring among patients.

Resident Steven Reynolds (Steven.Reynolds@LeeHealth.org)

Co-Authors Alvaro Beltran, Elisabeth Caulder, Edgar Turner, Suzanne Turner

Practice Site Lee Health

Abstract Title Adjunctive use of intravenous tigecycline in patients with severe Clostridioides difficile infections (CDI)

Background

C. difficile remains one of the most commonly identified causes of health-care associated diarrhea. Tigecycline is a protein synthesis inhibitor that has strong in vitro antimicrobial activity against C.

difficile. According to the IDSA guidelines, intravenously administered tigecycline has been used as adjunctive therapy in patients not responding to vancomycin and metronidazole, but conclusive clinical trials are lacking. Previous retrospective cohort studies have found higher rates of overall

clinical cure when using tigecycline while other studies found no significant difference compared to standard treatment. The objective of this project is to evaluate the clinical efficacy of adjunctive tigecycline in patients with severe CDI compared to standard of care (SOC) within a multicenter

community health system.

Methodology

This study was a retrospective cohort study performed at Lee Health in Fort Myers and Cape Coral, FL comparing the use of adjunctive tigecycline intravenous versus SOC in patients with severe CDI. Adult

patients admitted between January 2015 through August 2019 were identified for inclusion by tigecycline administration and positive C. difficile results. Patients were matched 1:1 (tigecycline: standard of care) according to age, ICU admission, fulminant CDI and ATLAS score. The primary

outcome of this study was initial clinical cure, defined as resolution of CDI symptoms requiring no additional SOC treatment beyond 14 days (excluding tapering and pulsed doses of oral vancomycin)

and no in-hospital mortality. Secondary outcomes included in-hospital, 30-day and 90-day recurrence, in-hospital and 90-day all-cause mortality and colectomy rates.

Results

A total of 146 patients with severe CDI were included in the unmatched analysis and 50 patients in each group were matched using propensity scoring. There was no significant difference in initial

clinical cure for the matched groups of adjunctive tigecycline vs SOC (24% vs 42%; p = 0.06). For the matched secondary outcomes, there was no significant difference for in-hospital recurrence (6% vs 0%; p = 0.23), 30-day recurrence (8% vs 8%; p = 0.67), 90-day recurrence (10% vs 10%; p = 0.67), in-hospital mortality (6% vs 4%; p = 0.57), 90-day mortality (4% vs 8%; p = 0.57) and colectomy (6% vs

4%; p = 1.00).

Conclusions In patients with severe CDI receiving adjunctive tigecycline, there was no difference in efficacy in any

measured outcome compared to SOC alone. There is insufficient evidence to recommend the addition of tigecycline to SOC for patients with severe CDI.

Resident Julia Sikorski (julia.sikorski@va.gov)

Co-Authors Joseph Hong, Victoria Koenig, Peter Pasek

Practice Site Bay Pines VA Healthcare System - Bay Pines

Abstract Title Impact of the BioFire FilmArray Gastrointestinal Panel on antimicrobial stewardship in Veterans

with suspected infectious diarrhea

Background

Acute gastroenteritis (AGE) is currently one of the leading causes of death worldwide. AGE may be viral, bacterial or parasitic in etiology. Most cases of infectious diarrhea in adults are self-

limiting and resolve with symptomatic care alone. However, it is not uncommon for providers to initiate antibiotics pending further clinical workup. The difficulty of isolating causative infectious

agents in AGE may contribute to excessive empiric antibiotic utilization. The availability of molecular tests such as BioFire FilmArray Gastrointestinal (GI) Panel may help recognize bacterial,

viral, or parasitic pathogens.

Methodology

This is a single-center pre- and post-intervention study conducted at Bay Pines Veterans Affairs Healthcare System. Antibiotic avoidance will be compared between patients receiving BioFire

FilmArray GI Panel testing versus usual stool diagnostic assays (i.e., fecal leukocytes, stool culture, or Ova and Parasite screen). Data was obtained between October 2018 to March 2019 and

October 2019 to March 2020 for the pre- and post-intervention groups respectively. The primary outcome was to determine differences in antibiotic avoidance rates between patients receiving BioFire FilmArray GI Panel testing versus usual stool diagnostic assays. Antibiotic avoidance was

defined as early discontinuation or deferral of antibiotic therapy. Mean duration of antibiotic therapy and time to antibiotic discontinuation, adjustment, and initiation were collected if

indicated. Secondary outcomes include differences in length of hospital stay, mortality, microbiological yield, and mean time to test results.

Results Pending

Conclusions Pending

Resident Julio C. Simon (julio.simon@jhsmiami.org)

Co-Authors Ana D Vega

Practice Site Jackson Memorial Hospital

Abstract Title Antimicrobial Stewardship and Its Impact on Fluoroquinolone Prescribing Patterns

Background

Fluoroquinolones are an effective class of antimicrobials; however, their use is not without consequence. Recent warnings have led to the recommendation by the FDA to reserve this class of antimicrobials for cases lacking alternative treatment options. Antimicrobial stewardship has been shown to significantly reduce targeted antimicrobial use, improve susceptibility patterns,

decrease superinfection rates and reduce healthcare-associated costs. Literature on fluoroquinolone stewardship by antimicrobial stewardship programs report similar outcomes

with reduced fluoroquinolone use, Clostridium difficile infection (CDI), extended-spectrum beta-lactamase (ESBL)-producing and methicillin-resistant S. aureus (MRSA) infection.

Methodology

This retrospective cohort study consisted of a two-phase chart review of fluoroquinolone orders. Adults receiving at least 3 days of a fluoroquinolone for either pneumonia or urinary tract

infections were identified through a clinical surveillance program and included. Orders were assessed for prescribing patterns, appropriateness of duration of therapy and antibiotic choice by

indication. The primary outcome was reduction of fluoroquinolone days-of-therapy (DOT) over both phases. Secondary outcomes included hospital length-of-stay (LOS), 3-month post-exposure

rates of CDI and MDR infection, proportion of interventions accepted, and events of QT prolongation.

Results

A total of 333 cases were reviewed. We observed a significant reduction in median DOT over both phases (7 days vs. 4 days) and within phase II pre-intervention versus post-intervention groups (7

days vs. 4 days). Median LOS was 8 days and did not differ between groups. After adjusting for identifiable causes, we observed no difference in rates of QT prolongation, CDI or ESBL infection.

However, these results were limited by diagnostic testing for QT prolongation and inability to assess for contributing factors related to infection control.

Conclusions Antimicrobial stewardship is an effective intervention to reduce fluoroquinolone use. We did not

observe an increased length of stay despite patients being switched to parenteral therapies, however more data would be needed to assess for changes related to adverse events.

Resident John Stanas (john.stanas@bayfronthealth.com)

Co-Authors Ashley Lockwood

Practice Site Bayfront Health - St. Petersburg

Abstract Title Analysis of increased use of daptomycin

Background

Daptomycin is typically deferred for infections refractory to initial treatment due to its efficacy in combatting complicated infections caused by MRSA and vancomycin-resistant enterococci (VRE).

Local quality measures indicate that daptomycin utilization from 2016 to 2018 has increased dramatically at Bayfront Health St. Petersburg. Through this project, we aim to analyze factors

potentially responsible for the increasing use of daptomycin in a for-profit academic tertiary level II trauma center.

Methodology

Electronic medical charts were reviewed for 180 patients receiving daptomycin between January 1, 2016 and December 31, 2018. Initial information collected aimed at assessing the

appropriateness of daptomycin prescribing. Further data was collected to analyze potential population changes over the three years, including history of chronic kidney disease, diabetes

mellitus, obesity and age.

Results

Reported allergies to vancomycin were responsible for 24% of daptomycin use, however only 15% of these allergies had adequate documentation. Reasons for inappropriate daptomycin utilization remained relatively similar from 2016 to 2018, the most common being empiric

treatment for non-severe infections and inappropriate allergy designations. While daptomycin was often used to spare patients from potential vancomycin-associated nephrotoxicity, renal

protection was cited significantly more often in 2018 than 2016 and 2017, as were documented VRE infections. Rates of epidemiologic risk factors such as CKD, diabetes, obesity, and heart

failure were not significantly different between years.

Conclusions While daptomycin is being used for appropriate indications in the majority of patients, there are

still opportunities for education on appropriate use of daptomycin.

Resident Abdul Naveed Syed (absyed@mhs.net)

Co-Authors Josephine Jean-Postell, Corey Frederick, Brian McKee, Leanne Lai

Practice Site Memorial Regional Hospital

Abstract Title Assessing the clinical efficacy and safety of area under the curve based vancomycin dosing at a

small community hospital: a retrospective chart analysis

Background

The 2009 Infectious Diseases Society of America’s vancomycin dosing guidelines advocate for a trough goal of 15–20 mg/L for complicated infections. Recent literature suggests vancomycin

therapy should target an AUC/MIC of 400-600mg*h/L which can provide a similar pharmacodynamic effect, while reducing nephrotoxicity. The purpose of this study is to achieve therapeutic target attainment with an AUC/MIC level 400-600mg*h/L to produce efficacy while

reducing nephrotoxicity.

Methodology

Hospitalized adults who received IV vancomycin between November 2018-January 2019 (Trough group) and November 2019-January 2020 (AUC/MIC group). Patients were included if they were: ≥18 years old, received at least 3 doses of vancomycin, and have at least one trough or calculated

AUC level of value.

Results

Data was analyzed for 35 patients in trough group and 5 patients in AUC/MIC group. In the trough group, 17.1% had a trough <10 mcg/mL, 57.1% had trough of 10-20 mcg/mL, and 25.7% had

trough >20 mcg/mL; whereas, in AUC/MIC group, 80% were at goal of 400-600mg*h/L and 20% were < 400 mg* h/L. Patients in the AUC/MIC group were 16.1% less likely to be readmitted (30

days) and to have nephrotoxicity than patients in the trough group [adjusted OR 1.16 (0.12-11.4]. Duration of treatment per indication was not significant [95% CI (0.36-4.66); p=0.08]. Dose

(gram/day) per indication was not significant [95% CI (-1.27-0.23); p=0.16].

Conclusions Further investigation of AUC/MIC dosing will be needed with a larger sample size and longer

duration to get an adequate estimation of the clinical efficacy and clinical failure.

Resident Hannah Thorfinnson (hannah.thorfinnson@va.gov)

Co-Authors Bradley Stein, Julie King, Shannon Strausser

Practice Site James A. Haley Veterans Hospital

Abstract Title Ascorbic acid and prevention of urinary tract infections in spinal cord injury patients

Background

Most spinal cord injury (SCI) patients have some form of neurogenic bladder (NB), a bladder dysfunction from neurologic damage leading to disruption in communication between the brain

and bladder muscles. Urinary tract infections (UTIs) are a potentially life-threatening complication of NB and prevention is critical due to the high incidence of recurrence. Theories suggest ascorbic acid (AA) aids in preventing recurrent UTIs by causing a bacteriostatic effect in urine mediated by

the reduction of urinary nitrites to reactive nitrogen oxides. The objective of this study is to determine the utility of AA in preventing UTIs in SCI patients.

Methodology

This is a retrospective, self-controlled case series utilizing data extracted from the Veterans Affairs Corporate Data Warehouse to assess SCI patients treated with AA between June 1st, 2008-May 31, 2018 at eight hospitals within a Veterans Integrated Services Network (VISN). In this self-controlled study design, the patient population will serve as their own control group in order to

determine the number of UTI diagnoses before and after initiation of therapy with AA. Total time on AA (exposure period) will be compared to total time off AA (observational period) and the

incidence of UTI diagnosed during each period. The association between AA use and UTI diagnosis will be evaluated by means of an incident rate ratio.

Results Pending

Conclusions Pending

Resident Emily Thorp (emily.n.thorp@leehealth.org)

Co-Authors Mallory Fiorenza, Megan Patch, Mary Beth Saunders

Practice Site Lee Health

Abstract Title Time to appropriate antifungal therapy initiation: a comparison between candidemia identified by

blood culture vs. T2Candida rapid diagnostic assay

Background

Blood cultures are commonly used to identify candidemia which can take days to detect organism growth. This method to identify candidemia can delay time to initiation of antifungal therapy as well

as discontinuation of antifungal therapy, if negative. The T2 magnetic resonance (T2MR) candida species panel utilizes a polymerase chain reaction (PCR) and nuclear magnetic resonance (NMR) to identify five candida species from a whole blood specimen within 3 to 5 hours. The purpose of this

study was to assess the time to appropriate antifungal therapy initiation in patients who had candidemia identified by blood culture vs. T2Candida rapid diagnostic assay.

Methodology

This was a retrospective chart review that included adult patients who had a T2Candida assay performed with a positive or negative result or had a positive blood culture for Candida species - C. albicans, C. tropicalis, C. glabrata, C. krusei, and C. parapsilosis between October 2015 and October

2019. The primary objective was to compare the difference in time to appropriate antifungal therapy between blood cultures and the T2Candida rapid diagnostic assay. Data collected included the time to

Candida detection with T2Candida assay, time to discontinuation of antifungal therapy when T2Candida results were negative, time difference between Candida identification through T2Candida

versus a positive blood culture, 30-day all-cause mortality, presence of risk factors for invasive candidemia and the duration of antifungal therapy.

Results

Of the 1,922 patients reviewed, 1,672 patients were included in the data analysis. 186 patients had positive a T2Candida RDA, 139 patients had blood cultures positive for the five included Candida

species and 1,347 patients had a negative T2Candida RDA. There were no significant differences in baseline characteristics between groups. Time to initiation of appropriate antifungal therapy was

decreased by 37.3 hours utilizing the T2Candida RDA compared to utilizing blood cultures for candidemia detection (6.9 [1.5 – 12.5] vs. 44.2 [20.7 – 66.4]) (P < 0.001). 30-day-all-cause mortality occurred in 11.3% more patients in the T2Candida group (24.2%) compared to the positive blood

culture group (12.9%) (P = 0.012), however patients in the T2Candida RDA group had more risk factors for candidemia compared to the blood culture group (5.0 + 1. vs. 3.7 + 1.4). There was no significant

difference in hospital length of stay. Duration of antifungal therapy was not statistically different between the positive T2Candida RDA and positive blood culture groups, however when the T2Candida RDA was negative, median time to antifungal discontinuation was 3.1 hours from lab result (3.1 [0.6 –

7.7]) in this study.

Conclusions

Utilizing the T2Candida RDA decreases time to appropriate antifungal therapy in patients with candidemia due to C. albicans, C. tropicalis, C. glabrata, C. krusei, or C. parapsilosis compared to blood culture. Due to the high specificity of the test, a negative T2Candida RDA allows antifungal therapy to be confidently discontinued. Within this study, when T2Candida RDA was negative, median time to

antifungal discontinuation was 3.1 hours from lab result (3.1 [0.6 – 7.7]).

Resident Martie Vicent (martie.vicent@adventhealth.com)

Co-Authors Michael Geisel, Sarah Minor

Practice Site AdventHealth Orlando

Abstract Title Compliance with guideline-recommended duration of therapy after implementing a mandatory

antimicrobial duration in patients with community acquired pneumonia

Background

The Infectious Diseases Society of America (IDSA) published guidelines in 2016 for implementing an Antimicrobial Stewardship Program (ASP). One of the main responsibilities of an ASP is to

implement interventions to decrease duration of antibiotic therapy to ultimately reduce resistance. In 2013, AdventHealth, a large community hospital system, implemented a mandatory

antimicrobial duration for each antimicrobial order entered through the computer physician order entry (CPOE) system. The objective of this study is to determine if entering the required

duration increased compliance with the 2007 IDSA guideline-recommended duration of antibiotic therapy for community acquired pneumonia (CAP).

Methodology

This retrospective chart analysis compared patients from January to June 2012 and January to June 2014 as the pre- and post- groups respectively across seven different AdventHealth

campuses in the Central Florida region. Patients with CAP were identified by an electronic medical record software using Diagnosis-Related Group (DRG) classification to further include

patients. Data collected to determine the primary outcome included the total duration of therapy of both inpatient and discharge antibiotic regimens. Results of each group were compared to

determine the overall outcome associated with mandatory antimicrobial duration and used to enforce evidence-based medicine. Data collected to assess secondary outcomes included readmission within 30 days, total length of stay, total cost of stay, rates of hospital-onset

Clostridioides difficile infection during hospital stay or within the following 30 days of care if re-admitted.

Results Pending

Conclusions Pending

Resident Allyssa Webb (awebb@tgh.org)

Co-Authors Andrew Brueckner, Angela Logan, Amanda Al-Bahou, Rajendra Baliga, Lyndsey Bowman

Practice Site Tampa General Hospital

Abstract Title Maintenance steroids in the setting of alemtuzumab induction post-kidney transplant increases

risk of infection and hospital readmission

Background This study sought to assess the safety of steroid-containing maintenance immunosuppression in

the setting of alemtuzumab induction.

Methodology

Adult kidney transplant recipients transplanted 1/1/2015-12/31/2017 who received alemtuzumab induction were included. Per institution protocol, steroids are discontinued on post-operative day (POD) 4 in all recipients receiving alemtuzumab induction, except patients

with a panel of reactive antibody ≥30%, an acceptable reactive crossmatch, prior transplant, and delayed graft function. Cohorts were stratified into 2 groups according to those maintained on

steroids at POD 37. The primary outcome was the incidence of infection within 12 months post-transplant.

Results

Total of 445 recipients were included, 189 steroid and 256 steroid-free. Patients maintained on steroids had higher incidence of infection (67.2% vs 56.3%, p=0.019), driven primarily by bacterial

infection (55.6% vs 37.9%, p<0.001). Patients maintained on steroids also had higher mean number of hospitalizations (1.3±1.9 vs 0.86±1.3, p=0.007), and hospitalizations secondary to

infection (0.67±1.2 vs 0.38±0.8, p=0.005). Time to hospitalization was significantly lower in the steroids group. No difference was seen in new onset diabetes, weight change, and LDL. The

steroid group had a lower mean eGFR at 12 months (53.22±17.4 vs 57.51±17.2, p=0.015). Similar rates of rejection, graft loss, and death were seen between groups.

Conclusions

Infections and hospital admissions are higher amongst patients maintained on steroids post-alemtuzumab induction compared with steroid-free patients, but do not exhibit a higher

incidence of rejection, graft loss, or death. Consider limiting maintenance steroids in the setting of alemtuzumab induction, especially in those patients at higher risk for infection.

Resident Sara Wu (sara.wu@ascension.org)

Co-Authors Maryam Alikhil, Rochelle Forsyth, Bryan Allen

Practice Site St. Vincent's Healthcare

Abstract Title Impact of potentially unwarranted intravenous antibiotics targeting pulmonary infections in the setting of

acute decompensated heart failure

Background

Acute decompensated heart failure (ADHF) presents similarly to pulmonary conditions, including community-acquired pneumonia and acute exacerbation of chronic obstructive pulmonary disease.

Definitive diagnosis between conditions remains challenging in patients with non-specific symptoms such as dyspnea. Consequently, patients may receive intravenous antibiotics (IVAB) for suspected pulmonary infections. Mainstay of ADHF treatment is diuretics with fluid and salt restriction. The additional volume

and sodium received from IVAB can be counterproductive, especially when strong evidence of infection is lacking. The purpose of this study was to evaluate the impact of potentially unwarranted IVAB in ADHF

patients.

Methodology

Multi-center, retrospective, observational study was conducted across Ascension St. Vincent's. Adults admitted between July 2014 and July 2019 with a diagnosis with ADHF and a chest radiograph within 24

hours of admission, BNP greater than 100 pg/ml, and either received no IVAB or IVAB for at least 48 hours were included. Patients were excluded if they had antibiotic use within 30 days of admission, antibiotics for indications other than suspected pulmonary infections, proven infections, were receiving hemodialysis or renal replacement therapy, or transferred to ICU within 24 hours of admission. Subjects were then divided

into IVAB and no IVAB groups. Data were obtained from the electronic medical record. The primary outcome was the hospital length of stay. Secondary outcomes included the amount of loop diuretics,

volume and sodium from IV fluids, in-hospital mortality, 30-day readmissions, C. difficile infection rate, and intubation rate after 24 hours from admission.

Results

Of 654 patients screened, 240 patients were included where 120 received IVAB and 120 did not receive IVAB. Baseline characteristics were similar between groups except for age, COPD, and atrial

fibrillation being higher in the IVAB group. The primary outcome, LOS, was significantly longer in the IVAB group compared to the no IVAB group (5.12 days vs. 3.73 days; p<0.0001). After adjusting for covariates in

the propensity score matched cohort, LOS remained significantly longer in the IVAB group (5.26 days vs. 3.70 days; p<0.0001) shown in Figure 1. A subgroup analysis of patients that were never admitted to the ICU also demonstrated a significantly longer LOS in patients that received antibiotics (4.77 days vs 3.43 days; p=0.0003). The median volume from IVF, including IVAB, was significantly higher in patients that

received IVAB compared to no IVAB (1580 mL vs 0 mL; p<0.0001). The median Na from IVF, including IVAB, was also significantly higher in patients that received IVAB (14.67 g vs 0 g; p<0.0001). ICU admission rate

was significantly higher with IVAB compared to no IVAB (20% vs. 7.5%; p=0.0049). All-cause mortality was numerically higher with IVAB, but this finding was not statistically significant (2.5% vs. 0.83%; p=0.6218). There were no significant differences in total loop diuretic dose, intubation rate, and 30-day readmission

rates between groups. No patients developed C. difficile infection during admission.

Conclusions

This study demonstrated an association between unwarranted IVAB and increased hospital LOS supporting previous findings by Frisbee et al. However, previously observed differences in total loop

diuretic dose or readmissions were not corroborated. In addition, patients receiving IVAB were 12.5% more likely to be admitted to the ICU, which may have been a result of higher volume and Na from IVAB use.

However, the subgroup analysis demonstrated that IVAB increases LOS even in patients that are not admitted to the ICU. Limitations of this study include its retrospective nature and potential documentation bias. Strengths include clear definitions for including ADHF patients and excluding patients eligible for IVAB based on a diagnosis of CAP, AECOPD, or non-pulmonary infection, which improves the generalizability of these results to patients where IVAB may be unwarranted. This study met the estimated sample size and was adequately powered to detect a difference between groups. The use of propensity score matching

further strengthens the internal and external validity. ADHF patients with unwarranted intravenous antibiotics had significantly longer hospital LOS and were more likely to be admitted to the ICU.

Resident Darren Yum (Darren.Yum@hcahealthcare.com)

Co-Authors Kayihura Manigaba, Heather Ellis

Practice Site North Florida Regional Medical Center

Abstract Title Impact of negative methicillin-resistant Staphylococcus aureus (MRSA) nasal swab on total

duration of MRSA therapy for pneumonia patients

Background

Recent literature has highlighted MRSA nasal screening as a possible antimicrobial stewardship program tool for avoiding unnecessary empiric anti-MRSA therapy for pneumonia. Negative

MRSA nasal swab has been shown to have a high negative predictive value (>95%) across different types of pneumonia.

Methodology

This will be a retrospective cohort study that will assess MRSA nasal swab data from June 2018 to June 2019. This study was submitted through CARRIE (Centralized Algorithms for Research Rules on IRB Exemption) and was determined to be IRB-exempt. The study will include patients greater than or equal to 18 years old with clinical primary diagnosis of pneumonia on anti-MRSA therapy (vancomycin, linezolid, and ceftaroline). The Wilcoxon Signed Rank test will be used to measure continuous data while the Chi Square or Fisher's Exact test will be used to measure categorical data. The primary endpoint of the study will be to assess the MRSA antibiotic days of therapy between patients with negative MRSA nasal screening versus no MRSA nasal screening. The

secondary endpoints will include the length of stay of the patients, cost, 30 day all cause mortality, and nephrotoxicity as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The following data points will be collected: patient demographics, labs,

imaging, antibiotic administration, length of hospital stay, length of intensive care unit stay, and microbiology.

Results Pending

Conclusions Pending

Resident Michael Zaccaro (michael.zaccaro@uhsinc.com)

Co-Authors Leanne Stefanski, Stephanie Brown

Practice Site Manatee Memorial Hospital

Abstract Title Analysis of antibiotic de-escalation practices in a community based teaching hospital

Background

The object of this study was to evaluate antibiotic de-escalation practices for patients with pneumonia at a 319 bed community based teaching hospital. Antibiotic de-escalation is

important as it ensures the use of the most appropriate medication therapy in order to help prevent resistance via reducing exposure to unnecessary antibiotics and potentially reduce

hospital length of stay.

Methodology

Data was retrospectively collected from Manatee Memorial Hospital's electronic medical records. Patients were identified via positive sputum cultures collected during the year 2019. Only those with a diagnosis of pneumonia and sputum cultures collected at admission were included as a

way to limit confounding variables. The list of positive sputum cultures were screened in random order until 100 eligible patients were identified. Collected data included: time to antibiotic de-

escalation, isolated organism, length of stay, initial/tailored regimen, and patient demographics. Data was then analyzed to determine if any correlations exist.

Results

In 2019, there were 352 patients with positive sputum cultures. From the 100 patient study sample; the most common empiric and targeted regimen was vancomycin with piperacillin-

tazobactam and piperacillin-tazobactam respectively and the most commonly isolated organism was methicillin susceptible Staph aureus. Average time to de-escalation and length of stay was

4.16 and 12.58 days respectively (2.91 and 8.50 days for patients with pneumonia as the primary diagnosis).

Conclusions Initial review of the data suggests that 29 regimens were identified as suboptimal, 5 of which

were inappropriate for the isolated organism. A final analysis of the data will be presented at the Florida Residency Conference.