Epps, Kevin L

Abstract Objectives: Community-acquired intra-abdominal infections (CA-IAIs) are a leading cause of US hospitalizations. Piperacillin-tazobactam is often used to empirically treat CA-IAIs, despite national guidelines recommending narrower-spectrum antibiotics for these infections. The overuse of broad-spectrum agents such as piperacillin-tazobactam contributes to antibiotic resistance, which poses serious public health challenges. This resident-led quality improvement initiative aimed to reduce unnecessary piperacillin-tazobactam use for treating CA-IAIs measured as DOT/1,000 patient-days by 10% without adversely affecting hospital length of stay (LOS). Methods: Using the DMAIC (define, measure, analyze, improve, control) framework, we identified barriers to appropriate antibiotic use and developed a treatment algorithm for CA-IAIs that included clear guidelines and exclusion criteria. This algorithm was disseminated to internal medicine residents and emergency department physicians along with educational sessions to highlight updated CA-IAI treatment recommendations, antibiotic resistance, and appropriate antibiotic ordering via the electronic health record. Antimicrobial stewardship pharmacists provided overnight support to assist with de-escalation. Data were collected over a 10-month period spanning 2 intervention phases. The primary outcome was piperacillin-tazobactam use, measured as days of therapy (DOT) per 1,000 patient-days and DOT per patient LOS. Mean LOS served as the balancing measure. Results: Piperacillin-tazobactam use was significantly reduced ( P < .001) after the interventions without increasing the mean LOS. Conclusion: This project raised awareness of antibiotic resistance and led to lasting improvements in reducing the inappropriate use of piperacillin-tazobactam to treat CA-IAIs, without affecting the mean LOS. This was attributed to the strong collaboration among a multidisciplinary team of infectious disease physicians, antimicrobial stewardship team members, residents, emergency department physicians, and faculty.

Objective: We evaluated the impact of a methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) protocol on the vancomycin length of therapy (LOT) for skin and soft tissue infections (SSTIs). Design: Retrospective quasi-experimental pre- and post- MRSA nasal PCR protocol implementation study. Setting: Tertiary-care academic medical center in Jacksonville, Florida. Patients: Eligible patients received empiric vancomycin for SSTIs from January 1st to September 30th 2020 (pre-implementation group) and from January 1st to September 30th 2022 (post-implementation group). Intervention: The electronic health system software was modified to provide a best-practice advisory (BPA) prompt to the pharmacist upon order verification of vancomycin for patients with SSTIs. Methods: We reviewed patient records to determine the time from vancomycin prescription to de-escalation. The secondary outcomes were incidence of acute kidney injury (AKI), number of vancomycin levels collected, and hospital length of stay (LOS). Results: The study included 131 patients (pre-implementation, n = 86 and post-implementation, n = 45). There was no significant difference in vancomycin length of therapy (LOT) between implementation groups: mean LOT in days and standard deviation (SD) were 2.7 (1.9) and 2.6 (1.3), respectively, p-value 0.493. Of significance, in the post-implementation group, vancomycin LOT between patients with a negative and positive MRSA PCR were 2.3 (1.1) and 3.9 (1.6), p-value 0.006. There was no difference in secondary outcomes. Conclusion: The utilization of the MRSA nasal PCR to guide vancomycin de-escalation did not significantly change the vancomycin LOT, however in the post-implementation group there was a significant difference in vancomycin LOT between negative and positive MRSA PCRs.