Reviewed by: Valeria Fabre, MD, Johns Hopkins University School of Medicine
Antibiotic stewardship (AS) interventions have traditionally focused on the inpatient setting and carried out by physicians and pharmacists. Two articles published in Infection Control & Hospital Epidemiology highlight 2 opportunities for AS activities.
Dickinson and colleagues performed a descriptive study of patients discharged from hospitals to nursing homes (NHs) on antibiotics between January 2011 and June 2014 in Los Angeles County and Orange County in California. 40 paired hospital and nursing home (NH) charts representing 37 patients discharged from 13 hospitals and transferred to 25 NHs were included. 12 of 40 transitions of care (TOCs) (30%) were inappropriate. The most common inappropriate change included dose timing (given either too early or too late at the NH, mean of 19 hours and 9 hours respectively). Another common inappropriate change was related to antibiotic safety monitoring (usually labs performed less frequently or not performed at all). 50% of TOC documentation contained missing or conflicting information with final progress notes. In most cases, transfers occurred after business hours and pharmacy support was no longer available at the NH. Limited by its retrospective nature and small number of patients, this study sheds light into the issues associated with antibiotic use at transitions of care.
In the second study, Margallo et al. report on the experience of a nurse-driven allergy assessment for patients seen at a pre-operative clinic. A simple, paper-based, 5-question, structured allergy assessment was developed by a multidisciplinary antimicrobial stewardship team and implemented by nurses at a pre-procedure outpatient clinic (PPOC). A job aid was included with the structured allergy assessment to help distinguish IgE-mediated reactions from non–IgE-mediated reactions, and nurses were trained to ask whether the patient had received other β-lactam antibiotics. The electronic medical records of 313 patients who received surgical prophylaxis following PPOC evaluation from 2015 to 2016 were retrospectively reviewed for utilization of β-lactam surgical prophylaxis. Overall, 271 patients (86.6%) described remote reactions (>10 years prior or could not recall). Symptoms possibly consistent with an IgE-mediated reaction were reported by 186 patients (59%). Mild or non-allergic reactions were described by the remaining 127 patients (41%), most often involving mild rash. A β-lactam was ultimately administered in 245 of 313 patients (78.3%) who previously reported a β-lactam allergy, without any clinically significant reactions. We observed 135 patients who safely tolerated β-lactam prophylaxis (cefazolin in 131 of 135, 97.0%) despite initially reported symptoms consistent with a possible severe or IgE-type β-lactam reaction. Nearly all of these patients (131 of 135, 97.0%) described β-lactam reactions only to penicillin or aminopenicillins. Among these patients, most reported a remote reaction history (113 of 135, 83.7%), lack of immediate onset (77 of 135, 57.0%), and/or could not recall requiring medical intervention for the reaction (83 of 135, 61.5%). In summary, simple interventions to improve penicillin allergy documentation can effectively increase β-lactam use among patients requiring surgical prophylaxis.
References:
Margallo J-EP, et al. (2019). Optimizing utilization of beta-lactam surgical prophylaxis through implementation of a structured allergy assessment tool in a presurgical clinic. Infection Control & Hospital Epidemiology, https://doi.org/10.1017/ice.2019.274
Dickinson DT, et al. (2019). Errors in antibiotic transitions between hospital and nursing home: How often do they occur?. Infection Control & Hospital Epidemiology, https://doi.org/10.1017/ice.2019.270