73. Improving Cephalosporin Utilization in the Emergency Department for Penicillin Allergic Patients

Background

Penicillin (PCN) allergies impact acute-care antibiotic prescribing practices, limit the use of first-line antibiotic agents and are associated with poor patient outcomes. Cephalosporins (CPN) are inconsistently prescribed to patients reporting PCN allergies despite reported low allergy cross-reactivity. The purpose of this study is to assess the impact of an education intervention on prescribing practices for CPN use in PCN allergic patients in the emergency department (ED).

Methods

This is a retrospective study evaluating all PCN allergic patients receiving a CPN in the ED from 07/01/2018 to 07/31/2019. The education intervention (consisting of circulating a locally developed guideline directing ED physicians to optimal CPN use given a designated PCN allergy along with lectures on suitable use of the guideline in recurring in-person sessions) occurred during 01/2019. We compared patient characteristics, CPN use, PCN allergy notation and adverse reactions between the “pre” (07/01/2018 – 12/31/2018) and “post” (02/01/2019 – 07/31/2019) groups.

Antibiotic Allergy Cross Reactivity/Sensitivity Chart

Results

A total of 123 patients are included (53 “pre” vs. 70 “post”). Patient characteristics are similar (Table 1). 31 (12.1% vs. 13%, P = 0.5) received previous treatment with CPN with the most common choices being cefazolin (14, 11.3%), ceftriaxone (18, 14.6%) and cefepime (9, 7.3%). 14 (11.3%) received pretreatment prior to CPN use. CPN given to patients in the ED include cefazolin (6 vs. 7), cephalexin (4 vs. 3), ceftriaxone (32 vs. 45) and cefepime (11 vs. 11). Common indications for CPN use include “empiric therapy” (38, 30.8%), “UTI” (17, 13.8%) and “pelvic region infection” (15, 12.1%). CPN administration routes include oral (10, 8.1%), intravenous (91, 73.9%) and intramuscular (22, 17.8%). 80 patients (65%) received a single dose of a CPN (37 vs. 43). No significant difference is noted in CPN use between groups (P = 0.1). Increased PCN allergy notation on tolerance to CPN after CPN use is noted, but later use of CPN use did not increase after notation (Table 2). No adverse events occurred from any CPN use.

Conclusion

Education interventions on CPN use in PCN allergic patients require support with other strategies and tools. This intervention provides groundwork to initiate efforts to further improve CPN use in PCN allergic patients.

Disclosures

All Authors: No reported disclosures

The Association of ICH Exclusion Criteria With Mortality and Disability Rates in ICH Patients Receiving 4F-PCC for Anticoagulation Reversal

BACKGROUND

Intracranial hemorrhage (ICH) exclusion criteria in the landmark four-factor prothrombin complex concentrate (4F-PCC) trial have not been incorporated into clinical practice and incremental predictive ability is unknown.

OBJECTIVES

Evaluate the association of meeting at least 1 ICH exclusion criterion with the composite end point in-hospital mortality and modified Rankin Scale [mRS] score 5 or 6. Determine the number and combination of criteria associated with poor outcomes.

METHODS

Retrospective review of adult ICH patients who received 4F-PCC for anticoagulant reversal. Patient demographics, ICH exclusion criteria, in-hospital mortality, disability, and disposition were collected. χ² Analysis and logistic regression were used to assess differences between patients with and without ICH exclusion criteria.

RESULTS

Data from 167 patients were analyzed: 103 (61.7%) met at least 1 ICH exclusion criterion. The composite end point occurred more in those with at least 1 ICH exclusion criterion (74.8% vs 39%; P < 0.0001). Presence of 2 or more ICH exclusion criteria was associated with higher odds of the composite end point, higher mRS score, and long-term care facility disposition (P < 0.0001). Glasgow Coma Scale score <7 and at least 1 other ICH exclusion criterion had negative effects on composite end point and mortality: 95% to 100% and 85% to 100%, respectively.

CONCLUSION AND RELEVANCE

Patients meeting at least 1 ICH exclusion criterion had greater death/disability compared with those who did not. More ICH exclusion criteria were associated with higher rates of death, disability, and worse disposition. These data may aid in developing optimal 4F-PCC use criteria.

Pharmacist involvement in trauma resuscitation across the United States: A 10-year follow-up survey

PURPOSE

A national survey performed in 2007 found that only 23% of American College of Surgeons (ACS) trauma centers involved pharmacists in trauma resuscitation. This study describes interval change in use, perceptions, and responsibilities from 2007 to 2017.

METHODS

Of the 419 trauma centers identified from the ACS website, contact information was available for 335. In March 2017, a survey assessing hospital demographics, pharmacist coverage and services, and perception of pharmacist value and use was emailed to the identified trauma representatives. Data were analyzed using descriptive statistics and chi-square analysis, as appropriate.

RESULTS

The response rate was 33% (110/335). Pharmacist involvement with trauma resuscitation increased significantly from 23% in 2007 to 70% (p < 0.001) and in 71% of trauma centers was provided by pharmacists practicing within the emergency department. Pharmacist involvement was greatest in the Midwest (p < 0.01), but with similar distribution with regards to ACS designation, institution type, and patient volume. Common bedside responsibilities include calculating dosages (96%), preparing medications (89%), and providing medication information (79%), while trauma program/administrative responsibilities (45%) include trauma team education, pharmacy operations, medication safety, quality improvement data collection, research, review of quality assurance cases, ACS accreditation preparation, and others. The primary reason for not considering pharmacist involvement was unfamiliarity with these roles/benefits.

CONCLUSION

Pharmacists are an increasingly important component of the trauma team, as evidenced by growth over the last decade. In addition to clinical benefit at the bedside, pharmacists can support the regular activities of a trauma program in many meaningful ways.

An introductory review module for an anti-infectives therapeutics course

OBJECTIVE

To determine whether an introductory review module using a hybrid-learning approach helped students learn infectious disease management in an anti-infectives therapeutics course.

DESIGN

An introductory module consisting of an online pharmacology review, pre-class assignment, 2 classroom lectures, and 1 case-based lecture was developed and implemented.

ASSESSMENT

Among the 110 students who completed pre- and post-tests on the material covered, average scores increased from 71% to 83% (p<0.0001). Performance on knowledge-based question improved for 8 out of 10 questions (p<0.05) and student confidence increased from the first lecture to completion of the module (p<0.001 for all comparisons). Of the 129 students who completed an evaluation of the introductory module, 98% strongly agreed or agreed that the content was essential for course success.

CONCLUSION

The addition of an introductory module using a hybrid-learning approach to review and solidify concepts of medical microbiology and pharmacology provided the foundation necessary for success in an infectious diseases module.