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Background: Vancomycin area-under-the-curve (AUC) monitoring is associated with reduced nephrotoxicity but may increase cost and workload for personnel compared to trough monitoring.Objective: The purpose of this study was to compare the accuracy of vancomycin AUC calculated by open-access, online, trough-only calculators to AUCs calculated by the trapezoidal method (TM) using peak and trough concentrations.Methods: This retrospective, multi-center study included adults ≥18 years old with stable renal function who received vancomycin with steady-state peak and trough concentrations. Areas under the curve calculated by TM were compared to AUCs calculated by 3 online calculators using trough-only options for calculation: ClinCalc, VancoVanco, and VancoPK. The primary outcome was actual difference in AUC between TM and the online calculators. Secondary outcomes were percent difference in AUC and clinical alignment in dose adjustments between methods.Results: Seventy patients were included for analysis. There was a statistically significant difference in AUC between TM and ClinCalc (median actual difference: −52, P< 0.001) and VancoVanco (median actual difference: 95, P< 0.001), whereas there was no significant difference between TM and VancoPK (median actual difference: −0.8, P= 0.827). Discordant dose adjustments were indicated when comparing ClinCalc, VancoVanco, and VancoPK to TM in 28%, 36%, and 12% of cases, respectively.Conclusion: The AUC calculator most closely aligned with TM was VancoPK, whereas other included calculators were statistically different. Owing to the cost and complexity of obtaining multiple levels, our findings support using a single steady-state trough using VancoPK as an alternative to TM for calculation of vancomycin AUC.

AbstractObjectives:The typical 5-day work week affects healthcare outcomes. Structured work hours have also been implicated in antimicrobial prescribing choice. We developed a visualization tool to aid in evaluating breadth of antibiotic use in various time (day of week and hour of day) and space (patient location) combinations.Methods:We evaluated antibiotic administration data from a tertiary-care academic medical center between July 1, 2018, and July 1, 2020. We calculated a cumulative empiric antibiotic spectrum score by adapting a previously validated antibiotic spectrum index (ASI) and applying that score to empiric antibiotic use. We visualized these data as a heat map based on various day-of-week–time combinations and then compared the distribution of scores between weekday nights, weekend days, and weekend nights to the typical workweek hours (weekday days, weekday days) using the Mann-Whitney Unonparametric test with a Bonferroni correction.Results:The analysis included 76,535 antibiotic starts across 53,900 unique patient admissions over 2 years. The mean cumulative ASI was higher in all 3 night and weekend combinations (weekday nights, 7.3; weekend days, 7.6; weekend nights, 7.5) compared to the weekday daytime hours (weekday days, 7.1) and the distribution of scores was different in all groups compared to the weekday daytime reference. The cumulative ASI was also higher in intensive care units.Conclusions:Empiric antibiotic prescribing patterns differed across space and time; broader antibiotic choices occurred in the intensive care units and on nights and weekends. Visualization of these patterns aids in antimicrobial prescribing pattern recognition and may assist in finding opportunities for additional antimicrobial stewardship interventions.

Allergy assessments and penicillin skin testing are associated with reductions in high‐Clostridioides difficileinfection (CDI)‐risk antibiotic use and lower hospital‐acquired CDI rates; however, these activities require substantial personnel and resource allocation. Recently, many antimicrobial stewardship programs’ (ASPs) focus shifted towards supporting the COVID‐19 pandemic response. We evaluated the impact of the COVID‐19 pandemic on a pharmacist‐led allergy assessment and penicillin skin testing program. Patients undergoing allergy assessment and/or penicillin skin testing (PST) from 1 January 2017 through 30 April 2021 were included for review. Monthly PST and allergy assessment rates were calculated and defined as the number of PSTs or allergy assessments per 1000 unique patient encounters for each month, respectively. The study used interrupted time series regression to assess potential level and slope changes in allergy assessments and PSTs during the pandemic. 200 058 total inpatient encounters by 188 867 unique patients occurred during the study period. ASP performed 918 allergy assessments and 204 PSTs. The local onset of the SARS‐CoV‐2 pandemic during March 2020 was associated with significant level reductions in allergy assessments and PSTs. Additional responsibilities added to the ASP team during the COVID‐19 pandemic limited the ability to perform core antimicrobial stewardship activities with proven patient care benefits.

Background:Quantitative evaluation of antibiotic spectrum is an important, underutilized metric in measuring antibiotic use (AU) and may assist antimicrobial stewards in identifying targets and strategy for intervention. We evaluated the spectrum of initial antibiotic choices by hospital location, day of the week, and time of day to determine whether these factors may be associated with broad-spectrum antibiotic choices. Methods:We identified all admissions with antibiotic exposure in medical and surgical wards and critical care units in a tertiary academic medical center between July 1, 2014, and July 1, 2019. The antibiotic spectrum index (ASI), proposed by Gerber et al, is a numeric score based on the number of pathogens covered by a particular agent. We defined ASI for initial antibiotic choice as follows: ASI for each unique antibiotic administered within 24 hours of the first antibiotic administration was summed and assigned to the administration time of the first dose. We categorized time into 4 distinct categories: weekday days (Monday–Friday, 7 a.m.–7 p.m.), weekday nights, weekend days, and weekend nights. Weekend time began 7 p.m.Friday and ended 7 a.m.Monday. We constructed heatmaps stratified by hospital location. Mann-Whitney U tests were applied to evaluate differences in the distributions of ASI using weekday days as a reference. Results:Data included 90,455 unique antibiotic admissions with initial antibiotic starts in medical and surgical wards and critical care units. Patterns of ASI for initial antibiotic choice varied between unit locations and time (Figs. 1 and 2). Mean and median ASIs for initial antibiotic choices were higher for medical ward and medical ICUs than for surgical wards and surgical ICUs. Initial antibiotic choices had higher ASIs during overnight hours for all units except the surgical ICU. Notable differences in ASIs were identified between weekday and weekend prescribing for surgical units, whereas medical units demonstrated less extreme differences. Conclusion:We observed a “weekend effect” across hospital units; the most extreme occurred in surgical wards. This observation may be due to differences in patient volume and rounding patterns. For example, hospitalist and critical care units have 7-day schedules, whereas surgical wards are highly influenced by operating room schedules. Antimicrobial stewardship teams may use these data to identify strategies targeting the most opportune time and place to intervene on the spectrum of initial antibiotic choice.Funding:NoneDisclosures:None

To improve the quality and safety of antimicrobial prescribing while minimizing unnecessary cost, antimicrobial stewardship programs (ASPs) require the unique services of a variety of healthcare and ancillary personnel with varied skill sets. At the center of such teams are pharmacists and physicians with specialty training in infectious diseases (ID). The potential implementation of regulations and accreditation standards requiring institutions to have antimicrobial stewardship programs (ASP)s, along with growing evidence to their effectiveness and their increasing presence in different practice settings, are likely to increase the demand for such programs. An assessment of present and potential future antimicrobial stewardship (AS) operations is required to ensure the supply of trained clinicians to meet the growing demand. Presently, the majority of training is achieved either through private study or as part of experiential postgraduate programs. While postgraduate ID-focused programs for pharmacists generally incorporate antimicrobial AS training, such experiences are rarely part of the formalized experience for ID-trained physicians. Although some professional organizations are addressing the perceived lack of individuals with formal postgraduate ID training through certification programs, there are currently no formal regulations or guidelines for such training. It is unlikely the present supply of ID-trained pharmacists will meet the future demands in this area. Therefore, novel strategies (such as access to AS networks, the expanded use of communication and/or information technology, use of alternate personnel, and/or intermittent programs) may increase access to AS-trained clinicians.