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Impact of an Antimicrobial Stewardship Program Comprehensive Care Bundle on Management of Candidemia

Authors

  • Allen Antworth,

    1. Departments of Pharmacy Services, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
    2. Department of Infection Control and Hospital Epidemiology, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
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  • Curtis D. Collins,

    1. Departments of Pharmacy Services, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
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  • Anjly Kunapuli,

    1. Departments of Pharmacy Services, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
    2. University of Michigan College of Pharmacy, Ann Arbor, Michigan
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  • Kristin Klein,

    1. Internal Medicine, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
    2. University of Michigan College of Pharmacy, Ann Arbor, Michigan
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  • Peggy Carver,

    1. Departments of Pharmacy Services, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
    2. University of Michigan College of Pharmacy, Ann Arbor, Michigan
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  • Tejal Gandhi,

    1. Internal Medicine, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
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  • Laraine Washer,

    1. Internal Medicine, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
    2. Department of Infection Control and Hospital Epidemiology, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
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  • Jerod L. Nagel

    Corresponding author
    • Departments of Pharmacy Services, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan
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  • Dr. Carver has received research support from Asellas Pharma US, Inc., and Merck & Co., Inc.

For questions or comments, contact Jerod Nagel, Pharm.D., University of Michigan Hospital and Health Systems, 1500 East Medical Center Drive, UH B2D301, Ann Arbor, MI 48109; e-mail: nageljl@umich.edu.

Abstract

Study Objective

To analyze the impact of a comprehensive care bundle directed by an antimicrobial stewardship team (AST) on the management of candidemia.

Design

Single-center, quasi-experimental study.

Setting

A 930-bed academic hospital.

Patients

Seventy-eight patients with candidemia were evaluated; 41 patients received the candidemia care bundle (AST group), and 37 did not (historical control group).

Measurements and Main Results

A candidemia care bundle was developed by an interdisciplinary AST, incorporating key elements from the Infectious Diseases Society of America's Clinical Practice Guidelines for the Management of Candidemia. The AST made prospective recommendations in accordance with the care bundle. Bundle elements were utilization of appropriate antifungal agents with appropriate duration of use, removal of intravenous catheters, repeat blood cultures, monitoring of time until clearance of candidemia, and performance of ophthalmologic examinations. Compliance with all candidemia care bundle elements was significantly higher in the AST group versus the control group (78.0% vs 40.5%, p=0.0016). Implementation of the care bundle significantly improved rates of ophthalmologic examination (97.6% vs 75.7%, p=0.0108), selection of appropriate antifungal therapy (100% vs 86.5%, p=0.0488), and compliance with an appropriate duration of therapy (97.6% vs 67.7%, p=0.0012). In addition, the AST group had fewer excess total days of therapy beyond the recommended duration than the control group (5 vs 83 total antifungal days). Length of hospitalization (20 vs 21 days, p=0.9184), time until clearance of candidemia (3 vs 3 days p=0.610), rate of persistent candidemia (22% vs 40.5%, p=0.126), and rate of recurrent candidemia (4.9% vs 5.4%, p=0.916) were similar in the AST group versus the control group.

Conclusion

A comprehensive candidemia care bundle directed by our institution's AST improved the management of patients with candidemia. We encourage further exploration into the use of care bundles by ASTs as part of their multifaceted approach to promoting appropriate antimicrobial utilization and optimizing the management of patients with infectious diseases.

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