title: Implementation of a cefazolin-based stewardship pathway for methicillin-susceptible Staphylococcus aureus bloodstream infections paired with infectious diseases consultation.
abstract: Methicillin-susceptible Staphylococcus aureus (MSSA) infections have been successfully treated both with cefazolin and antistaphylococcal penicillins; cefazolin appears effective in MSSA bloodstream infections (BSIs). Thus, our antimicrobial stewardship programme (ASP) implemented a clinical pathway supporting cefazolin use in MSSA-BSIs and restricting oxacillin use to infectious diseases (ID) consultation due to cefazolin's lower cost and more convenient dosing. This before and after quasi-experimental study was conducted to describe the impact on outcomes and process of care measures associated with implementing this pathway among patients with MSSA-BSI. Definitive treatment with cefazolin increased over the study period from 17.3% to 69.8% post-implementation. Clinical failure (5.8% vs. 2.3%; P = 0.62) and in-hospital mortality (3.8% vs. 0%; P = 0.50) were rare pre- and post-implementation. Median hospital length of stay among survivors was similar between pre- and post-implementation periods (P = 0.31). Duration of bacteraemia [median (IQR) 3 (2-4) days vs. 2 (2-3) days; P = 0.002] and rates of re-infection after culture clearance (9.6% vs. 0%; P = 0.06) were reduced post-implementation. Frequency of source control (P = 0.71) and time to source control (P = 0.52) were similar between study periods. Significant increases in ID consultations (33.3% [3/9] vs. 73.3% [22/30]; P = 0.047) and median (IQR) 24-h daily doses [2 (1-3) g vs. 6 (3-6) g; P < 0.01] were seen for patients treated with cefazolin post-implementation. ASPs may find implementation of a similar pathway to be an effective means of improving the care of patients infected with MSSA.
authors.affiliation: Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Lee
authors.affiliation: Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.
authors.forename: Sonia N
authors.initials: SN
authors.lastname: Rao
authors.affiliation: Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA; Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA.
authors.forename: Sheila K
authors.initials: SK
authors.lastname: Wang
authors.affiliation: Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.
authors.forename: Jane Y
authors.initials: JY
authors.lastname: Lee
authors.affiliation: Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.
authors.forename: Irfana Y
authors.initials: IY
authors.lastname: Lakada
authors.affiliation: Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Pharmacy Practice, Chicago State University College of Pharmacy, Chicago, IL, USA.
authors.forename: Elise M
authors.initials: EM
authors.lastname: Gilbert
authors.affiliation: Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Pharmacy Practice, College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
authors.forename: Viktorija O
authors.initials: VO
authors.lastname: Barr
authors.affiliation: Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Postelnick
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
authors.forename: Sarah H
authors.initials: SH
authors.lastname: Sutton
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
authors.forename: Teresa R
authors.initials: TR
authors.lastname: Zembower
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
authors.forename: Maureen
authors.initials: M
authors.lastname: Bolon
authors.affiliation: Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.
authors.forename: Marc H
authors.initials: MH
authors.lastname: Scheetz
authors.affiliation: Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA. Electronic address: nrhode@midwestern.edu.
authors.forename: Nathaniel J
authors.initials: NJ
authors.lastname: Rhodes
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D000073602:Antimicrobial Stewardship; D016470:Bacteremia / Q000188:drug therapy* / Q000382:microbiology; D002437:Cefazolin / Q000627:therapeutic use*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008712:Methicillin / Q000627:therapeutic use; D008875:Middle Aged; D010068:Oxacillin / Q000627:therapeutic use; D013203:Staphylococcal Infections / Q000188:drug therapy*; D013211:Staphylococcus aureus / Q000187:drug effects*
chemical_list: D000900:Anti-Bacterial Agents; D002437:Cefazolin; D008712:Methicillin; D010068:Oxacillin
keywords: Antimicrobial stewardship; Bloodstream infection; Cefazolin; Infectious diseases consultation; Methicillin-susceptible Staphylococcus aureus; Oxacillin