Antibiotic Stewardship in Medical ICU Patients: Impact of ...
Transcript of Antibiotic Stewardship in Medical ICU Patients: Impact of ...
IDWeek
San Diego, CA, October 2017
Antibiotic Stewardship in Medical ICU Patients:
Impact of a Pneumonia Diagnostic Bundle with Pharmacist InterventionJames M. Kidd, PharmD, BCPS; Daniel Speredelozzi, MD; Hannah Spinner, PharmD, BCCCP; Jennifer J.
Schimmel, MD; Abigail Orenstein, MD, MPH; Erica Housman, PharmD, BCPS (AQ-ID)
B A C K G R O U N D
▪ Acute bacterial pneumonia is a common empiric
diagnosis in Medical ICU (MICU) patients.
▪ It is difficult to distinguish from non-bacterial
causes of lung inflammation or infection.
▪ Barriers to antibiotic de-escalation or
discontinuation may include:
▪ Incomplete diagnostic workup at initiation.
▪ Misinterpretation of or lack of follow up on
diagnostic data.
▪ Setting: Baystate Medical Center MICU
▪ 16-bed MICU with overflow into 16-bed
Surgical ICU
▪ 533 MICU patient-days per month
▪ Clinical pharmacist attends MICU patient care
rounds 7 days per week
1. Bouadma L, et al. Lancet 2010; 375:463-74.
2. Kalil AC, et al. Clin Infect Dis 2016 July 14;
doi: 10.1093/cid/ciw353
3. Cochrane Database Syst Rev 2012;9:CD007498.
4. Schuetz P, et al. Clin Infect Dis 2012;55(5):651-62.
▪ To reduce the duration of unnecessary
antibiotics in MICU patients by:
▪ Bundling pneumonia diagnostic and
treatment orders into a single
comprehensive order set.
▪ Implementing a daily pharmacist-driven
antibiotic time out.
DISCLOSURES
Authors of this presentation have the following to disclose concerning
possible financial or personal relationships with commercial entities
that may have a direct or indirect interest in the subject matter of this
presentation.
James M. Kidd; Daniel Speredelozzi; Hannah Spinner; Jennifer J.
Schimmel; Abigail Orenstein; Erica Housman: nothing to disclose
M E T H O D S c o n ’ t
ICU Pneumonia Order Set (Cerner)
Diagnostics
✓ Procalcitonin level STAT
✓ Procalcitonin level T+24 hours
✓ Procalcitonin level T+72 hours
✓ Respiratory Pathogen Panel by PCR
(nasopharyngeal swab)
Now
✓ Sputum* Gram stain and culture*from expectorated sputum, ET aspirate, or BAL (mini or
bronchoscopic)
Now
Medications
Community Acquired Pneumonia
Ceftriaxone 1 Gm, IVPB, every 24h
***PLUS***
Azithromycin 500 mg, IVPB, every 24h
***OR***
Levofloxacin Dosing order set
***OR***
Doxycycline 100 mg, IVPB, every 12h
Healthcare Associated and Hospital Acquired Pneumonia
Vancomycin Adult Dosing order set
***PLUS***
Piperacillin/Tazobactam Dosing order set
If prolonged hospitalization or MDR risk, add
Tobramycin Once Daily Dosing order set
If penicillin allergy (NOT anaphylaxis)
Cefepime 2 Gm, IVPB, every 12h
Contact infectious disease department for severe penicillin and
cephalosporin allergy (anaphylaxis)
▪ Retrospective cohort before and after study
from December 2015 – March 2016 and
December 2016 – March 2017.
▪ Antibiotic discontinuation was assessed by
comparing days of antibiotic therapy per 1000
MICU patient-days
▪ Statistical analysis
▪ Z-scores were calculated for antibiotic
usage comparisons and 2-tail P-values are
reported.
▪ Rate difference was reported and 95% CI
were calculated using Byar’s method.
▪ Implementation of a pneumonia diagnostic
bundle and treatment order set combined with
pharmacist-driven antibiotic time-out was
associated with:
▪ Decreased total antibiotic usage in the
MICU when compared to the same months
of the prior year.
▪ Decreased broad spectrum antibiotic
usage.
▪ Some increased narrow spectrum antibiotic
usage suggesting a shift towards more
targeted therapy.
▪ Application of appropriate diagnostics and
focused pharmacist follow-up are beneficial to
antimicrobial stewardship efforts.
O B J E C T I V E S
M E T H O D S
C O N C L U S I O N S
MICU Antibiotic Days of Therapy per 1000 Patient-Days
Baseline
Period
Study
period
Rate
diff. 95% CI P value
All
antibiotics*905.7 688.4 -217.3 -270.8 to -163.9 <0.0001
Piperacillin-
Tazobactam426.1 316.3 -109.8 -146.3 to -73.4 <0.0001
Vancomycin 350.8 277 -73.8 -107.4 to -40.3 <0.0001
Cefepime 109.3 43.9 -65.4 -82.0 to -48.9 <0.0001
Gentamicin 77.8 24.4 -53.4 -66.9 to -39.8 <0.0001
Linezolid 55.9 13.5 -42.5 -53.6 to -31.3 <0.0001
Azithromycin 108.5 77.2 -31.3 -49.6 to -13.1 <0.001
Ceftriaxone 193.7 164.2 -29.5 -54.8 to -4.1 0.22
Oxacillin 42 16.8 -25.2 -35.4 to -14.9 <0.0001
Meropenem 39.7 32.9 -6.7 -18.1 to 4.7 0.24
Tobramycin 9.3 2.6 -6.7 -11.4 to -2.1 0.004
Levofloxacin 26.7 21.6 -5.1 -14.4 to 4.2 0.284
Clindamycin 18.7 20.4 1.7 -6.7 to 1 0.69
Penicillin G
Potassium15.5 20.4 4.9 -3.1 to 1.3 0.23
Amoxicillin-
Clavulanate4.6 17.3 12.7 6.43 to 18.9 <0.0001
Doxycycline 7.2 21.76 14.5 7.4 to 21.7 <0.0001
Ampicillin-
Sulbactam36.7 52.6 15.8 3.2 to 28.4 0.014
Ertapenem 9.77 27.75 18.0 9.8 to 26.2 <0.0001
Cefazolin 32.3 66.7 34.4 21.1 to 47.7 <0.0001
*Includes only antibiotics which would typically be used for
bacterial pneumonia
R E F E R E N C E S
Erica Housman, PharmD, BCPS (AQ-ID)[email protected]
▪ Pneumonia order set created to include:
▪ Pre-selected diagnostic tests including serial
procalcitonin (PCT) levels, respiratory
pathogen panel (includes 17 viruses and 3
bacteria), and sputum culture.
▪ Recommended empiric antibiotics for CAP,
HCAP, and HAP based on local antibiogram
▪ PCT interpretation algorithm provided.
▪ Clinical ICU pharmacist performed antibiotic
time-outs 7 days per week during patient care
rounds.
▪ Educational sessions presented to critical care
providers.
L I M I T A T I O N S
▪ Unable to directly determine usage of the
diagnostic bundle order set .
▪ PCT level result was not available in a timely
manner to be useful in affecting antimicrobial
therapy.
▪ Patient-specific factors were not assessed.
▪ A cost-benefit analysis was not performed.
▪ Single unit evaluation limits generalizability.
▪ Single respiratory season limits evaluation of
sustainability.
R E S U L T S