Pharmacist-led antimicrobial stewardship within emergency departments appears to be effective and improve adult antibiotic prescribing
Pharmacist-led antimicrobial stewardship with emergency departments is associated with more appropriate antibiotic prescribing in adults who present with a range of infectious conditions. This was the conclusion of a systematic review and meta-analysis by a team from the Department of Pharmacy and the Department of Emergency Medicine, Mayo Clinic, Minnesota, US.
Research from the US suggests that an estimated 30% of outpatient, oral antibiotic prescriptions may have been inappropriate, highlighting a need for effective antimicrobial stewardship programs within an emergency departments. However, one systematic review addressing this topic concluded that while such interventions may improve patient care, the optimal combination of interventions is unclear. While the review did not consider pharmacist-led interventions, other reviews have demonstrated that within an inpatient setting, pharmacist-led educational antimicrobial stewardship interventions are effective at increasing guideline compliance and reducing duration of antimicrobial therapy. Although prior research has demonstrated that a clinical pharmacist within an emergency department is of value, the impact of a pharmacist-led antimicrobial stewardship program within emergency departments remains unknown.
For the present study, the US team set their primary aim as an assessment of the impact of pharmacist-led antimicrobial stewardship interventions, on the appropriateness of antibiotic prescribing within emergency care settings. The secondary aim was to assess the impact of any such interventions on time to culture review, time to appropriate antibiotics and emergency care return rates.
The literature review identified 22 studies including 5,062 patients that were suitable for analysis, the majority of which were retrospective observational cohorts, including before and after assessments though there were no randomised, controlled trials.
The nature of the studies varied and interventions included pharmacist-led culture reviews, the presence of a pharmacist in the department, pharmacist directed clinical algorithms, clinician education and one prospective antibiotic review.
In an assessment of appropriate versus inappropriate antibiotics, the pooled odds ratio (OR) was 3.47 (95% CI 2.39 – 5.03) when chosen by a pharmacist during the intervention. For specific conditions, appropriate antibiotic selection was more appropriate with pharmacist involvement for pneumonia (OR = 3.74) and urinary tract infections (OR = 1.76).
In subgroup analysis, the presence of a pharmacist led to improvements in each of the areas examined. For example, pharmacist presence within the department for antibiotic selection was better than no pharmacist for appropriate antibiotic selection (OR = 3.13), culture review (OR = 2.22) and pharmacist directed algorithms and clinical education (OR = 5.23).
However, the time to culture review and time to patient contact were no different with or without a pharmacists, although the time to appropriate antibiotic was significantly shorter in the presence of a pharmacist (mean difference 18.86 hours).
The authors concluded that the presence of a pharmacist or pharmacist-led antimicrobial stewardship interventions appeared effective for ensuring appropriate prescribing of antibiotics in adult patients presenting to emergency departments despite how the majority of included studies had a moderate risk of bias.