Pharmacist-led antimicrobial stewardship ensures appropriate prescribing in EDs

2nd February 2022

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.

Findings

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.

Citation

Kooda K et al. Impact of Pharmacist-Led Antimicrobial Stewardship on Appropriate Antibiotic Prescribing in the Emergency Department: A Systematic Review and Meta-Analysis Ann Emerg Med 2022.

Treatment failure in clinically stable CAP patients associated with male gender and age

20th October 2021

Treatment failure in clinically stable CAP patients after 15 days is significantly associated with only male gender and age.

Treatment failure in patients with community-acquired pneumonia (CAP) who are deemed clinically stable is associated with being male and age, according to a study by a team from the Infectious Disease Unit, Raymond-Poincare University Hospital, Paris, France. Treatment failure rates in CAP have been found to range between 2.4 and 31% among hospitalised patients and it is a serious complication that is associated with high morbidity and mortality rates. Nevertheless, once CAP patients achieve clinical stability, deterioration is much less likely as witnessed by a study of nearly 700 adults hospitalised with CAP which found that  less than 1% worsened once stable.

Shorter antibiotic treatment courses for those hospitalised with CAP have the potential to reduce antibiotic resistance, adverse events and related costs. In a recent trial, the Paris team undertook a double-blind, randomised, placebo-controlled trial, the Pneumonia Short Treatment (PTC), among adult patients admitted to hospital with moderately severe CAP. The purpose of the trial was to determine whether there was a need for an additional 5-day course of β-lactam antibiotic treatment in CAP patients who were clinically stable after 3 days of treatment. The study’s primary outcome was cure, 15 days after the first antibiotic intake, defined by apyrexia, resolution or improvement of respiratory symptoms and no additional antibiotic treatment for any cause. The results showed that discontinuing β-lactam treatment after 3 days was non-inferior to 8 days of treatment.

For their latest study, the team performed a secondary analysis of data from the PTC trial to examine the factors associated with treatment failure. Details of the patient population, outcome measures etc were provided in the PTC study publication.

Findings

The PTC trial included 310 patient and the secondary analysis comprised 291 of these patients with a mean age of 69.6 years (59.8% male). The overall treatment failure rate was 26.8% (78 patients) and mainly due to a lack of symptom resolution (79.5%), including purulent sputum. dyspnoea and cough. Other causes of treatment failure were the need for additional antibiotics (10.2%) and fever at day 15 (5.1%).

Multivariate analysis revealed that male gender was significantly associated with treatment failure (odds ratio, OR = 1.92, 95% CI 1.08 – 3.49, p = 0.03) as was age (OR = 1.02, 95% CI 1.0 – 1.05, p = 0.03). This latter result was not surprising given that the mean age of those in the failure group was 76.2 years compared to 67.2 years in the cure group (p = 0.01). Interestingly, as noted in the original PTC study, the duration of antibiotic therapy had no impact on treatment failure.

The authors concluded that among clinically stable patients with CAP who received a 3-day course of antibiotics, only age and male gender, not disease severity or co-morbidities, were significantly associated with treatment failure. They suggested that these results should be taken into account in the treatment of those with CAP.

Citation

Dinh A et al.Factors Associated With Treatment Failure in Moderately Severe Community-Acquired Pneumonia. A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021