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)erica.housman@baystatehealth.org

▪ 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