In this episode, I’ll discuss an abstract by a pharmacy resident about the use of a combination antibiotic bag (CAB) in severe sepsis and septic shock.
At the NYSCHP annual assembly, I saw a presentation about a novel way to increase compliance with the sepsis core measure bundle of antibiotics and 30 ml/kg of crystalloid fluids for septic shock.
The primary author of this investigation is Michael Lorenzo, and he agreed to join me on the podcast to discuss his intervention. Pharmacy Mike is a Doctor of Pharmacy and PGY-1 resident at Upstate University Hospital in Syracuse, NY.
Below is a summary of his abstract – listen to the episode to hear the full interview!
Title
Impact of a Combination Antibiotic Bag on Compliance with Surviving Sepsis Campaign Goals in Emergency Department Patients with Severe Sepsis and Septic Shock
Authors
Lorenzo M, MacConaghy L, Meola G, Miller C, Pratt B, Steele J, Probst L, Seabury R
Purpose
The authors sought to determine whether the use of a combination antibiotic bag (CAB) of 2 grams cefepime plus 1 gram vancomycin mixed in 1 liter of normal saline impacts compliance with quality measures related to antibiotics and fluids within 3 hours of presentation for patients with severe sepsis or septic shock.
Methods
This was a retrospective chart review in the ED of a single academic medical center. Patients receiving > 1 antibiotic were included if they met criteria for severe sepsis or septic shock.
The primary endpoint was the administration of two antibiotics and a 30 mL/kg crystalloid challenge within three hours of ED triage. The secondary endpoint was 14-day in-hospital mortality.
Results
80 patients in the CAB group and 80 patients in the non-CAB group were included in this analysis. The CAB group met the primary outcome more frequently than the non-CAB group (63.8% vs. 22.5%). No difference in 14-day in-hospital mortality was noted although the CAB group trended towards a lower mortality rate compared to the non-CAB group (25% vs. 32.5%). The median time to administration of two antibiotics and the median time to administration of a 30 mL/kg crystalloid challenge were also shorter in the CAB group.
Conclusion
The authors concluded:
The CAB improved the proportion achieving guideline recommendations for crystalloid and antibiotic administration in a cohort of ED patients with severe sepsis or septic shock. Such an intervention has not been previously reported and could play a meaningful role in the management of severe sepsis and septic shock.
Discussion
Listen to the episode for a discussion of the study limitations and author’s next steps.
References discussed:
1 gram initial dose of vancomycin & impact on outcome
Vancomycin AUC:MIC estimator
CAB stability data: Vance VH. Stability of cefepime admixed with vancomycin, metronidazole, ampicillin, clindamycin, tobramycin, netilmicin, TPN solution, and PD solution. Syracuse, NY: Bristol-Myers Company; 1992 Oct 14
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Great work. Very informative.
Great study! Was there a problem in detecting ADRs though? What if the patient developed a reaction from the CAB? There’s no way to find out the causative agent. That would be my only concern. There was no difference in 14-day mortality. However, did patients improve in other endpoints? Did they require less fluids? Did they get downgraded faster? If Pharmacy Mike can answer these questions, that’ll be super.
Great question – I actually asked Mike to comment on that when I saw his presentation at the meeting. My feeling is that it is not possible to differentiate ADRs with sequential abx administration and therefore in severe sepsis/septic shock there is no difference from an ADR standpoint between sequential and simultaneous antibiotic administration. I’ll ask Mike to comment on the other points.
It definitely would be difficult to differentiate between ADR’s outside of ones that are very characteristic (ie, Redmans), but I agree with Joe in that if you are rapidly administering separate antibiotics sequentially, the same issue would be present. As far as other outcomes, the design of this initial investigation was intended to assess the impact of the CAB on Surviving Sepsis Campaign goals that have been associated with positive outcomes. Since we have found that the CAB increased the probability of this care being provided, we hope to continue its use and assess its impact on other outcomes as you have brought up, but at this point, alot of that data has not been collected or assessed. Thanks for the feedback!
Thank you Pharmacy Joe and Mike for the reply! Good stuff.
This is amazing! Such a simple solution to a complex problem we all face in Emergency Medicine & Sepsis treatment. I have tried incorporating / ‘pushing for’ IV push ABX in my ED but it hasn’t really taken off on a systems level / in my absence (hard to break traditional norms, people forget which ABX can be pushed and which cant, etc.). I will typically push Cefepime in acute patients but system wide it is a hard pattern to break. Now having the meds available premade in pyxis along with first liter …. genius.
I will definitely trial this in my ED.
Great stuff and thanks for sharing.
Ash
PS Pharm Joe – I am upset I wasn’t the first guest host…?! I guess I need to ‘up my game’ 😉 All kidding aside this was a great podcast. Great job guys!!!
Awesome – thanks, Ash! Please keep us updated on how your trial of the CAB turns out!
How fast did you run the 1L vanco/cefepime over?
I believe they ran it in over an hour