In this episode I’ll:
1. Discuss an article comparing two types of antibiotic stewardship interventions.
2. Answer the drug information question “Can amiodarone cause acute pulmonary toxicity?”
3. Share a resource for listening to free emergency medicine talks.
Every week in the Critical Care Pharmacy Academy, I keep pharmacists up to date on the latest critical care literature. For this Monday’s literature digest, I reviewed 163 titles in 24 critical care journals and summarized and commented on the top articles in video & audio format for Academy members.
Click here to learn more about the Academy.
Article
Lead author: Pranita D. Tamma
Published in Clinical Infectious Diseases online December 2016
Background
In an attempt to determine the optimal approach to conducting antibiotic stewardship interventions, the authors compared days of antibiotic therapy (DOT) using pre-prescription authorization (PPA) versus post-prescription review with feedback (PPRF) strategies.
Methods
The study was a crossover trial involving four medicine teams. Two teams were assigned to pre-prescription authorization and two were assigned to post-prescription review with feedback for 4 months. The teams then switched assignments for another 4 months. Two or more infectious diseases trained clinicians adjudicated the appropriateness of antibiotic use.
Results
Each group had over 2600 patients admitted. 29% of patients in the pre-prescription authorization and 27% of patients in the post-prescription review with feedback group received antibiotics. Median patient days of antibiotic therapy in the PPA and PPRF arms were 8 and 6 DOT per 1,000 patient days. This difference was statistically significant (p=0.03). The difference in antibiotic guideline compliance was also statistically different between groups. Antibiotic therapy was guideline-noncompliant in 34% and 41% of patients and in 57% and 36% of patients on days 1 and 3, in the PPA and PPRF groups, respectively.
Conclusion
The authors concluded:
PPRF may have more of an impact on decreasing antibiotic DOTs compared with PPA. This information may be useful for institutions without sufficient resources to incorporate both stewardship approaches.
Discussion
I have a very strong personal preference for post-prescription review with feedback as the preferred method of antibiotic stewardship. In my opinion, pre-prescription authorization creates an adversarial relationship between the treating physician and the stewardship team. It also creates the need for an appeals process and on-call person to adjudicate differences. Many patients initially present with an unclear diagnostic picture that becomes clear after 2-3 days. Post-prescription review with feedback gives deference to the treating provider’s initial judgment, yet allows the stewardship team to provide education and corrective action after the dust settles.
Drug information question
Q: Can amiodarone cause acute pulmonary toxicity?
A: Yes.
A retrospective review found that 3 of 7 patients who received amiodarone and died in the ICU with a clinical diagnosis of ARDS had pathological features of amiodarone-induced pulmonary toxicity. The authors of the article concluded:
Acute amiodarone pulmonary toxicity is a definite pathological entity in ICU patients. High oxygen concentrations may be a risk factor, while pre-existing pathology, e. g. ARDS, may mask its development. Amiodarone should be used with caution in this group of patients.
Resource
FreeEmergencyTalks.net was created by residents of the Temple University Hospital Emergency Medicine program to help distribute the vast Emergency Medicine lecture library of Dr. Joe Lex. The website is now run by Dr. Jason Hine. It contains audio from thousands of emergency medicine related lectures. Searching through the talks is aided by a system of tags.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
In the ER, what I find most useful is an onsite ED pharmacist who can raise concerns with me face-to-face and who I can curbside consult with my drug concerns.
The easy availability of pharmacists helps me relate to them as a resource and a colleague rather than as gatekeeper and a critic.
Obviously this will only be feasible in certain busy centers, but even if availability is limited to certain hours and certain days, seeing the pharmacist in the flesh down WHERE THE PATIENTS ARE has a tremendous positive impact on that working relationship. I take it much better when the person raising the concern for QT prolongation with Haldol is also listening to the psych patient screaming his promise to kill us all, and we can then turn as fellow soldiers in that foxhole to the question of what, if anything, might be safer or better.
Such fantastic points, thank you! I much prefer to be elbow-to-elbow solving the problem as it is occurring than the general that rides through after the battle is fought and points out what went wrong!
Joe