In this episode, I’ll discuss the impact two new recommendations in the Surviving Sepsis guidelines on hospital pharmacy practice.
The new Surviving Sepsis Guidelines are out and at least two new recommendations are going to keep hospital pharmacists busy implementing.
The first is on extended infusions of beta-lactam antibiotics:
For adults with sepsis or septic shock, we “recommend” using prolonged infusion of beta-lactams for maintenance (after an initial loading dose) over bolus administration.
(strong recommendation, moderate certainty evidence)
This is a recommendation that was revisited from prior guideline versions and the strength of the recommendation was upgraded to “strong” based on the Bling III randomized trial which showed extended infusions improved mortality. In this study, patients randomized to receive the meropenem or piperacillin-tazobactam via continuous infusion received the prescribed dose over 24 hours following an initial bolus dose by intermittent infusion over 30 minutes. If the patient switched from one antibiotic to another, a new bolus was given, but the new continuous infusion was started 4 hours after the bolus. While most hospitals have switched to continuous infusion for piperacillin-tazobactam, not as many have made the switch for meropenem. But with this being a strong recommendation, it is likely that clinicians will want to implement continuous beta-lactam infusions as soon as possible, which will require protocol development and nursing education provided by pharmacists. The protocol used in the Bling III trial can be found in the supplemental data tab of the JAMA website for the article.
The second is on selective decontamination of the digestive tract:
In mechanically ventilated adults with sepsis or septic shock in units with a low prevalence of antimicrobial resistance, we “suggest” using selective decontamination of the digestive tract.
(conditional recommendation, moderate certainty evidence)
This is a weaker guideline statement, given as a suggestion or conditional recommendation rather than a strong recommendation. Selective decontamination of the digestive tract (SDD) is a preventive infection-control strategy consisting of administering nonabsorbable, topical antimicrobial agents to the oropharynx and upper gastrointestinal tract (oropharyngeal decontamination), along with a short-term course of broad-spectrum IV antimicrobial therapy in mechanically ventilated patients. SDD is intended to eliminate pathogenic aerobic bacteria while preserving anaerobic gut bacteria that is essential to digestion and immune function.
The guideline recommendation was based on a meta-analysis that suggested a reduction in short-term mortality. After the guideline recommendations were finalized, the SuDDICU trial results were published in NEJM. This trial found no mortality benefit at 90 days but significant reductions in new bloodstream infections, and fewer antibiotic-resistant organisms cultured. The protocol for this study is resource-intensive for pharmacists as it involves a paste and enteral solution of colistin, tobramycin, and nystatin as well as IV ceftriaxone. Given the fact that this is presented by the guideline authors as a suggestion instead of a strong recommendation, the effects on practice will not be as widespread as with the prolonged infusion of beta-lactams.
The topic in this episode is inspired by an in-depth training available to members of my Hospital Pharmacy Academy. The Hospital Pharmacy Academy is my online membership site that will teach you practical critical care and hospital pharmacy skills you can apply at the bedside so that you can become confident in your ability to save lives and improve patient outcomes. To get immediate access to this and many other resources to help in your practice, go to pharmacyjoe.com/academy.
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.
Leave a Reply