In this episode I’ll:
1. Discuss an article about antimicrobial stewardship and empiric antibiotic timing.
2. Answer the drug information question “Should a patient on apixaban at home who presents with massive PE receive thrombolytic therapy?”
3. Share a resource for infectious disease pharmacotherapy.
Thursday April 6, 2017 members of my Critical Care Pharmacy Academy will have access to my new Masterclass: Interpreting laboratory data in the ICU. To learn more about the Academy and sign up go to pharmacyjoe.com/academy.
Article
Lead author: Tiffany E. Bias
Published in American Journal of Health-System Pharmacy April 2017
Background
An internal review of time to first antibiotic dose at the center that this study was conducted revealed significant delays. The center developed and evaluated an antimicrobial stewardship protocol aimed at reducing the time to first antibiotic after positive blood culture.
Methods
The study was a single-center retrospective before-after design. Adult inpatients were included if their infection developed 2 or more days after hospital admission and their blood culture grew an organism that was not a common skin contaminant such as coag negative staph.
The intervention was the implementation of a rapid administration of antimicrobials by an infectious diseases specialist (RAIDS) protocol. The RAIDS protocol changed the workflow in the hospital for notification of positive blood cultures during the hours of 8 am to 5 pm.
The original workflow involved microbiology notifying a nurse of a positive blood culture who notified a physician who would then write an antibiotic order to be verified and administered. The RAIDS workflow involved microbiology notifying an infectious diseases pharmacist of the positive blood culture, who obtained an antibiotic order from a physician and delivered the antibiotic to the patient’s nurse for administration.
Results
There were 62 patients in the pre-RAIDS group and 71 patients in the post-RAIDS group. A total of 111 bacteremic patients were included in the analysis. The median time to first antibiotic dose was approximately 8 hours faster in the post-RAIDS group than in the pre-RAIDS group (9:09 hr:min versus 1:23 hr:min).
Patients in the post-RAIDS group had a greater than 50% reduction in infection-related mortality that was statistically significant (p = 0.047). Other variables such as all-cause 30-day mortality and length of stay were similar between groups.
Conclusion
The authors concluded:
Early notification of an infectious diseases pharmacist about positive blood cultures using the RAIDS protocol led to increased appropriateness of empirical drug selection and a dramatic reduction in the administration of antibiotics and was associated with decreased infection-related mortality.
Discussion
This RAIDS protocol is a novel method of employing the equivalent of real-time clinical surveillance without the expense of implementing a computerized surveillance system.
The structure of the protocol seems to borrow from Lean / Six Sigma approaches in that significant amounts of time-wasting or redundant activities are eliminated from the workflow. The impressive reduction in time to first antibiotic dose is a logical consequence of the workflow improvements with the RAIDS protocol.
Other studies have demonstrated that mortality increases with each hour that antibiotics are delayed, and mortality from infections was reduced by 56% in this study.
I can’t help but view this study through the same lens as the vitamin C in sepsis study discussed in episode 177. Both studies are before-after retrospective studies that show impressive reductions in mortality. Where are the media articles that pharmacists are the cure for hospital-acquired infections?!?
Rather than adopting this RAIDS protocol immediately at your hospital, I would suggest first examining the time to first antibiotic for patients who develop positive blood cultures after hospital admission. If the time to first antibiotic is too long, then the RAIDS protocol seems like a legitimate way to go about shortening it.
Studies continue to be published exploring how pharmacists can have an impact on patient outcomes when focusing antimicrobial stewardship initiatives on patients with newly discovered bacteremia.
Pharmacist improve outcomes in Staph Aureus Bacteremia https://t.co/12oTK3fKFi Proud to work with great team! @OSUWexMed @osu_pharmacy
— Tony Gerlach (@SICUPharmD) April 4, 2017
Awesome be sure to give a shout out to my colleagues (pharmacists) @OSUWexMed and the authors @TheBack140 @idpharmd @TheIDApprentice https://t.co/4CycshDWn7 — Tony Gerlach (@SICUPharmD) April 5, 2017
Drug information question
Q: Should a patient on apixaban at home who presents with massive PE receive thrombolytic therapy?
A: Probably.
Shout out to “Pharmacy Tricia” for bringing up this topic in the Pharmacy Nation Slack group. I was unable to find a clear-cut answer to this question. However, according to the CHEST guidelines, patients already on anticoagulation for PE who deteriorate can receive a thrombolytic on top of the anticoagulation.
If anti-Xa testing for apixaban is available and the level is elevated, I would give consideration to half-dose alteplase (50 mg) or catheter directed therapies if your institution can accomplish that.
You can join the free Pharmacy Nation Slack group to ask and answer pharmacy related questions in real-time with hundreds of other pharmacists by signing up at pharmacynation.org.
Resource
The resource for this episode is the website idstewardship.com. This site was founded by Timothy Gauthier, Pharm.D., BCPS-AQ ID, a pharmacist trained in infectious diseases and antimicrobial stewardship. The website provides a free study guide for infectious diseases pharmacotherapy, a compendium of antimicrobial stewardship resources, and original articles on pharmacy-related topics.
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