Impact of Pharmacist Intervention on Selection and Timing of Appropriate Antimicrobial Therapy in Septic Shock

2017 ◽  
Vol 31 (1) ◽  
pp. 46-51 ◽  
Author(s):  
Melanie E. Laine ◽  
Jeremy D. Flynn ◽  
Alexander H. Flannery
Keyword(s):  
Septic Shock ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Empiric Therapy ◽  
Pharmacist Intervention ◽  
Entire Cohort ◽  
Sepsis Bundle ◽  
Selection Of ◽  
Antimicrobial Administration

Background: Current guidelines for septic shock management recommend administration of appropriate, broad-spectrum antimicrobials within 1 hour of recognition. Objective: To evaluate the interventions pharmacists make as part of a sepsis response team and to determine if these interventions increase the proportion of patients with appropriate empiric antimicrobial therapy. Methods: A retrospective cohort study was undertaken reviewing adult patients in a large, academic medical center with confirmed septic shock who had an order for a “sepsis bundle,” which includes notification of a pharmacist to assess adequacy of empiric therapy. Pharmacist interventions with regard to selection of empiric antimicrobials were documented. The proportion of patients with initial successful selection of antimicrobial therapy (SSAT) before and after pharmacist intervention was assessed as well as the time to first antimicrobial administration and time to appropriate antimicrobial administration. Results: A total of 76 patients were included. Pharmacist intervention increased the proportion of patients with SSAT from 66% to 80% ( P = .04). Median time to first antimicrobial administration was 43 minutes, and time to appropriate antimicrobial therapy was 1 hour, 34 minutes for the entire cohort, with pharmacist intervention decreasing the latter time significantly in patients without SSAT on initiation of the “sepsis bundle” ( P < .001). Conclusion: Pharmacist assessment of patients in septic shock offers the opportunity to improve SSAT. Systems designed to use a pharmacist responder for the care of patients with septic shock maximize the selection of antimicrobials, facilitate rapid administration, and improve surrogate outcomes for mortality in septic shock.

scholarly journals Impact of Inactive Empiric Antimicrobial Therapy on Inpatient Mortality and Length of Stay

2006 ◽  
Vol 50 (10) ◽  
pp. 3355-3360 ◽  
Author(s):  
Kimberly K. Scarsi ◽  
Joe M. Feinglass ◽  
Marc H. Scheetz ◽  
Michael J. Postelnick ◽  
Maureen K. Bolon ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Bloodstream Infections ◽  
Empiric Therapy ◽  
Inpatient Mortality ◽  
In Vitro Susceptibility ◽  
Empiric Antimicrobial Therapy

ABSTRACT The consequences of inactive empiric antimicrobial therapy are not well-described and may cause prolonged hospitalization or infection-related mortality. In vitro susceptibility results for 884 patients hospitalized at an academic medical center with gram-negative bloodstream infections (GNBI) from 2001 to 2003 were matched to antimicrobial orders within 24 h of culture. Clinical characteristics, organism, inpatient mortality, and length of stay after culture for patients with GNBI were compared between patients receiving active versus inactive empiric antimicrobial therapy. A total of 14.1% of patients with GNBI received inactive empiric therapy, defined as no antimicrobial therapy within 24 h of the culture active against the identified organism based on in vitro microbiology reports. Patients who received inactive therapy were more likely to be younger, to be infected with Pseudomonas aeruginosa, to have a nosocomial infection, and to receive antimicrobial monotherapy but less likely to be bacteremic with Escherichia coli or to have sepsis (P < 0.05). There were no significant differences in mortality between patients receiving active versus inactive empiric therapy (16.1% versus 13.6%, respectively) or in length of stay after positive culture (11.5 days versus 12.6 days, respectively). Only 45 patients had greater than 2 days of exposure to inactive therapy; however, 8/30 patients (26.7%) who never received active antimicrobial therapy died while in the hospital. Inactive empiric therapy was more common in healthier patients. Inactive antimicrobial therapy in the first 24 h did not significantly impact average outcomes for GNBI among hospitalized patients but may have caused harm to specific individuals.

scholarly journals 183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S98-S98
Author(s):  
Hannah Kafisheh ◽  
Matthew Hinton ◽  
Amanda Binkley ◽  
Christo Cimino ◽  
Christopher Edwards
Keyword(s):  
Emergency Department ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Positive Culture ◽  
Culture Result ◽  
Academic Medical ◽  
Positive Culture Result ◽  
Therapy Modification

Abstract Background Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI). Methods This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed. Results A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p &lt; 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p &lt; 0.01). Conclusion The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA. Disclosures All Authors: No reported disclosures

Comparison of Unit-Specific and Hospital-Wide Antibiograms Potential Implications for Selection of Empirical Antimicrobial Therapy

2006 ◽  
Vol 27 (7) ◽  
pp. 682-687 ◽  
Author(s):  
Shawn Binkley ◽  
Neil O. Fishman ◽  
Lori A. LaRosa ◽  
Ann Marie Marr ◽  
Irving Nachamkin ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Medical Center ◽  
Tertiary Care ◽  
General Medicine ◽  
Bacterial Isolates ◽  
Anatomic Site ◽  
Empirical Antimicrobial Therapy ◽  
Tertiary Care Medical Center ◽  
Surgical Icu ◽  
Selection Of

Objective.To identify differences between unit-specific and hospital-wide antibiograms and to determine the potential impact of these differences on selection of empirical antimicrobial therapy.Setting.A 625-bed tertiary care medical center.Methods.Antimicrobial susceptibility results were collected for all inpatient clinical bacterial isolates recovered over a 3-year period; isolates were categorized by the hospital location of the patient at the time of sampling and by the anatomic site from which the isolate was recovered. Antibiograms from each unit were compiled for the most commonly isolated organisms and were compared to the hospital-wide antibiogram.Results.A total of 9,970 bacterial isolates were evaluated in this study, including 2,646 enterococcal isolates, 2,806 S. aureus isolates, 2,795 E. coli isolates, and 1,723 Pseudomonas aeruginosa isolates. The percentages of bacterial isolates resistant to antimicrobials were significantly higher in the medical ICU and surgical ICU than the hospital-wide antibiogram would have predicted, whereas the percentages of isolates susceptible to antimicrobials were significantly higher in the non-ICU units, compared with the hospital overall. However, on general medicine units, the prevalence of susceptibility to levofloxacin was significantly lower than that for the hospital overall.Conclusions.Unit-specific antibiograms are important for making informed decisions about empirical antimicrobial therapy, because the hospital-wide antibiogram may mask important differences in susceptibility rates across different units. These differences may have important implications for selecting the optimal empirical antimicrobial therapy.

Implementation of a pharmacist-provided pharmacogenomics service in an executive health program

2021 ◽  
Author(s):  
Ina Liko ◽  
Lisa Corbin ◽  
Eric Tobin ◽  
Christina L Aquilante ◽  
Yee Ming Lee
Keyword(s):  
Health Program ◽  
Medical Center ◽  
Academic Medical Center ◽  
Test Results ◽  
Sample Collection ◽  
Team Members ◽  
University Of Colorado ◽  
Academic Medical ◽  
Previous Medication ◽  
Selection Of

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose We describe the implementation of a pharmacist-provided pharmacogenomics (PGx) service in an executive health program (EHP) at an academic medical center. Summary As interest in genomic testing grows, pharmacists have the opportunity to advance the use of PGx in EHPs, in collaboration with other healthcare professionals. In November 2018, a pharmacist-provided PGx service was established in the EHP at the University of Colorado Hospital. The team members included 3 physicians, a pharmacist trained in PGx, a registered dietitian/exercise physiologist, a nurse, and 2 medical assistants. We conducted 4 preimplementation steps: (1) assessment of the patient population, (2) selection of a PGx test, (3) establishment of a visit structure, and (4) selection of a billing model. The PGx consultations involved two 1-hour visits. The first visit encompassed pretest PGx education, review of the patient’s current medications and previous medication intolerances, and DNA sample collection for genotyping. After this visit, the pharmacist developed a therapeutic plan based on the PGx test results, discussed the results and plan with the physician, and created a personalized PGx report. At the second visit, the pharmacist reviewed the PGx test results, personalized the PGx report, and discussed the PGx-guided therapeutic plan with the patient. Overall, the strategy worked well; minor challenges included evaluation of gene-drug pairs with limited PGx evidence, communication of information to non-EHP providers, scheduling issues, and reimbursement. Conclusion The addition of a PGx service within an EHP was feasible and provided pharmacists the opportunity to lead PGx efforts and collaborate with physicians to expand the precision medicine footprint at an academic medical center.

Clinical Pharmacist–Led Impact on Inappropriate Albumin Use and Costs in the Critically Ill

2019 ◽  
Vol 54 (2) ◽  
pp. 105-112
Author(s):  
Mitchell S. Buckley ◽  
Kristen D. Knutson ◽  
Sumit K. Agarwal ◽  
Jake M. Lansburg ◽  
Laura M. Wicks ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Critically Ill ◽  
Clinical Pharmacist ◽  
Medical Center ◽  
Academic Medical Center ◽  
Intervention Strategy ◽  
Cost Savings ◽  
Pharmacist Intervention ◽  
Total Annual Cost ◽  
Inappropriate Use

Background:Optimal albumin use in the intensive care unit (ICU) remains challenging with inappropriate use approaching 50%. No published reports have described clinical pharmacist impact aimed at mitigating inappropriate albumin use in the ICU. Objective: To evaluate the clinical and economic impact of a clinical pharmacist–led intervention strategy targeting inappropriate albumin in the ICU. Methods: A retrospective cohort study evaluated all adult (≥18 years) ICU patients administered albumin at an academic medical center over a 2-year period. Institutional guidelines were developed with clinical pharmacists targeting inappropriate albumin use. The primary end point was to compare inappropriate use of albumin administered before and after pharmacist intervention implementation. Secondary analyses compared the overall albumin use between study periods. In-hospital mortality, length of stay, and albumin-related costs between study periods were also compared. Results: A total of 4419 patients were identified, with 2448 (55.4%) critically ill patients included. The pharmacist-led strategy resulted in a 50.9% reduction of inappropriate albumin use ( P < 0.001). The rate of inappropriate albumin use was 44.3 ± 10.5 and 5.5 ± 2.9 g per patient-day in the preimplementation and postimplementation periods, respectively ( P < 0.001). Costs associated with overall and inappropriate albumin use in the ICU decreased by 34.8% and 87.1%, respectively. Total annual cost-savings was $355 393 in the ICUs. No differences in clinical outcomes were found. Conclusion and Relevance: Clinical pharmacist–led interventions reduced overall and inappropriate albumin use and costs without negatively affecting clinical outcomes.

Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis

2020 ◽  
pp. 106002802098072
Author(s):  
Melissa M. Durst ◽  
Elizabeth A. Eitzen ◽  
Scott T. Benken
Keyword(s):  
Septic Shock ◽  
Hospital Mortality ◽  
Medical Center ◽  
Cohort Analysis ◽  
Academic Medical Center ◽  
Treatment Strategies ◽  
Severity Of Illness ◽  
Discharge Disposition ◽  
Increase Risk ◽  
Vasopressor Use

Background Patients with cirrhosis have immune dysfunction, altered inflammatory response, and hemodynamic changes which increase risk of septic shock and potentially prolong management with fluids, vasopressors, and other therapies. Due to limited available guidance, this study aimed to characterize vasopressor use in patients with cirrhosis in relation to patients without cirrhosis in septic shock. Methods This was a retrospective matched cohort analysis of 122 patients admitted to the intensive care unit (ICU) at an academic medical center from January 2015 to November 2017. Patients were grouped based on the presence or absence of cirrhosis and matched based on severity of illness scoring. The primary outcome was vasopressor duration. Secondary comparisons included total vasopressor requirement, length of hospital and ICU stay, in-hospital mortality, change in organ function, and discharge disposition. Results The group with cirrhosis had significantly longer median (interquartile range [IQR]) durations of vasopressor therapy compared with the group without cirrhosis (86.0 [42.0-164.5] vs 39.0 [14.5-82.0] hours; P = 0.003) leading to increased median (IQR) vasopressor exposure (71.7 [15.5-239.5] vs 24.7 [5.3-77.9] mg norepinephrine [NE] equivalents; P = 0.003). No difference was found in in-hospital mortality between groups. However, regression analysis showed vasopressor exposure was associated with in-hospital mortality. Conclusion and Relevance Patients with cirrhosis in septic shock have increased vasopressor durations and overall requirements compared with patients without cirrhosis. Increased durations and requirements is associated with poorer outcomes independent of presence of cirrhosis. Future studies are needed to improve vasopressor treatment strategies and end points utilized in cirrhosis.

Hemodynamic Response to Vasopressin Dosage of 0.03 Units/Min vs. 0.04 Units/Min in Patients With Septic Shock

2020 ◽  
pp. 088506662097718 ◽  
Author(s):  
Seth R. Bauer ◽  
Gretchen L. Sacha ◽  
Simon W. Lam ◽  
Lu Wang ◽  
Anita J. Reddy ◽  
...  
Keyword(s):  
Septic Shock ◽  
Primary Outcome ◽  
Medical Center ◽  
Academic Medical Center ◽  
Initial Dosage ◽  
Hemodynamic Response ◽  
Adjusted Relative Risk ◽  
Covariate Balance ◽  
Academic Medical ◽  
Medical Intensive Care

Background: Arginine vasopressin (AVP) is suggested as an adjunct to norepinephrine in patients with septic shock. Guidelines recommend an AVP dosage up to 0.03 units/min, but 0.04 units/min is commonly used in practice based on initial studies. This study was designed to compare the incidence of hemodynamic response between initial fixed-dosage AVP 0.03 units/min and AVP 0.04 units/min. Methods: This retrospective, multi-hospital health system, cohort study included adult patients with septic shock receiving AVP as an adjunct to catecholamine vasopressors. Patients were excluded if they received an initial dosage other than 0.03 units/min or 0.04 units/min, or AVP was titrated within the first 6 hours of therapy. The primary outcome was hemodynamic response, defined as a mean arterial pressure ≥65 mm Hg and a decrease in catecholamine dosage at 6 hours after AVP initiation. Inverse probability of treatment weighting (IPTW) based on the propensity score for initial AVP dosage receipt was utilized to estimate adjusted exposure effects. Results: Of the 1536 patients included in the observed data, there was a nearly even split between initial AVP dosage of 0.03 units/min (n = 842 [54.8%]) and 0.04 units/min (n = 694 [45.2%]). Observed patients receiving AVP 0.03 units/min were more frequently treated at the main campus academic medical center (96.3% vs. 52.2%, p < 0.01) and in a medical intensive care unit (87.4% vs. 39.8%, p < 0.01). The IPTW analysis included 1379 patients with achievement of baseline covariate balance. There was no evidence for a difference between groups in the incidence of hemodynamic response (0.03 units/min 50.0% vs. 0.04 units/min 53.1%, adjusted relative risk 1.06 [95% CI 0.94, 1.20]). Conclusions: Initial AVP dosing varied by hospital and unit type. Although commonly used, an initial AVP dosage of 0.04 units/min was not associated with a higher incidence of early hemodynamic response to AVP in patients with septic shock.

1258: Utilization of Angiotensin II in Septic Shock at a Large Academic Medical Center

2020 ◽  
Vol 49 (1) ◽  
pp. 634-634
Author(s):  
Klayton Ryman ◽  
Lloyd McKee ◽  
Vivek Kataria ◽  
Ariel Modrykamien
Keyword(s):  
Septic Shock ◽  
Angiotensin Ii ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical

scholarly journals 2101. Impact of “Code Sepsis” on Antimicrobial Utilization at an Academic Medical Center

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S710-S710
Author(s):  
Minji Kang ◽  
Francesca J Torriani ◽  
Rebecca Sell ◽  
Shira Abeles
Keyword(s):  
Organ Dysfunction ◽  
Early Recognition ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospitalized Patients ◽  
Antibiotic Administration ◽  
Academic Medical ◽  
Sepsis Bundle ◽  
The Impact ◽  
Infectious Source

Abstract Background Balancing antimicrobial stewardship with sepsis management is a challenge. At our academic medical center, a “Code Sepsis” was implemented as a nursing driven initiative to improve early recognition and management of sepsis. Per protocol, Code Sepsis is activated in patients who meet two or more systemic inflammatory response syndrome (SIRS) criteria due to a suspected infection to allow for early implementation of the sepsis bundle, which includes laboratory testing, fluid resuscitation, and antibiotic administration (Figure 1). We analyzed the impact that Code Sepsis had on antimicrobial use among hospitalized patients over a six month period. Methods We reviewed the electronic medical records of hospitalized patients with Code Sepsis activation between January 1, 2018 and June 30, 2018 to determine whether antibiotics were “escalated” or “not escalated.” Among patients who had antibiotic escalation, escalation was classified as “indicated” or “not indicated” (Figure 2). A logistic regression model was used to identify characteristics, SIRS or organ dysfunction criteria predictive of indicated antimicrobial escalation. Results Code Sepsis was activated in 529 patients with antibiotics escalated in 247 (47%) and not escalated in 282 (53%) (Table 1). Among patients whose antibiotics were escalated, 64% (152) had an indication. In 36% (89), escalation was not indicated as Code Sepsis was due to a suspected noninfectious source, known infectious source already on appropriate antimicrobials, or a suspected infectious source in which diagnostic results had already shown the absence of the infection (Figure 2). Odds of indicated antibiotic escalation increased with the number of SIRS and organ dysfunction criteria (Table 2). Conclusion In our efforts to improve sepsis outcomes, we focused on early recognition (Code Sepsis) and intervention (sepsis bundle). However, our Code Sepsis inadvertently led to antibiotic overutilization. By refocusing Code Sepsis on early recognition of severe sepsis and septic shock, we hope to optimize resource utilization and improve patient outcomes. Disclosures All authors: No reported disclosures.

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