Improving care for critically ill patients with community-acquired pneumonia. (3rd June 2019)

• Record Type: Journal Article
• Authors: Bianchini, Monica L; Mercuro, Nicholas J; Kenney, Rachel M; Peters, Michael A; Samuel, Linoj P; Swiderek, Jennifer; Davis, Susan L
• Is Part Of: American journal of health-system pharmacy. Volume 76:Number 12(2019)
• Page Start: 861
• Page End: 868
• Publication Date: 2019-06-03
• Subjects: antibiotic stewardship -- community-acquired infections -- diagnostic tests -- intensive care units -- pharmacists -- pneumonia; Hospital pharmacies -- United States -- Periodicals; 615.1
• DOI: 10.1093/ajhp/zxz068
• Languages: English
• ISSNs: 1079-2082

Abstract

Abstract: Purpose: The purpose of this study was to improve antimicrobial management and outcomes of critically ill patients with community-acquired pneumonia (CAP) through implementation of a pharmacist-driven bundle for ordering evidence-based diagnostic tests in a medical intensive care unit (MICU). Methods: An inpatient collaborative practice agreement (CPA) was established for MICU pharmacists to order criteria-driven diagnostic testing for CAP from November 2017–March 2018. Adults admitted to the MICU and started on empiric antibiotics for CAP were included. The intervention arm was compared with a standard of care (SOC) group from November 2016–March 2017. Results: Ninety-one patients were included in each group. There was no difference in the median antibiotic duration between SOC and CPA, at 7 days (interquartile range [IQR], 6–10) versus 7 days (IQR, 6–8), respectively. The overall use of evidence-based diagnostic tests increased in the CPA group. Patients in the CPA group had more frequent pathogen identification (SOC and CPA, respectively: 31 [34%] versus 46 [51%], p = 0.035) and antimicrobial deescalation (24 [26%] versus 53 [58%], p < 0.001). There was no significant difference in length of intensive care unit stay, at 4 days for SOC (IQR, 2–10) versus 6 days for CPA (IQR, 3–10), and no significant difference in inpatient all-cause mortality (13 [14%] versus 7 [8%]), retreatment 14 [15%] versus 11 [12%]), or 30-day readmission 16 ([18%] versus 13 [14%]) for SOC and CPA, respectively. The CPA was the only variable that was independently associated with antimicrobial deescalation (odds ratio, 4.030; 95% confidence interval, 2.101–7.731) in a multiple logistic regression. Conclusion: Implementation of a pharmacy-driven pneumonia diagnostic stewardship bundle improved the use of evidence-based diagnostics and increased the frequency of pathogen identification. This intervention was associated with increased antimicrobial deescalation without a negative impact on patient safety outcomes.