Computerized provider order entry improves compliance of vancomycin dosing guidelines in the emergency department

Optimizing Pharmacokinetics-Pharmacodynamics of Antimicrobial Management in Patients with Sepsis: A Review

Critically ill patients with sepsis or septic shock are at an increased risk of death. Early and aggressive interventions are essential for improving clinical outcomes. There are a number of therapeutic and practical challenges in the management of antimicrobials in patients with sepsis. These include the timely selection and administration of appropriate antimicrobials, significant physiological alterations that can influence antimicrobial pharmacokinetics, and significant interpatient variability of antimicrobial concentrations using standard dosing approaches. Understanding the impact of these factors on the probability of attaining pharmacokinetic-pharmacodynamic target goals is essential to guide optimal therapy. Using rapid diagnostic technology could facilitate timely selection of antimicrobials, and therapeutic drug monitoring would provide a more individualized dosing approach. Using an interdisciplinary sepsis team would also be beneficial in coordinating efforts to overcome the challenges encountered during this critical period to ensure optimal care.

A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department

BACKGROUND/OBJECTIVE

To improve antimicrobial utilization, development and implementation of antimicrobial stewardship programs in the emergency department (ED) has been recommended. The primary objective of this review was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes or process of care and/or reduce consequences of antimicrobial use.

METHODS

This study was completed as a systematic review. The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science. Randomized controlled trials, nonrandomized controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-measures studies evaluating AMS interventions in the ED were included in the review. Studies published in languages other than English were excluded.

RESULTS

A total of 43 studies meeting inclusion criteria were identified from our search. Patient or provider education and guideline or clinical pathway implementation were the most commonly reported interventions. Few studies reported on audit and feedback, and no study evaluated preauthorization. Impact of interventions showed variable results. Where identified, benefits of AMS interventions primarily included improvement in delivery of care or a decrease in antimicrobial utilization; however, most studies were rated as having unclear or high risk of bias.

CONCLUSION

AMS interventions in the ED may improve patient care. However, the optimal combination of interventions is unclear. Additional studies with more rigorous design evaluating core components of AMS programs, including prospective audit and feedback are needed.

Appropriate Antibiotic Therapy

Prescribing antibiotics is an essential component of initial therapy in sepsis. Early antibiotics are an important component of therapy, but speed of administration should not overshadow the patient-specific characteristics that determine the optimal breadth of antimicrobial therapy. Cultures should be drawn before antibiotic therapy if it does not significantly delay administration. Combination antibiotic therapy against gram-negative infections is not routinely required, and combination therapy involving vancomycin and piperacillin/tazobactam is associated with an increase in acute kidney injury. Emergency practitioners should be aware of special considerations in the administration and dosing of antibiotics in order to deliver optimal care to septic patients.

A pre-postintervention study to evaluate the impact of dose calculators on the accuracy of gentamicin and vancomycin initial doses

OBJECTIVES

Gentamicin and vancomycin are narrow-therapeutic-index antibiotics with potential for high toxicity requiring dose individualisation and continuous monitoring. Clinical decision support (CDS) tools have been effective in reducing gentamicin and vancomycin dosing errors. Online dose calculators for these drugs were implemented in a London National Health Service hospital. This study aimed to evaluate the impact of these calculators on the accuracy of gentamicin and vancomycin initial doses.

METHODS

The study used a pre-postintervention design. Data were collected using electronic patient records and paper notes. Random samples of gentamicin and vancomycin initial doses administered during the 8 months before implementation of the calculators were assessed retrospectively against hospital guidelines. Following implementation of the calculators, doses were assessed prospectively. Any gentamicin dose not within ± 10% and any vancomycin dose not within ± 20% of the guideline-recommended dose were considered incorrect.

RESULTS

The intranet calculator pages were visited 721 times (gentamicin=333; vancomycin=388) during the 2-month period following the calculators' implementation. Gentamicin dose errors fell from 61.5% (120/195) to 44.2% (95/215), p<0.001. Incorrect vancomycin loading doses fell from 58.1% (90/155) to 32.4% (46/142), p<0.001. Incorrect vancomycin first maintenance doses fell from 55.5% (86/155) to 33.1% (47/142), p<0.001. Loading and first maintenance vancomycin doses were both incorrect in 37.4% (58/155) of patients before and 13.4% (19/142) after calculator implementation, p<0.001.

CONCLUSIONS

This study suggests that gentamicin and vancomycin dose calculators significantly improved the prescribing of initial doses of these agents. Therefore, healthcare organisations should consider using such CDS tools to support the prescribing of these high-risk drugs.

The effects of an electronic order set on vancomycin dosing in the ED

OBJECTIVE

The objective of the study was to assess the impact of a computer physician order entry (CPOE) electronic order set on appropriate vancomycin dosing in the emergency department (ED).

METHODS

We conducted a retrospective study examining ED dosing of vancomycin before and after the implementation of an electronic weight-based vancomycin order set. Preimplementation and postimplementation patient records were analyzed between the dates of June 1st and August 31st 2010 for the pre-CPOE group and January 1st to March 31st 2013 for the post-CPOE group.

STATISTICAL ANALYSIS

χ(2) analysis, Fisher exact test, and t tests were performed with a 2-sided P value <.05 denoting statistical significance, where appropriate.

RESULTS

A total of 597 patients were included in the study, with 220 in the pre-CPOE group and 377 in the post-CPOE group. The use of the electronic order set resulted in a 21.9% increase (P < .05) in appropriate dosing with 67.4% (254/377) of post-CPOE vancomycin doses considered appropriate vs 45.5% (100/220) in the pre-CPOE group. In critically ill patients, there was a 16.3% increase in appropriate dosing with 44.7% (38/85) in the post-CPOE group compared with 28.4% (19/67) in the pre-CPOE group.

CONCLUSION

The implementation of an electronic order set increased the percentage of ED patients receiving appropriate initial vancomycin doses. The impact of increasing compliance to vancomycin guidelines is in accordance with stewardship principles that promote optimization of antimicrobial dosing based on individual patient characteristics. More studies are needed to assess the relationship between appropriate vancomycin loading doses in the ED and therapeutic outcomes.