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Atkins PE, Bastin MLT, Morgan RJ, Laine ME, Flannery AH. Pharmacist Involvement in Sepsis Response and Time to Antibiotics: A Systematic Review. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2023; 6:942-953. [PMID: 37608990 PMCID: PMC10441617 DOI: 10.1002/jac5.1723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/28/2022] [Indexed: 08/24/2023]
Abstract
Introduction Sepsis is a life-threatening medical emergency and a leading cause of morbidity and mortality worldwide. Reductions in time to antibiotics in patients presenting with sepsis or septic shock are associated with reduced mortality, and Surviving Sepsis Campaign guidelines recommend antibiotics within one hour of recognition. Pharmacists are well-equipped to help navigate the therapeutic and operational challenges associated with achieving this goal. Objectives To assess the association of pharmacist involvement in sepsis response with time to antibiotics in hospitalized patients with sepsis and septic shock. Methods A systematic review of the following databases was conducted: PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. Studies must have included a designated role of an individual pharmacist in the management of sepsis or septic shock and not be considered an operational change. The primary outcome of interest was time to antibiotic administration, with secondary outcomes including intensive care unit (ICU) and hospital length of stay as well as in-hospital mortality. Results We identified 10 studies including 1772 patients with sepsis or septic shock that evaluated a sepsis response in which a pharmacist was included. Studies included patients in the ICU, emergency department, and hospital ward setting. Seven studies demonstrated a significant reduction in time to antibiotics, with two other studies supporting this conclusion in extrapolation or sensitivity analysis. There was not a consistent reduction in ICU or hospital length of stay nor in-hospital mortality between those interventions involving a pharmacist compared with their defined control groups. Conclusion Pharmacist involvement in sepsis response, often as part of a multi-professional team-based approach to sepsis care, is associated with a reduced time to antibiotic administration for hospitalized patients with sepsis or septic shock.
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Affiliation(s)
- Payton E. Atkins
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Rebecca J. Morgan
- University of Kentucky Medical Center Library, Lexington, Kentucky, USA
| | - Melanie E. Laine
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
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Chiotos K, Weiss SL. A Wrinkle in Time to Antibiotics in Sepsis: When Should ONE Hour Be the Goal? J Pediatr 2021; 233:13-15. [PMID: 33545195 DOI: 10.1016/j.jpeds.2021.01.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/29/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine; Division of Infectious Diseases, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine; Pediatric Sepsis Program, Children's Hospital of Philadelphia; Antimicrobial Stewardship Program, Children's Hospital of Philadelphia
| | - Scott L Weiss
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine; Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis 2021; 72:541-552. [PMID: 32374861 DOI: 10.1093/cid/ciaa059] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022] Open
Abstract
The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Strich JR, Heil EL, Masur H. Considerations for Empiric Antimicrobial Therapy in Sepsis and Septic Shock in an Era of Antimicrobial Resistance. J Infect Dis 2020; 222:S119-S131. [PMID: 32691833 PMCID: PMC7372215 DOI: 10.1093/infdis/jiaa221] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Patients with sepsis present across a spectrum of infection sites and severity of illnesses requiring complex decision making at the bedside as to when prompt antibiotics are indicated and which regimen is warranted. Many hemodynamically stable patients with sepsis and low acuity of illness may benefit from further work up before initiating therapy, whereas patients with septic shock warrant emergent broad-spectrum antibiotics. The precise empiric regimen is determined by assessing patient and epidemiological risk factors, likely source of infection based on presenting signs and symptoms, and severity of illness. Hospitals should implement quality improvement measures to aid in the rapid and accurate diagnosis of septic patients and to ensure antibiotics are given to patients in an expedited fashion after antibiotic order.
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Affiliation(s)
- Jeffrey R Strich
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- United States Public Health Service, Commissioned Corps, Rockville, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Henry Masur
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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