β-Lactams: The Competing Priorities of Nephrotoxicity, Neurotoxicity, and Stewardship

Understanding the role of antibiotic-associated adverse events in influencing antibiotic decision-making

Objective

To (1) understand the role of antibiotic-associated adverse events (ABX-AEs) on antibiotic decision-making, (2) understand clinician preferences for ABX-AE feedback, and (3) identify ABX-AEs of greatest clinical concern.

Design

Focus groups.

Setting

Academic medical center.

Participants

Medical and surgical house staff, attending physicians, and advanced practice practitioners.

Methods

Focus groups were conducted from May 2022 to December 2022. Participants discussed the role of ABX-AEs in antibiotic decision-making and feedback preferences and evaluated the prespecified categorization of ABX-AEs based on degree of clinical concern. Thematic analysis was conducted using inductive coding.

Results

Four focus groups were conducted (n = 15). Six themes were identified. (1) ABX-AE risks during initial prescribing influence the antibiotic prescribed rather than the decision of whether to prescribe. (2) The occurrence of an ABX-AE leads to reassessment of the clinical indication for antibiotic therapy. (3) The impact of an ABX-AE on other management decisions is as important as the direct harm of the ABX-AE. (4) ABX-AEs may be overlooked because of limited feedback regarding the occurrence of ABX-AEs. (5) Clinicians are receptive to feedback regarding ABX-AEs but are concerned about it being punitive. (6) Feedback must be curated to prevent clinicians from being overwhelmed with data. Clinicians generally agreed with the prespecified categorizations of ABX-AEs by degree of clinical concern.

Conclusions

The themes identified and assessment of ABX-AEs of greatest clinical concern may inform antibiotic stewardship initiatives that incorporate reporting of ABX-AEs as a strategy to reduce unnecessary antibiotic use.

Nephrotoxin Stewardship

Drugs are the third leading cause of acute kidney injury (AKI) in critically ill patients. Nephrotoxin stewardship ensures a structured and consistent approach to safe medication use and prevention of patient harm. Comprehensive nephrotoxin stewardship requires coordinated patient care management strategies for safe medication use, ensuring kidney health, and avoiding unnecessary costs to improve the use of nephrotoxins, renally eliminated drugs, and kidney disease treatments. Implementing nephrotoxin stewardship reduces medication errors and adverse drug events, prevents or reduces severity of drug-associated AKI, prevents progression to or worsening of chronic kidney disease, and alleviates financial burden on the health care system.

Quality of care after AKI development in the hospital: Consensus from the 22nd Acute Disease Quality Initiative (ADQI) conference

BACKGROUND

Acute kidney injury (AKI) is independently associated with increased morbidity and mortality. Quality improvement has been identified as an important goal in the care of patients with AKI. Different settings can be targeted to improve AKI care, broadly classified these include the inpatient and outpatient environments. In this paper, we will emphasize quality indicators associated with the management and secondary prevention of AKI in hospitalized patients to limit the severity, duration, and complications.

METHODS

During the 22nd Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for AKI-related quality indicators (QIs) and care processes to improve patient outcomes. The management and secondary prevention of AKI in hospitalized patients were discussed, and recommendations were summarized.

RESULTS

The first step in optimizing the quality of AKI management is the determination of baseline performance. Data regarding each institution's/center's performance can provide a reference point from which to benchmark quality efforts. Quality program initiatives should prioritize achievable goals likely to have the highest impact according to the setting and context. Key AKI quality metrics should include improvement in timely recognition, appropriate diagnostic workup, and implementation of known interventions that limit progression and severity, facilitating recovery, and mitigating AKI-associated complications. We propose the Recognition-Action-Results framework to plan, measure, and report the progress toward improving AKI management quality.

CONCLUSIONS

These recommendations identified and outlined an approach to define and evaluate the quality of AKI management in hospitalized patients.

Quality Improvement Goals for Acute Kidney Injury

AKI is a global concern with a high incidence among patients across acute care settings. AKI is associated with significant clinical consequences and increased health care costs. Preventive measures, as well as rapid identification of AKI, have been shown to improve outcomes in small studies. Providing high-quality care for patients with AKI or those at risk of AKI occurs across a continuum that starts at the community level and continues in the emergency department, hospital setting, and after discharge from inpatient care. Improving the quality of care provided to these patients, plausibly mitigating the cost of care and improving short- and long-term outcomes, are goals that have not been universally achieved. Therefore, understanding how the management of AKI may be amenable to quality improvement programs is needed. Recognizing this gap in knowledge, the 22nd Acute Disease Quality Initiative meeting was convened to discuss the evidence, provide recommendations, and highlight future directions for AKI-related quality measures and care processes. Using a modified Delphi process, an international group of experts including physicians, a nurse practitioner, and pharmacists provided a framework for current and future quality improvement projects in the area of AKI. Where possible, best practices in the prevention, identification, and care of the patient with AKI were identified and highlighted. This article provides a summary of the key messages and recommendations of the group, with an aim to equip and encourage health care providers to establish quality care delivery for patients with AKI and to measure key quality indicators.