Implementation of a Pharmacist-Directed Antimicrobial Stewardship Protocol Utilizing Rapid Diagnostic Testing

The Role of Clinical Pharmacists in Antimicrobial Stewardship Programs (ASPs): A Systematic Review

Antimicrobial resistance (AMR) is a major global health threat, increasing deaths and healthcare costs. Antimicrobial stewardship programs (ASPs) have been implemented to optimize antibiotic use and curb resistance. This systematic review aimed to summarize evidence on the role and impact of pharmacists in hospital ASPs. A comprehensive literature search was conducted across databases to identify relevant studies published from 2016 to 2023. Twenty-four studies met the inclusion criteria, comprising global observational and randomized clinical trials. Pharmacists performed various stewardship activities, including prospective audits, formulary management, de-escalation, guideline development, and education. Pharmacist-led interventions significantly improved antibiotic prescribing, reduced unnecessary antibiotic use, optimized therapy, and enhanced outcomes. Multiple studies found that pharmacist reviews decreased the time to optimal antibiotics and improved guideline compliance without affecting readmissions or revisits. De-escalation programs safely reduced antibiotic duration and length of stay. Acceptance rates for recommendations were high. Pharmacist stewardship curbed overall antibiotic use, costs, and duration across hospital departments, leading to savings. While most studies showed positive impacts, fewer detected significant changes in resistance or mortality over short periods. More research is needed, but current evidence demonstrates that pharmacists play critical roles in ASPs, leading to improved antibiotic use and patient outcomes. These findings support integrating pharmacists into stewardship activities, significantly extending programs to ambulatory settings.

The role of the clinical pharmacist in antimicrobial stewardship in Asia: A review

Clinical pharmacist-driven antimicrobial stewardship programs (ASPs) have been successfully implemented. Although relevant guidance and several studies suggest that clinical pharmacists be integrated into the current ASP team model, barriers still exist in Asia, primarily due to lack of dedicated personnel and lack of career advancement. We review the effectiveness and the ideal role of clinical pharmacist among ASPs in Asia. Several studies conducted in Asia have shown the effectiveness of pharmacist-led ASP interventions in hospitals and other healthcare settings. However, opportunities to expand the role of clinical pharmacists in ASPs in Asia exist in the implementation of rapid diagnostic test and drug allergies.

Impact on time to active antimicrobial therapy with 24-hour pharmacist review of Accelerate Pheno BC Kit results

The Accelerate Pheno platform provides rapid identification and susceptibility data. We demonstrate successful incorporation of 24-hour pharmacist review of Accelerate Pheno results that reduced the number of patients going >3 hours from result without an order for active antimicrobial therapy from 29 (2.8%) of 1,043 to 9 (0.85%) of 1,053 (P < .001).

Impact of Pharmacist Involvement on the Utility of a Gram-Negative Blood Culture Identification Panel on Antimicrobial Usage

Background: A rapid molecular diagnostic test (MDT) is a test used to identify several different species of gram-negative bacteria and their genetic resistance markers. However, the impact of rapid MDT has not been established when combined with pharmacist involvement. Objective: To determine the impact of pharmacy involvement on patient outcomes when using rapid MDT. The primary outcome is the time from gram stain result to the first dose of the targeted antibiotic. Methods: This is a single-center, quasi-experimental, 1-group pretest-posttest design study of patients with gram-negative bacteremia in a community hospital. Hospitalized patients 18 years or older were included if they had a gram-negative blood culture. Patients were excluded if they were discharged or expired prior to culture results. Outcomes were compared between patients prior to and after implementation of the automated MDT. This research was determined to be exempt from institutional review board oversight consistent with West Florida Healthcare and in accordance with institutional policy. Results: The use of rapid MDT combined with pharmacist intervention resulted in a statistically significant decrease in the time to targeted antibiotic therapy (pre-intervention group, n = 77, 44.8 ± 17.8 hours versus post-intervention group, n= 80, 4.4 ± 5.8 hours; P ≤.001). There was no significant difference found between secondary outcomes. Limitations included small sample size as well as inconsistent documentation. Conclusions: The use of rapid MDT combined with pharmacist intervention resulted in a statistically significant decrease in the time to targeted antibiotic therapy.

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

BACKGROUND

Antimicrobial stewardship (AMS) programmes optimize antimicrobial use and address antimicrobial resistance. Pharmacists are often key agents of these programmes. The effectiveness of hospital-based AMS interventions when they are led by pharmacists, however, has not previously been reported.

AIM

To evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use for hospital inpatients.

METHODS

Standard systematic review methods were used. The search strategies and databases used in a previous Cochrane review were applied. Studies that reported pharmacist-led AMS interventions were included. Narrative synthesis was used to report the findings. PRISMA guidelines were followed.

FINDINGS

From 6971 records retrieved and screened, 52 full-text articles were included. Most studies were undertaken in teaching hospitals (N = 45) and many were conducted in North America (N = 27). Most interventions targeted junior or ward physicians and lasted between one and six months. All studies evaluated educational interventions often in combination with other interventions and reported improvements 'in compliance with target AMS practice'. Greater compliance was achieved with multiple interventions. Pharmacist-led interventions reduced the duration of antimicrobial therapy without increasing mortality. No consistency of evidence was achieved in relation to interventions and reduced duration of hospital stay, nor infections due to antimicrobial resistance or occurrence of Clostridium difficile.

CONCLUSION

This is the first systematic review to evaluate the effectiveness of pharmacist-led AMS interventions in hospital inpatients. Education-based interventions were effective in increasing guideline compliance and reducing duration of antimicrobial therapy. Future hospital-based AMS programmes should consider the involvement of pharmacists to deliver and promote AMS interventions and programmes.

Clinical impact of pharmacist-directed antimicrobial stewardship guidance following blood culture rapid diagnostic testing

BACKGROUND

Rapid diagnostic testing (RDT) has been shown to be associated with improved clinical outcomes.

AIM

To evaluate the clinical outcomes of using RDT paired with well-defined pharmacist-directed antimicrobial stewardship programme (ASP) guidance to achieve targeted treatment in patients with bacteraemia.

METHODS

In this quasi-study, a retrospective (pre-intervention) phase was compared with a prospective (post-intervention) phase. Adult patients with positive blood cultures identified using the BacT/ALERT system were included. Bacterial identification and susceptibility were provided by VITEK 2. During the post-intervention phase, Verigene ASP guidance was developed to optimize antibiotic selection. Pharmacists received the results from the microbiology laboratory, evaluated the appropriateness of current therapy (if any), and communicated the recommended antimicrobial therapy to the treating physician accordingly.

FINDINGS

The cohort consisted of 164 patients in the pre-intervention group and 148 patients in the post-intervention group. When comparing the post-intervention period with the pre-intervention period, the median time to culture identification was 22 vs 96 h (P<0.0001), median time to targeted antibiotics was 2 vs 22 h (P<0.0001), median time for antibiotic de-escalation was 12.2 vs 27 h (P<0.0001), and median time to escalation was 1.3 vs 24 h (P<0.003), respectively. In-hospital mortality and 30-day re-admission were significantly lower in the post-intervention group (P<0.003 and 0.034, respectively). Length of hospital stay was significantly shorter in the post-intervention group (6.5 vs 8 days; P=0.03).

CONCLUSION

Rapid identification of bacteraemia combined with a pharmacist's recommendation as an ASP initiative significantly improved time to optimal therapy, and may have decreased the risk of mortality and re-admission.

Pharmacist-Driven Implementation of Fast Identification and Antimicrobial Susceptibility Testing Improves Outcomes for Patients with Gram-Negative Bacteremia and Candidemia

Bloodstream infections (BSI) are associated with increased morbidity and mortality, especially when caused by Gram-negative or fungal pathogens. The objective of this study was to assess the impact of fast identification-antimicrobial susceptibility testing (ID/AST) with the Accelerate Pheno system (AXDX) from May 2018 to December 2018 on antibiotic therapy and patient outcomes. A pre-post quasiexperimental study of 200 patients (100 pre-AXDX implementation and 100 post-AXDX implementation) was conducted.

Bloodstream infections (BSI) are associated with increased morbidity and mortality, especially when caused by Gram-negative or fungal pathogens. The objective of this study was to assess the impact of fast identification-antimicrobial susceptibility testing (ID/AST) with the Accelerate Pheno system (AXDX) from May 2018 to December 2018 on antibiotic therapy and patient outcomes. A pre-post quasiexperimental study of 200 patients (100 pre-AXDX implementation and 100 post-AXDX implementation) was conducted. The primary endpoints measured were time to first antibiotic intervention, time to most targeted antibiotic therapy, and 14-day hospital mortality. Secondary endpoints included hospital and intensive care unit (ICU) length of stay (LOS), antibiotic intensity score at 96 h, and 30-day readmission rates. Of 100 patients with Gram-negative bacteremia or candidemia in each cohort, 84 in the preimplementation group and 89 in the AXDX group met all inclusion criteria. The AXDX group had a decreased time to first antibiotic intervention (26.3 versus 8.0, P = 0.003), hours to most targeted therapy (14.4 versus 9, P = 0.03), hospital LOS (6 versus 8, P = 0.002), and average antibiotic intensity score at 96 h (16 versus 12, P = 0.002). Both groups had a comparable 14-day mortality (0% versus 3.6%, P = 0.11). In this analysis of patients with Gram-negative bacteremia or candidemia, fast ID/AST implementation was associated with decreased hospital LOS, decreased use of broad-spectrum antibiotics, shortened time to targeted therapy, and an improved utilization of antibiotics within the first 96 h of therapy.

Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management

Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.

Common Models Used for Inpatient Diabetes Management

PURPOSE OF REVIEW

Diabetes affects about a third of all hospitalized patients and up to 50% of inpatients go on to experience hyperglycemia. Despite strong evidence supporting the importance of adequate glycemic control, as well detailed guidelines from major national organizations, many patients continue to have hypo- and hyperglycemia during their hospital stay. While this may be partially related to provider and patient-specific factors, system-based barriers continue to pose a major obstacle. Therefore, there is a need to go beyond merely discussing specific insulin protocols and provide guidance for effective models of care in the acute glycemic management of hospitalized patients.

RECENT FINDINGS

To date, there is limited data evaluating the various models of care for inpatient diabetes management in terms of efficacy or cost, and there is no summary on this topic guiding physicians and hospital administrators. In this paper, four common models of inpatient diabetes care will be presented including those models led by the following: an endocrinologist(s), mid-level provider(s), pharmacist(s), and a virtual glucose management team. The authors will outline the intrinsic benefits as well as limitations of each model of care as well as cite supporting evidence, when available. Discussion pertaining to how a given model of care shapes and formulates a particular organization's structured glucose management program (GMP) will be examined. Furthermore, the authors describe how the model of care chosen by an institution serves as the foundation for the creation of a GMP. Finally, the authors examine the critical factors needed for GMP success within an institution and outline the nature of hospital administrative support and accompanying reporting structure, the function of a multidisciplinary diabetes steering committee, and the role of the medical director.