Empirical antibiotic treatment of sepsis: impact of specialist pharmacist review
Guidelines from the National Institute for Health and Care Excellence recommend that empirical antibiotic courses initiated in hospital inpatients should be reviewed within 72 hours; a revised decision for ongoing therapy should be made in light of culture results, investigations and clinical progress. This process is essential in ensuring the optimal use of antibiotics in hospitals as a part of the wider antimicrobial stewardship push.
A UK government quality improvement incentive, or ‘Commissioning for Quality and Innovation’ (CQUIN) target, was introduced in 2016/2017 to improve review-and-revise decision-making in antibiotic prescribing, and has been extended to 2019. The updated CQUIN specifies that the review must be carried out by either a senior clinician, an infectious diseases or microbiology doctor, or specialist pharmacist.
The CQUIN targets for Q1 and Q2 of 2017/2018 (requiring evidence of clinical review in 25% and then 50% of a sample of 30 patients) had been achieved by Southport and Ormskirk NHS Trust, but the results had fallen short of the more demanding targets of 75% and 90%, which were required for Q3 and Q4. Therefore, during Q3 of 2017/2018, the antimicrobial management team launched an initiative for the targeted follow-up of patients being treated empirically for sepsis.
A daily report was requested from the information department, which listed patients seen in the emergency department the previous day or weekend with sepsis listed as the diagnosis. These patients were then followed up by the antimicrobial pharmacist within the 24–72-hour time frame. An initial office-based virtual review of the identified patients was conducted using the patient management system and the notes were made by microbiologists on the local laboratory information management system. Patients who were still in hospital and who had no evidence of a microbiology review were then reviewed at ward level by the antimicrobial pharmacist. Preparation for the ward-level review was facilitated by preregistration pharmacists, who completed a pro forma before the ward visit, which included patient identifiers, allergies, results of liver and kidney function tests, any colonisation with resistant organisms, history of Clostridium difficile, microbiology results and trends in infection markers, including white blood cell count and C-reactive protein since admission.
Of the 324 patients identified by the daily sepsis report in Q3 and Q4, 266 had received an initial virtual review and 181 were then reviewed on the ward; 58 were not reviewed owing to absence of the antimicrobial pharmacist (for reasons such as annual leave, off-site meetings, public holidays or other clinical commitments). There was no ward review of 85 patients because they had died, been discharged or had already been reviewed by a microbiologist within 72 hours of admission. It should be noted that all patients with a positive blood culture or who had been admitted to intensive care had evidence of a microbiology review within 72 hours.
Of the 181 patients reviewed on the ward, a switch from intravenous to oral antibiotic was recommended in 28 (15%) cases in accordance with local criteria; neutropenic sepsis was the most common exclusion to this. A change of antibiotic therapy was recommended in 16 (9%) cases — examples of which included addition of methicillin-resistant Staphylococcus aureus antibiotic cover in a colonised patient; change caused by a drug–drug interaction; and change as a result of a urine culture showing resistance to the prescribed antibiotic. In two cases, the patient was discussed with microbiology; in one of these two cases, the patient had been prescribed an inappropriate antibiotic for a working diagnosis of meningitis. Advice to stop antibiotics was made in only one case. In 18 (10%) cases, documentation issues were addressed — usually the addition of a stop/review date or addition of an indication for treatment to the prescription. In 22 (12%) cases, miscellaneous contributions were made, including a recommendation to withhold prophylactic antibiotics, advice to withhold oral chemotherapy, advice to change dose, change owing to guidelines or kidney impairment, and advice that bloods should be rechecked or to do further testing (for influenza, for example). In 40 (22%) cases, the antibiotic treatment had already been reviewed and either stopped or de-escalated by the clinical team caring for the patient.
Following this intervention, Southport and Ormskirk NHS Trust met the CQUIN target for Q3, achieving 80.5% antibiotic reviews in septic patients, but still failed Q4, achieving 78.8% of the 90% reviews required for the target. Of the sample of 30 patients from which the CQUIN data were collated, 10 (33%) of the patients in Q3 had been reviewed by the antimicrobial pharmacist, and 4 (13%) of the patients in Q4. The patient samples used for the CQUIN data were drawn at random from a retrospective report of patients coded for sepsis during their admission, not necessarily correlating with the report of patients diagnosed with sepsis in the emergency department.
In conclusion, targeted follow-up of patients with sepsis by a specialist pharmacist can yield valuable clinical interventions, and can potentially be financially viable if CQUIN targets are achieved that would otherwise have been missed.
Potential limitations are that while specialist antimicrobial pharmacists are well placed to advise on optimal therapy, they may not feel confident in advising that antibiotic therapy is not indicated and should be stopped. This makes the support and buy-in of clinicians and medical microbiologists essential. The way in which patients were identified here captured only sepsis diagnosed in the emergency department. Any patients who developed sepsis on the ward would not have been included. At the time of writing, most inpatient records at Southport and Ormskirk NHS Trust are paper-based. Electronic systems would allow more reliable reporting of patients who require follow-up and would provide more opportunities for initiatives like this.
Christina Adam, preregistration pharmacist (now rotational pharmacist), Southport and Ormskirk NHS Trust
Katherine Gray, consultant medical microbiologist and antimicrobial lead, Southport and Ormskirk NHS Trust
John Gwilliam, lead pharmacist — antimicrobials, Southport and Ormskirk NHS Trust
Amy Roughley, preregistration pharmacist (now rotational pharmacist), Southport and Ormskirk NHS Trust
Citation: Clinical Pharmacist DOI: 10.1211/CP.2018.20205616
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