Pharmacist-driven antimicrobial stewardship in intensive care units in East China: A multicenter prospective cohort study.
- Pharmacist-driven antimicrobial stewardship in intensive care units in East China: A multicenter prospective cohort study.
Antimicrobial stewardship programs, particularly pharmacist-driven programs, help reduce the unnecessary use of antimicrobial agents. The objective of this study was to assess the influence of pharmacist-driven antimicrobial stewardship on antimicrobial use, multidrug resistance, and patient outcomes in adult intensive care units in China.
We conducted a multicenter prospective cohort study with a sample of 577 patients. A total of 353 patients were included under a pharmacist-driven antimicrobial stewardship program, whereas the remaining 224 patients served as controls. The primary outcome was all-cause hospital mortality.
The pharmacist-driven antimicrobial stewardship program had a lower hospital mortality rate compared with the nonpharmacist program (19.3% vs 29.0%; P = .007). Furthermore, logistic regression analysis indicated that the pharmacist-driven program independently predicted hospital mortality (odds ratio, 0.57; 95% confidence interval, 0.36-0.91; P = .017) after adjustment. Meanwhile, this strategy had a lower rate of multidrug resistance (23.8% vs 31.7%; P = .037). Moreover, the strategy optimized antimicrobial use, such as having a shorter duration of empirical antimicrobial therapy (2.7 days; interquartile range [IQR], 1.7-4.6 vs 3.0; IQR, 1.9-6.2; P = .002) and accumulated duration of antimicrobial treatment (4.0; IQR, 2.0-7.0 vs 5.0; IQR, 3.0-9.5; P = .030).
Pharmacist-driven antimicrobial stewardship in an intensive care unit decreased patient mortality and the emergence of multidrug resistance, and optimized antimicrobial agent use.
P : adult intensive care units in China, 577 patients
E : 353 patients were included under a pharmacist-driven antimicrobial stewardship program
C : 224 patients served as controls
The pharmacist-driven antimicrobial stewardship program had a lower hospital mortality rate compared with the nonpharmacist program (19.3% vs 29.0%; P = .007).
Furthermore, logistic regression analysis indicated that the pharmacist-driven program independently predicted hospital mortality (odds ratio, 0.57; 95% confidence interval, 0.36-0.91; P = .017) after adjustment.
T : multicenter prospective cohort study
Antimicrobial stewardship modes
Pharmacist-driven antimicrobial stewardship was implemented in 4 of the included ICUs during 2012 with the approval of hospital leadership. Pharmacists are introduced into antimicrobial stewardship programs in the ICUs on the basis of guideline recommendations and hospital resources aiming at the supervision and direction of antimicrobial agent use.
Pharmacists and physicians are trained in appropriate antimicrobial agent use and antimicrobial stewardship.
The following processes are audited by pharmacists:
appropriate culture checking before antimicrobial therapy administration,
initial administration of antimicrobial agent(s) intravenously for 72 hours, antibiotic escalation or de-escalation, identification of antimicrobial agents administered for more than 7 days, identification of antimicrobial agents adminis- tered for more than 14 days, and changing to an oral alternative.
Pharmacists monitor physicians on daily rounds in the mornings from Monday-Friday and communicate immediately with physicians when inappropriate antimicrobial agents are prescribed.
After that, pharmacists recommend modifications to prescriptions and the data on recommendations are recorded and reported to the antimicrobial stewardship programs.
In cases in which pharmacists and physicians disagree, an infectious diseases specialist is consulted to make a final decision.
In addition, pharmacists review the reports of culture results and immediately recommend antibiotic de-escalation if necessary.
By contrast, the nonpharmacist antimicrobial stewardships implemented in the other 4 ICUs did not involve any pharmacists.
Physicians were trained in appropriate antimicrobial agent use and antimicrobial stewardship.
Moreover, physicians prescribed antimicrobial agents and reviewed prescription charts in daily practice. Physicians consulted an infectious diseases specialist to help make a decision in complex cases if necessary.
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The present study has strengths and limitations.
With respect to the strengths, this study was the first to describe the importance of pharmacist-driven antimicrobial stewardship in ICUs in China, the lack of pharmacist-driven antimicrobial stewardship was a risk factor for worse patient outcomes, and pharmacist-driven antimicrobial stewardship optimized antimicrobial use in ICUs and decreased the emergence of multidrug resistance.
The limitations included the potential selection bias of the clinical cohort, the small sample size (577 patients from 8 ICUs) might limit the evaluation of further stratification of multidrug-resistant organisms, and an observational study might be less convincing than a randomized controlled trial.