Using Pharmacist-Driven Recommendations to Optimize Management of Staphylococcal Bacteremia

The annual incidence of invasive Staphylococcus aureus infection is estimated at 31.8 to 38.2 per 100,000 person-years. Antibiotic resistance is common and bacteremia accounts for 75.2% of invasive methicillin resistant S. aureus infections with a mortality rate upwards of 20%. Infectious disease consultation is associated with increased adherence to treatment guidelines and decreased mortality in patient with S. aureus bacteremia (SAB). However, many institutions do not have the benefit of a physician-lead infectious diseases consult service. The American Society of Health-Systems Pharmacy calls for antimicrobial stewardship as a component of the pharmacy practice model and recommends pharmacist involvement in development, review, and approval of medication order sets, and adherence to medication-related national quality indicators and evidence-based practice guidelines. This study hypothesizes that an evidence-based treatment protocol with recommendations initiated by pharmacists for SAB will improve adherence to clinical guidelines and improve patient outcomes. The primary objective of the study is to determine appropriateness of therapy for SAB before and after implementation of the treatment protocol. Appropriateness is defined as (1) de-escalation of antibacterial therapy to a â-lactam in Methicillin-susceptible S. aureus, (2) treatment of methicillin-resistant S. aureus with vancomycin, daptomycin, and/or ceftaroline, and (3) documentation of therapy of 2 weeks therapy for uncomplicated bacteremia and 4-6 weeks for complicated bacteremia. Clinical staff will be educated about the availability of the evidence-based treatment protocol and it will be posted on the institutional intranet. All patients > 18 years old with a first episode of bacteremia during the study period and positive blood cultures for S. aureus will be screened for inclusion for analysis. They will be identified through use of rapid microbiological diagnostic technology. Patients will be excluded from analysis if they expired or were transferred to another facility within 48 hours of first positive culture or if they received comfort care measures only. The resident investigator or antimicrobial management team pharmacist will leave a structured note in the patient’s electronic medical record outlining treatment protocol. This note will be updated at 48 hours, on day 5, and on the last day of therapy or day of discharge (whichever comes first). The clinical pharmacist on the primary team will communicate recommendations and adherence to the protocol will be at the discretion of the physician team. Secondary objectives include adherence rates to individual components of protocol and total protocol adherence, time to de-escalation of therapy, days on therapy, antibiotic drug costs, length of hospital say, in-hospital mortality, recurrence of infection, and 30 day readmission rates. Results from this work will have a positive impact on pharmacy practice by empowering all pharmacists to incorporate best practice and antimicrobial stewardship principles across service lines and at institutions where infectious disease resources may be limited.