Impact of a Standardized Pharmacist-Led Intervention to Promote - - PowerPoint PPT Presentation

Ana Pellumbi, PharmD PGY1 Pharmacy Practice Resident

Co-authors: Derick Miranda, Monika Totoraitis, Megan Musselman, Matt Baker, Jeremy John

Impact of a Standardized Pharmacist-Led Intervention to Promote Guideline-Directed Empiric Use of Vancomycin in Adult Patients with Febrile Neutropenia

Conflict of Interest Disclosure

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The speaker has no actual

• r potential

conflict of interest in relation to this presentation

Background

Febrile neutropenia (FN)

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Febrile + ANC < 500 or < 1000 neutrophils/mL and predicted decrease to < 500 within 48 hours Most common complication of myelosuppressive chemotherapy IDSA and NCCN guidelines recommend empiric monotherapy with an anti- pseudomonal beta- lactam

ANC = absolute neutrophil count IDSA = Infectious Diseases Society of America NCCN = National Comprehensive Cancer Network

Background

• Recommend

against empiric use of antimicrobials targeting gram positive aerobes

Guidelines

• Suspected catheter-

related infections

• Skin or soft-tissue

infection

• Pneumonia
• Hemodynamic instability
• Positive blood cultures for

gram positive cocci

• Colonization with resistant

gram positive organisms

Exceptions

• Discontinue

after two days if no positive cultures

Initiated Empirically

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Consequences of Vancomycin

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Increased incidence of multidrug resistant

• rganisms

Acute kidney injury Unnecessary antimicrobial exposure

Study Rationale

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Adherence to recommendations remains a challenge Implementation of order sets or protocols may help guide clinicians

Objectives of the Study

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G-CSF = Granulocyte-colony stimulating factor FN = Febrile neutropenia

Evaluate the use of guideline-directed vancomycin for FN following a standardized intervention Assess the utilization of G-CSF during episodes of FN Analyze the rates of acute kidney injury related to vancomycin use

Study Design

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Retrospective review of empiric vancomycin utilization prior to pharmacist-led intervention Order set update and pharmacist education on standardized-intervention Retrospective review of impact of intervention

• n empiric vancomycin utilization

Order Set Update

Febrile neutropenia standard antibiotic regimen:

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Cefepime +/- Vancomycin

Vancomycin criteria for use

Hemodynamic instability Suspected catheter-related infection Skin or soft tissue infection Pneumonia Colonization with MRSA

MRSA = methicillin resistant Staphylococcus aureus

Study Design

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Pre-Intervention

January - July 2019 Vancomycin ordered per the

• rdering providers’ discretion

Post-Intervention

November 2019 - March 2020 Pharmacist to intervene to promote guideline-directed empiric vancomycin use

Pharmacist Intervention

Vancomycin ordered for FN Meets criteria for empiric use Verify order Criteria for empiric use not met Contact ordering physician

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De-escalate vancomycin after 48 hours if appropriate

FN = Febrile neutropenia

Study Design

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Inclusion Criteria

• Age > 18 years admitted for FN
• Hospitalization > 48 hours
• Received at least two

consecutive doses of vancomycin

• r discontinued empirically

Exclusion Criteria

• Complete course of FN was not

managed at our hospital

• Received anti-MRSA agent

within 7 days of hospitalization

• Documented vancomycin

allergy

FN = Febrile neutropenia MRSA = methicillin resistant Staphylococcus aureus

Outcomes

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Primary Outcome

• Composite of guideline-

directed empiric vancomycin initiation and discontinuation

Secondary Outcomes

• Guideline-directed empiric

vancomycin initiation

• Guideline-directed empiric

vancomycin discontinuation

• Length of stay
• Incidence of acute kidney injury
• Use of therapeutic G-CSF for FN

G-CSF = Granulocyte-colony stimulating factor FN = Febrile neutropenia

Results - Demographics

Demographics Pre-intervention n = 27 Post-intervention n = 15 Average age – years 67 61 Male gender – no. (%) 14 (52) 11 (73) Central line – no. (%) 19 (73) 14 (93) Received G-CSF outpatient – no. (%) 4 (15.3) 4 (26.7) Average baseline SCr – mg/dL 1.2 1.4

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G-CSF = Granulocyte-colony stimulating factor

• No. = number

SCr = Serum creatinine No = Number

Vancomycin Prescribing

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Pre-intervention n = 27 Post-intervention n = 15 Provider team ordering vancomycin – no. (%) ED – 11 (37) Primary – 11 (40.7) Heme/Onc – 5 (18.5) ID – 1 (3.7) ED – 7 (46.7) Primary – 3 (20) Heme/Onc – 2 (13.3) ID – 2 (13.3) Discipline who initiated de-escalation of vancomycin – no. (%) Heme/Onc – 8 (29.6) Primary – 6 (22.2) Pharmacist – 6 (22.2) ID – 5 (18.5) ED – 1 (3.7) ID – 4 (26.7) Pharmacist – 4 (26.7) Primary – 3 (20) Pulmonary – 2 (13.3) Heme/Onc – 1 (6.7) Other (patient expired) – 1 (6.7)

ED = Emergency department Heme/Onc = Hematology/Oncology ID = Infectious diseases No = Number

Results - Outcomes

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Primary Outcome Composite of guideline-directed empiric initiation and discontinuation of vancomycin – no. (%) Pre-intervention n = 27 Post-intervention n = 15 P – value 12 (44) 12 (80) 0.026 Secondary Outcomes

Outcome Pre-intervention n = 27 Post-intervention n = 15 P – value Guideline-directed empiric initiation

• f vancomycin – no. (%)

15 (57.7) 14 (93.3) 0.089 Guideline-directed discontinuation

• f vancomycin – no. (%)

16 (61.5) 12 (80) 0.307 Length of stay – days 7.6 8.3 0.82 Acute kidney injury – no. 1 4 0.047 Therapeutic G-CSF – no. (%) 20 (76.9) 12 (80) 1

G-CSF = Granulocyte-colony stimulating factor

• No. = number

Limitations

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Retrospective, single center study Small population size Unbalanced groups Data collected from different time of the year Duration of study We could not account for differences in AKI between the groups

AKI = Acute kidney injury

Conclusion

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G-CSF = Granulocyte-colony stimulating factor

Pharmacists can play a role in limiting antibiotic exposure Implementation of a standardized order set increases guideline- directed empiric vancomycin use Most patients received therapeutic G-CSF Use of empiric vancomycin in combination with other nephrotoxic agents should be further explored

Next Steps

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G-CSF = Granulocyte-colony stimulating factor FN = Febrile neutropenia

RE-EVALUATE THE APPROPRIATENESS OF THERAPEUTIC G-CSF ENCOURAGE PROVIDERS TO UTILIZE THE FN ORDER SET AS GUIDANCE PROMOTE GUIDELINE- DIRECTED MANAGEMENT OF FN

Ana Pellumbi

PGY-1 Pharmacy Resident North Kansas City Hospital Ana.pellumbi@nkch.org

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