Impact of a pharmacist-driven care package on Staphylococcus aureus bacteremia management in a large community healthcare network: A propensity score-matched, quasi-experimental study

doi:10.1016/j.diagmicrobio.2017.10.001

Diagnostic Microbiology and Infectious Disease

Volume 90, Issue 1, January 2018, Pages 50-54

https://doi.org/10.1016/j.diagmicrobio.2017.10.001 Get rights and content

Highlights

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Staphylococcus aureus bacteremia (SAB) is a difficult-to-treat infection
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Proper SAB management is paramount to treatment success
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We conducted a pharmacist-driven SAB management protocol in a community hospital
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Our pharmacist-driven SAB protocol reduced hospital readmission
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SAB management can be optimized with dedicated intervention by ID practitioners

Abstract

Objectives

Staphylococcus aureus bacteremia (SAB) is an important cause of morbidity and mortality. Suboptimal treatment has been associated with poor patient outcomes. Our antimicrobial stewardship program (ASP) evaluated SAB management based on predefined performance measures both prior to and after instituting a “care package” intervention led by clinical pharmacists and infectious diseases physicians. The primary outcome included a 4-point “optimal care score” (OCS) consisting of targeted antibiotic therapy within 24 hours, repeating blood cultures, antibiotic duration assessment, and appropriate duration of therapy. The presence of an ID consult, SAB readmission and mortality were also assessed.

Methods

This was a quasi-experimental, propensity score matched study of SAB management. Adult patients were retrospectively evaluated from October 2011 – October 2012, and intervention took place from November 2013 – December 2015. Intervention consisted of a clinical pharmacist contacting the primary team after identification of SAB to recommend (1) appropriate antibiotics within 24 hours, (2) repeat blood cultures to document clearance, (3) assessment for metastatic infection, (4) and appropriate duration of therapy. These constituted the 4-point OCS. ID consult was also recommended. Patients were propensity score matched 1:2 based on age, diabetes, presence of hardware, methicillin-resistant S. aureus (MRSA) isolate, and stratified infectious source. Patients ≥18 with SAB were included.

Results

Intervention was associated with improved adherence to each metric within the OCS, and more patients in the intervention cohort achieved a perfect OCS of 4. Intervention was associated with a lower rate of readmission and mortality.

Conclusion

A pharmacist-driven, ASP intervention on SAB therapy was associated with increased adherence to core SAB care metrics and reduced relapse and mortality.

Introduction

Staphylococcus aureus is the most common healthcare-associated pathogen and the leading cause of bloodstream infections in the United States, according to data from the National Healthcare Safety Network (NHSN) and Centers for Disease Control (CDC).(Sievert et al., 2013) Frequently, S. aureus bacteremia (SAB) is complicated by metastatic infections such as osteomyelitis, endocarditis, and pneumonia.(Holland et al., 2014) Despite expanding knowledge and practice regarding the treatment of S. aureus infections, mortality rates have remained at approximately 20% for decades.(Bai et al., 2015, Borde et al., 2014, Martin et al., 2015, Turner et al., 2016, Vogel et al., 2016) There are several possible reasons that outcomes have not improved, among them improper antimicrobial selection and duration of therapy, inappropriate screening for metastatic sites of infection, and lack of consultation with infectious diseases (ID) specialists. Several studies have demonstrated positive effects of various interventions on SAB outcomes, primary among them consultation with ID specialists.(Vogel et al., 2016) Recently, studies have demonstrated the positive effects on SAB outcomes with a “bundled” approach to SAB treatment that includes source control, confirming clearance of bacteremia through repeating blood cultures, appropriate screening for remote sites of infection, and targeted antibiotic therapy for the appropriate duration.(Lopez-Cortes et al., 2013, Nagao et al., 2016, Nguyen et al., 2015) The objective of our study was to demonstrate the clinical benefits a pharmacist-driven SAB intervention involving aspects of previously published bundled interventions in our large, community medical system in an effort to improve adherence to proper management of SAB and improve patient outcomes.

Section snippets

Study design and setting

This was an observational, quasi-experimental, propensity score matched study of patients with confirmed SAB from October 2011 – December 2015. The study was undertaken within the Cone Health System, a network of six community hospitals with over 1000 beds in the Piedmont Triad region of North Carolina. Patients ≥18 years of age were included if at least one blood culture grew S. aureus. Patients were excluded if they were <18 years of age, were placed on palliative care, were transferred to

Results

Eighty-six in the pre-intervention period met inclusion criteria, and 339 patients met inclusion criteria in the post-intervention period. After matching patients 1:2 between the groups, 86 patients and 172 patients were compared in the pre-intervention and post-intervention groups, respectively. Patient baseline characteristics were largely similar between the two groups (Table 1). However, patients in the pre-intervention group were more likely to use IV drugs and to have a high-risk

Discussion

To our knowledge, this is the first propensity score matched study comparing SAB management and outcomes between groups with and without an active SAB care intervention. This is also the first study to have a pharmacist-led intervention as the cornerstone of care, as others have been based on physician or multifaceted intervention. Here, we were able to demonstrate that pharmacist-led intervention decreased time to appropriate antibiotic therapy and is associated with enhanced adherence to

Conclusions

The evidence favoring a bundled approach to care of SAB continues to mount, and our study further establishes the ability of a targeted therapeutic approach to improve adherence to SAB core care components as well as prevent SAB readmission. Furthermore, we have demonstrated that a pharmacist-led, ASP intervention can have drastic impact on SAB care in an institution where such an intervention did not previously exist. Perhaps most importantly, these data further support the use of

Acknowledgements

Jordan R. Smith, Jeremy J. Frens, Cynthia Snider, and Kimberly C. Claeys report no conflicts of interest. No external funding was received for this study.

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Cited by (21)

"Mortality in Staphylococcus aureus bacteraemia remains high despite adherence to quality indicators: secondary analysis of a prospective cohort study"
2021, Journal of Infection
Citation Excerpt :
Even though not reaching statistical significance, SAB-associated 30-day mortality was lower in the subgroup of patients with a quality indicators compliance rate of ≥75%. In this sense, our results may be considered consistent with previous studies that evaluated similar quality indicators in the management of patients with SAB.13–22 The fact that ID consultations for patients with SAB were unsolicited in our hospital may justify the relatively good adherence to these quality indicators.
To evaluate the association between compliance with previously published quality indicators (QIs) for the management of Staphylococcus aureus bacteraemia (SAB) and 30-day mortality.
We conducted a post hoc analysis of all adult patients with SAB who were hospitalized at a Spanish university hospital between 2013 and 2018. We evaluated the compliance with 7 QIs of SAB management (i.e., Infectious Diseases consultation, follow-up blood cultures, early source control, echocardiography, early cloxacillin or cefazolin, vancomycin monitoring, and appropriate treatment duration). The QIs compliance rate was considered good if ≥75% of the QIs recommended in each patient were performed. We studied the impact of different risk factors (including QIs compliance) on 30-day all-cause mortality adjusting by multivariable modeling and propensity-matched analysis.
We included 441 patients with SAB. The QIs compliance rate was ≥75% in 361 patients (81.9%). A total of 95 patients (21.5%) died within 30 days after the index blood culture. In the multivariable model, the variables associated with 30-day mortality were: age (OR, 1.1; 95% CI, 1.0–1.1), Charlson comorbidity index (OR, 1.2; 95% CI, 1.1–1.4), persistent bacteraemia >72 h (OR, 6.0; 95% CI, 3.2–11.5), infective endocarditis (OR, 2.8; 95% CI, 1.2–6.7), and SAB of unknown source (OR, 3.3; 95% CI, 1.5–7.1). We did not find an association between a global QIs compliance rate of ≥75% or any individual QI with 30-day mortality.
SAB 30-day mortality remains high despite good adherence to previously published QIs for the management of SAB. Future research should focus on additional factors to further improve SAB-related mortality.
Impact of a pharmacist-facilitated, evidence-based bundle initiative on Staphylococcus aureus bacteremia management
2021, Diagnostic Microbiology and Infectious Disease
Citation Excerpt :
However, no statistically significant difference in time to IDC, time to definitive antibiotic therapy, or clinical outcomes including bacteremia duration, hospital and infection-related LOS, 30-day all-cause mortality, and 30-day readmission were observed. Smith and colleagues performed a propensity score-matched, quasi-experimental study to evaluate the impact of their AS 4-point bundle recommendations for SAB with 86 and 172 patients in the pre- and post-intervention cohorts, respectively (Smith et al., 2018). Their initiative was associated with improved adherence to their 4-item bundle recommendations (56% vs 93%, P < 0.001), appropriate antibiotic therapy within 24 hours (76% vs 98%, P < 0.001), IDC (74% vs 100%, P < 0.001), and 30-day readmission for SAB (11% vs 4%, P = 0.024).
To evaluate a pharmacist-facilitated evidence-based bundle (EBB) initiative with infectious disease consultation (IDC) for Staphylococcus aureus bacteremia (SAB).
This was a before-and-after quasi-experimental study of adult patients with SAB before and after the pharmacist-facilitated EBB initiative, which included IDC, timely definitive antibiotics, source control, echocardiography, and repeat blood cultures.
Ninety and 111 patients were included in pre- and post-intervention cohorts, respectively. We observed significant increases in adherence to all 5 (4.4% vs 68.5%, P < 0.001) and 4 (10.0% vs 76.6%, P < 0.001) EBB elements. Time to definitive antibiotics (48 vs 16 hours, P < 0.001), time to IDC (43.5 vs 32 hours, P < 0.001), SAB duration (95 vs 66 hours, P = 0.009), persistent SAB (18.9% vs 9.0%, P = 0.041), and length of stay (14 vs 13 days, P = 0.027) also improved. No statistically significant differences for SAB-related readmission or all-cause mortality were observed.
Our pharmacist-facilitated SAB initiative was associated with improved EBB adherence and clinical outcomes.
Reduction of 30-day death rates from Staphylococcus aureus bacteremia by mandatory infectious diseases consultation: Comparative study interventions with and without an infectious disease specialist
2021, International Journal of Infectious Diseases
Most Japanese hospitals need to keep to higher Staphylococcus aureus bacteremia (SAB) quality-of-care indicators (QCIs) and create strategies that can maximize the effect of these QCIs with only a small number of infectious disease specialists. This study aimed to evaluate the clinical outcomes of patients with SAB before and after the enhancement of the mandatory infectious disease consultations (IDCs).
This retrospective study was conducted at a tertiary care hospital in Japan. The primary outcome was the 30-day mortality between each period. A generalized structural equation model was employed to examine the effect of the mandatory IDC enhancement on 30-day mortality among patients with SAB.
A total of 114 patients with SAB were analyzed. The 30-day all-cause mortality differed significantly between the two periods (17.3% vs. 4.8%, P = 0.02). Age, three-QCI point ≥ 1, and Pitt bacteremia score ≥ 3 were the significant risk factors for 30-day mortality. The intervention was also significantly associated with improved adherence to QCIs.
Mandatory IDCs for SAB improved 30-day mortality and adherence to QCIs after the intervention. In Japan, improving the quality of management in patients with SAB should be an important target.
The benefits and safety of oral sequential antibiotic therapy in non-complicated and complicated Staphylococcus aureus bacteremia
2021, International Journal of Infectious Diseases
Citation Excerpt :
Staphylococcus aureus bacteremia (SAB) is one of the main infections of concern due to its high morbidity and mortality. In recent years, a number of studies have shown that proper management can help improve these patients’ prognoses (Bai et al., 2015; Goto et al., 2017; López-Cortés et al., 2013; Pérez-Rodríguez et al., 2019; Smith et al., 2018). The current clinical guidelines for treating this infection recommend intravenous treatment to reduce mortality and complications (e.g., septic embolism, recurrence) (Gudiol et al., 2015; Liu et al., 2011; Nathwani et al., 2008).
Treatment optimization for serious infections, such as Staphylococcus aureus bacteremia (SAB), is a challenge for antimicrobial stewardship teams. Currently, SAB guidelines recommend a completely intravenous therapy (CIT).
The objective of the study was to analyze the usefulness and safety of oral sequential therapy (OST) in SAB.
We conducted a retrospective, observational study in a tertiary teaching hospital in Spain. The inclusion criteria were complicated and non-complicated monomicrobial SAB and an adequate duration of therapy, with patients classified into OST or CIT. The primary endpoint was the 90-day recurrence of S. aureus infection. We also analyzed the mortality, the length of the hospital stay, and the duration of the intravenous antibiotic administration.
Of a total of 201 patients with SAB, 125 (62%) underwent OST. The most commonly administered oral antibiotic was trimethoprim-sulfamethoxazole (66% of patients). Of those administered OST, 43% had complicated bacteremia (most with an osteoarticular source of infection), and 6% had an intravascular device. The 90-day recurrence rate was 4%, with no differences between the two groups. The duration of the therapy (22 [16–28] vs. 13 days [8–17] for CIT and OST, respectively; p < 0.001) and the hospital stay (36 [27–71] vs. 18 days [13–29] for CIT and OST, respectively; p < 0.001) were shorter for OST. MRSA was related with mortality (OR 4.4, 95% CI [1.67−11.37]; p = 0.003).
OST for properly selected patients with SAB could be a safe therapeutic option and can reduce their use of CIT and their hospital stay.
Bugs and Drugs: Collaboration Between Infection Prevention and Antibiotic Stewardship
2020, Infectious Disease Clinics of North America
Comparison of knowledge to antimicrobial stewardship institution policies targeting Staphylococcus aureus bacteremia and candidemia between medical doctors and pharmacists in an academic teaching hospital in Japan
2019, Journal of Infection and Chemotherapy
Staphylococcus aureus bacteremia (SAB) and candidemia have significant impacts on mortality. Both have important implications for antimicrobial stewardship programs (ASPs). However, there are limited data regarding who should be educated and what components should be considered for the ASPs. Hence, we investigated the possibility of the key elements for implications of SAB and candidemia managements for ASPs.
We conducted a cross-sectional study on the knowledge of antimicrobial stewardship institution policies targeting SAB and candidemia for all medical doctors (MDs) and pharmacists to using an E-learning system. To compare the differences in proportions of appropriate knowledge between junior residents and other MDs, and all MDs and pharmacists, we performed bivariate analyses using Fisher's exact test and χ² test with odds ratios (ORs) with 95% confidence intervals (CIs).
In total, all 395 MDs (71 junior residents, 137 senior residents and fellows, and 187 attending doctors) and all 63 pharmacists including 4 antimicrobial stewardship teams pharmacists responded to survey. MDs other than junior residents responded significantly inappropriately to the questions on the candidemia than junior residents (OR = 0.6, 95% CI: 0.4–1.0). Pharmacists had a significantly lower proportion of appropriate knowledge to the candidemia than MDs (OR = 0.4, 95% CI: 0.2–0.8). The major pitfall was failure to consult an ophthalmologist (82.5%).
Next step, we will conduct educational intervention about institution policies, and evaluate whether to improve the knowledges and practices by pre-post test and chart review.

View all citing articles on Scopus

^☆: Acknowledgements of External Support: This research received no external funding

^☆☆: Portions of this study were presented at the Infectious Diseases Society of America IDWeek Meeting, New Orleans, Louisiana, October 26–30, 2016

View full text

Clinical StudiesImpact of a pharmacist-driven care package on Staphylococcus aureus bacteremia management in a large community healthcare network: A propensity score-matched, quasi-experimental study☆,☆☆

Highlights

Abstract

Objectives

Methods

Results

Conclusion

Introduction

Section snippets

Study design and setting

Results

Discussion

Conclusions

Acknowledgements

Clin Microbiol Infect

Diagn Microbiol Infect Dis

Am J Infect Control

J Infect

Infectious diseases Society of a. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia

Am J Respir Crit Care Med

Comparing paired vs non-paired statistical methods of analyses when making inferences about absolute risk reductions in propensity-score matched samples

Stat Med

Circulation

Infective endocarditis in adults: diagnosis, antimicrobial therapy, and Management of Complications: a scientific statement for healthcare professionals from the American Heart Association

Circulation

Impact of infectious disease consultation on quality of care, mortality, and length of stay in Staphylococcus aureus bacteremia: results from a large multicenter cohort study

Clin Infect Dis

2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults

Clin Infect Dis

Applications of propensity score methods in observational comparative effectiveness and safety research: where have we come and where should we go?

J Comp Eff Res

Adherence to an antibiotic stewardship bundle targeting Staphylococcus aureus blood stream infections at a 200-bed community hospital

Infection

Prospective study of 424 cases of Staphylococcus aureus bacteraemia: determination of factors affecting incidence and mortality

Intern Med J

Clinical management of Staphylococcus aureus bacteremia: a review

JAMA

Staphylococcus aureus bloodstream infections: risk factors, outcomes, and the influence of methicillin resistance in Calgary, Canada, 2000-2006

J Infect Dis

Clinical Studies
Impact of a pharmacist-driven care package on Staphylococcus aureus bacteremia management in a large community healthcare network: A propensity score-matched, quasi-experimental study☆,☆☆