Optimizing Empiric Vancomycin Use in Febrile Neutropenia Patients

Introduction: Febrile neutropenia (FN) is a complication of chemotherapy resulting in a temperature 100.4⁰F or greater plus an absolute neutrophil count (ANC) below 500 cells/mm3 or an ANC below 1000 cells/mm3 and expected to decrease below 500 cells/mm3 within 48 hours. Timely administration of broad-spectrum antimicrobial therapy is a cornerstone for the initial management of FN. However, prolonged empiric antimicrobial treatment can lead to resistance and toxicity. National guidelines and published literature do not support vancomycin as a routine part of empiric antimicrobial regimens in FN; it is only recommended in patients with specific clinical indications. This study aims to evaluate current use of vancomycin in FN and improve compliance with a guideline-driven algorithm (GDA) to ensure appropriate prescribing and therapy duration in a community hospital. Methods: This single-center, biphasic, quality improvement project includes both retrospective (Phase 1) and prospective (Phase II) review of adult patients receiving empiric vancomycin therapy for FN at Baptist Hospital. Phase I took place from January to December 2019, while Phase II took place from January to March 2021. Data collection points included patient demographics, indication, pertinent labs and cultures, therapy duration and compliance with the GDA. In Phase II, pharmacist interventions were made to recommend de-escalation or discontinuation of vancomycin as warranted. Primary outcomes included percent compliance with the GDA and duration of vancomycin therapy, while secondary outcomes included number of pharmacy interventions made and accepted in Phase II. Results: A total of 48 patients were reviewed during phase I of the study while 32 patients were reviewed during phase II. The percent compliance with the GDA increased from 15% in phase I to 38% in phase II. The average duration of therapy in phase I was 4.77 days (ranging from 1-16) vs 2.69 days in phase II (ranging from 1-9). The percentage of patients continued on vancomycin beyond 48 hours decreased from 81% in phase I to 34% in phase II. A total of 18 pharmacist interventions were made in phase II with an acceptance rate of 100%. Discussion: Pharmacist intervention had an impact in increasing compliance to national guideline recommendations and decreasing the duration of empiric vancomycin therapy in patients with FN

Optimizing Empiric Vancomycin Use in Febrile Neutropenia Patients

Introduction: National guidelines do not support routine empiric vancomycin use in the initial management of febrile neutropenia (FN) and only recommend it in patients with specific clinical indications. This bi-phasic quality improvement project aimed to evaluate current vancomycin use in FN and improve compliance with a guideline-driven algorithm (GDA) to ensure appropriate prescribing and therapy duration in a community hospital. Methods: Phase I was a retrospective review of charts of adults receiving empiric vancomycin therapy for FN at a community hospital. Phase II was a prospective review of charts of patients with FN, who received pharmacist-led interventions, to improve de-escalation of vancomycin as warranted. Results: A total of 48 and 32 patients were included in phase I and phase II, respectively. While initiation of vancomycin therapy according to guideline-recommended clinical indications was comparable among phases, appropriate de-escalation of vancomycin increased from 23% in phase I to 78% in phase II. Overall compliance with the GDA increased from 15% in phase I to 38% in phase II. Average duration of therapy in phase I was 4.77 days versus 2.69 days in phase II and there were less patients who continued vancomycin beyond 48 hours in phase II. The pharmacy intervention rate was 56% (18 of 32) and the health-care practitioner acceptance rate was 100%. Discussion: Pharmacist interventions had an impact in increasing compliance with national guideline recommendations and decreasing the duration of empiric vancomycin therapy in patients with FN

Pharmacists’ role in the management of patients receiving dual or triple antithrombotic therapy

Purpose: Patients on dual and triple antithrombotic therapy present the therapeutic dilemma of mitigating bleed risk while sustaining antithrombotic efficacy. Lack of literature and variability in existing published guidance potentiates inconsistent management of these patients. Furthermore, suboptimal dosing of direct oral anticoagulants is relatively common. One study reported as high as 43% of patients receive higher and 13% receive lower than clinically indicated doses. These findings were associated with a significantly increased risk of major bleeding and incidence of stroke, thus highlighting the importance of selecting an ideal regimen. The purpose of this project is to highlight pharmacists’ role in the optimization of antithrombotic therapy in patients with concurrent indications for antiplatelet and anticoagulant agents. Methods: This was a single center, quality improvement project including adult patients concomitantly receiving at least one antiplatelet agent and a therapeutic-dose anticoagulant between January and March 2021 at Baptist Hospital. Eligible patients were assessed and evaluated on a daily basis. Data collection included indications for prescribed antithrombotic agents and rationale for clinical recommendations. Potential therapeutic de-escalations and/or dose adjustments were communicated with the provider as necessary. The primary outcome of this study was appropriateness of anticoagulant and antiplatelet therapy based on their specific indications. Secondary outcomes included the types of pharmacy interventions made and accepted. Results: A total of 239 patients receiving dual or triple antithrombotic therapy were prospectively reviewed over the 10-week study period. The average age was 74 years, and 56% of patients were male. The majority of regimens reviewed (95.4%) were dual antithrombotic therapy. Overall, 82% of all reviewed regimens were considered appropriate at time of pharmacist review (85% of dual therapy regimens and 27% of triple therapy regimens were appropriate). After pharmacist intervention, regimen appropriateness increased to 97% overall, with dual therapy regimens adjusted to 96.5% appropriate (78% acceptance rate) and triple therapy regimens adjusted to 100% appropriate (100% acceptance rate). The most common intervention was antiplatelet discontinuation (46%), however the most clinically significant intervention was discontinuation of oral anticoagulation (7.8%). Conclusion: Pharmacist intervention resulted in optimization of dual and triple antithrombotic therapies by 15% with an intervention acceptance rate of 83%. Triple antithrombotic regimens had the greatest room for optimization, as was demonstrated by a 73% increase in regimen appropriateness as a result of pharmacist review and intervention