Evaluation of the Impact of Pharmacist-Led Communication of the Clinical Pulmonary Infection Score (CPIS) on Antibiotic Prescribing in the Intensive Care Unit – A Pilot Study

Pharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Abstract Background: Overprescribing of antibiotics for nosocomial pneumonia in the intensive care unit (ICU) is a prevalent issue for antimicrobial stewardship programs (ASP). Discontinuation of antibiotics based on a low Clinical Pulmonary Infection Score (CPIS) on day 3 of therapy is associated with decreased antibiotic days and antimicrobial resistance. However, the impact of a pharmacist-led CPIS initiative is unknown. Objectives: The primary objective was to assess feasibility of a pharmacist-led CPIS initiative. Secondary objectives included determining impact on antibiotic prescribing and patient-important outcomes, and discerning prescriber rationale for antibiotic continuation in patients eligible for discontinuation. Methods: This was a prospective, interventional pilot study of ICU patients treated for nosocomial pneumonia over eight weeks. Pharmacists suggested antibiotic discontinuation on Day 3 of treatment for patients with CPIS ≤6 on Days 1 and 3 of therapy. Physician rationale for continuing antibiotics beyond Day 3 for these patients was recorded. Comparisons were drawn between the study period and data collected previously under auspices of ASP, without pharmacist intervention. Results: During this study period, eleven patients met the inclusion criteria, with six patients eligible for discontinuation. Data was collected from 12 patients during the ASP period. Two discontinuations occurred during the study period, in comparison with none during ASP data collection. There were significantly fewer mean ICU antibiotic days during the study period (11.17 days; 95% CI 4.41-17.93) than the ASP period (22.67 days; 95% CI 19.03-26.31). Physician rationale for antibiotic continuation included positive sputum cultures and extra-pulmonary infections. Barriers identified during the study included prescriber unfamiliarity with the CPIS and pharmacist unavailability on weekends. Conclusions: The pilot study demonstrated feasibility of a pharmacist-led CPIS intervention and identified barriers that may have affected its impact. Pharmacist intervention was associated with significant reduction in mean antibiotic days. Larger studies would provide further insight into potential impacts of pharmacist-led CPIS interventions

Prolonged oral vancomycin for secondary prophylaxis of relapsing Clostridium difficile infection

Abstract Background Clostridium difficile infection (CDI) is an important cause of diarrhea and continues to be a major burden within healthcare institutions and in the community. For a small subset of patients with frequently relapsing CDI who do not have access to fecal microbiota transplantation (FMT), or fail FMT, there are no clear treatment recommendations. We review our experience with prolonged oral vancomycin for secondary prophylaxis of relapsing CDI. Methods We performed a retrospective chart review of cases from the C. difficile consultation service at our institution since 2013. The service had three primary physicians providing consultations and performing over 1000 FMTs over the five-year period. Patients with relapsing CDI who were not candidates for FMT, refused, or relapsed after FMT were treated with vancomycin, followed by long-term oral vancomycin at a dose of 125 mg once daily. Results Twenty patients received at least 8 weeks of once-daily oral vancomycin for prophylaxis of relapsing CDI. Patients had a median age of 80 years, and experienced a median of four episodes of CDI prior to long-term vancomycin. Most were female and 75% had received FMT. Only a single case of C. difficile relapse occurred while on long-term vancomycin during 200 patient-months of follow-up. Amongst those who stopped long-term vancomycin, 31% relapsed within 6 weeks. No adverse events were observed. Conclusions For elderly patients with frequently relapsing C. difficile, prolonged vancomycin once daily at a dose of 125 mg orally was effective in preventing further relapse. Vancomycin secondary prophylaxis may be considered in patients who have failed FMT, or in cases where FMT is not available