Clinical Impact of a Pharmacist-Led Antimicrobial Stewardship Initiative Evaluating Patients with Clostridioides Difficile Colitis

Abstract

Clostridioides difficile is the most common cause of healthcare-associated infection and gastroenteritis-associated death in the USA. Adherence to guideline recommendations for treatment of severe C. difficile infection (CDI) is associated with improved clinical success and reduced mortality. The purpose of this study was to determine whether implementation of a pharmacist-led antimicrobial stewardship program (ASP) CDI initiative improved adherence to CDI treatment guidelines and clinical outcomes. This was a single-center, retrospective, quasi-experimental study evaluating patients with CDI before and after implementation of an ASP initiative involving prospective audit and feedback in which guideline-driven treatment recommendations were communicated to treatment teams and documented in the electronic health record via pharmacy progress notes for all patients diagnosed with CDI. The primary endpoint was the proportion of patients treated with guideline adherent definitive regimens within 72 hours of CDI diagnosis. Secondary objectives were to evaluate the impact on clinical outcomes, including length of stay (LOS), infection-related LOS, 30-day readmission rates, and all-cause, in-hospital mortality. A total of 233 patients were evaluated. The proportion of patients on guideline adherent definitive CDI treatment regimen within 72 hours of diagnosis was significantly higher in the post-interventional group (pre: 42% vs post: 58%, p=0.02). No differences were observed in clinical outcomes or proportions of patients receiving laxatives, promotility agents, or proton pump inhibitors within 72 hours of diagnosis. Our findings demonstrate that a pharmacist-led stewardship initiative improved adherence to evidence-based practice guidelines for CDI treatment.

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

“…Of 16 studies that reported "audit and feedback" as an intervention, five did not meet the definition in our review [34,53,55,56,72], even though they described their intervention as "audit and feedback" in the title or the methods. The intervention in these five studies was educational outreach using review cases with the provision of recommendations for change.…”

“…The majority (n=39) of studies described the mode for providing pharmacist recommendations, 30 of which used verbal communication (face-toface contact, interaction during ward round, or by mobile phone) [23, 24, 27, 30-33, 36-39, 41-44, 46, 50, 51, 53-55, 57, 59, 60, 62, 66, 69-71, 73]. Nine additional studies used nonverbal (written recommendations in medical charts or electronic medical records) (n=5) [25,35,45,56,65] and both verbal and non-verbal communication (n=4) [28,52,58,72].…”

“…A total of 19 studies (2 RCTs and 17 NRS) reported mortality as an outcome. Interventions were not associated with increased mortality in any study [24,38,39,44,48,51,53,55,57,59,60,62,65,66,68,[70][71][72][73]. Three studies (all NRS) reported significant reductions in mortality [55,62,70].…”

“…How effective were they likely to be? Antimicrobial agents were prescribed for skin infections including prophylaxis for the prevention of surgical site infections (n=12) [22,32,37,42,43,49,50,52,53,58,64,67], upper or lower respiratory tract infection (n=9) [25,30,33,53,54,57,60,65,68], bacteraemia (n=7) [39,46,47,51,62,66,71], Clostridioides difficile infection (CDI) (n=2) [44,72], and non-specified/more than three indications (n=23) [23, 24, 26-29, 31, 34-36, 38, 40, 41, 45, 48, 56, 59, 61, 63, 69, 70, 73, 75].…”

The Effectiveness of Clinical Pharmacist-Led Consultation in the Treatment of Infectious Diseases: A Prospective, Multicenter, Cohort Study

“…ASP is instituted to promote the appropriate use of antimicrobials, improve patient outcome, reduce microbial resistance, and decrease the spread of infection caused by multidrug-resistant organisms (Charani et al, 2019). Meanwhile, the inclusion of clinical pharmacists in ASP has been shown to result in significant improvement in terms of the quality of antibiotic use from various aspects, such as improving guidelineconcordant antimicrobial prescribing (Smith et al, 2018;Wang et al, 2018;Fay et al, 2019;Bishop et al, 2020), lessening the emergence of multidrug resistance (Li et al, 2017), shortening the days of antibiotic therapy (Wirtz et al, 2020), reducing the hospital stay of patients (Sadyrbaeva-Dolgova et al, 2020), and decreasing patients mortality (Li et al, 2017). ASP in China was initiated in 2011 with the promulgation of the Guideline for Clinical Application of Antimicrobial Agents (GCAAA), which required clinical pharmacists to participate in the management of antimicrobials, particularly in special antibiotics (vancomycin, carbapenem, tigecycline).…”