Implementation of a Pharmacist-Led Culture and Susceptibility Review System in Urgent Care and Outpatient Settings
Background: Increasing prevalence of antibiotic resistance is an urgent public health threat. The purpose of this project is to implement a pharmacist-managed culture review service to decrease and prevent inappropriate use of antibiotics. This service will intervene in cases of mismatched antibiotic–bacteria combinations to decrease health care provider (HCP) and nursing interruptions, improve patient outcomes, and enhance prescribing practices to reduce occurrence of antibiotic resistance.
Observations: Patients requiring changes in antibiotic therapy after culture and susceptibility results were identified through the electronic health record. After results were returned, pharmacists assessed the antibiotic for appropriateness. If the isolated organism was not susceptible to the empiric antibiotic, the pharmacist adjusted the regimen, counseled the patient, documented the intervention electronically, and notified the HCP via an electronic note. Follow-up phone calls assessed for adverse effects and answered patient questions. Pharmacists could change antibiotic therapy without contacting HCPs because of an antimicrobial stewardship care coordination agreement between HCPs and pharmacists. Previously, HCPs were responsible for evaluating culture and susceptibility results as well as adjusting antimicrobial regimens. After implementing this project, 10 interventions were made out of 320 patients from August 2019 to February 2020.
Conclusions: Appropriateness of antibiotic therapy through antimicrobial stewardship could help combat the significant public health issue of antibiotic resistance.
Future Directions
Future endeavors regarding this project include modifying the scope of the service to allow pharmacists to prescribe antibiotics for patients with positive cultures and symptoms without empiric antibiotics in addition to continuing to modify empiric therapy. Additionally, improving dashboard efficiency through changes to include only isolated antibiotic mismatches rather than all antibiotics prescribed and all available cultures would reduce the pharmacists’ time commitment. Expanding to other parts of the medical center, including long-term care facilities and other outpatient clinics, would allow this service to reach more veterans. Integrating this service throughout the medical center will require continued HCP education and modifying care coordination agreements to include these facilities.
On a typical day, 60 to 90 minutes were spent navigating the dashboard and implementing this service. The CPRS dashboard should be modified to streamline patients identified to decrease the daily time commitment. Re-education of HCPs about resistance rates of fluoroquinolones and empirically prescribing these agents also will be completed based on empiric antibiotic interventions made with these agents throughout this project. Discussing HCP viewpoints on this service would be beneficial to ensure HCP satisfaction.
Conclusions
This pharmacy service and antimicrobial stewardship program reduced time patients were on inappropriate antibiotics. Pharmacists reviewed the dashboard daily under the scope of this project, which expedited needed changes and decreased provider burden because pharmacists were able to make changes without interrupting HCPs’ daily tasks, including patient care.
This program may also reduce readmissions. Patients who were still symptomatic were contacted could be given revised medication regimens without the patient returning to the facility for follow-up treatment. An interesting conclusion not included in the current scope of this service was possible reduced time to therapy initiation in cases of positive cultures and symptomatic patients without antibiotic therapy. If this occurred on the dashboard, patient’s symptoms could be assessed, and if symptoms were ongoing, the pharmacist contacted the HCP with a recommended antimicrobial therapy. In these cases, we were able to mail the antibiotic quickly, and many times, on the same day as this intervention through overnight mail. Implementation of a pharmacist-led antimicrobial review service has provided positive results overall for CVVAMC.
Acknowledgment
This material is the result of work supported with resources and the use of the facilities at the Carl Vinson VA Medical Center.
