Ashley M. Wilde, Pharm.D., BCPS-AQ ID, Matthew Song, Pharm.D., W. Paul Allen, Pharm.D., Leslie K. Kenney, B.S.Pharm., BCPS, Alice H. Beane, Pharm.D., BCPS, BCCCP, Alan D. Junkins, Ph.D., D(ABMM), Paul S. Schulz, M.D.
Norton Healthcare, Louisville, KY
Rapid diagnostic technologies in the microbiology laboratory have yielded limited patient improvement due to limitations in infectious diseases or antimicrobial stewardship resources. To address these issues, our 1500+ community health system implemented a Rapid Bacteremia Response Program (RBRP) that incorporated the pharmacy team as the central department of a comprehensive bacteremia response service.
The RBRP is a 24/7 blood culture management program where both positive blood culture Gram stains and rapid diagnostic results are called directly from the microbiology lab to the pharmacy department in real time. If the patient is not on adequate therapy at the time of Gram stain result, the pharmacist orders a one-time STAT dose of antimicrobial therapy per protocol, communicates with nursing, and expedites compounding and delivery of the antimicrobial. In the instance of gram positive cocci in clusters, the pharmacist also orders repeat blood cultures per protocol. A few hours later, the rapid diagnostic result is evaluated by the pharmacist who enters appropriate isolation orders if a drug resistance target is detected. The pharmacist then communicates the result to the admitting service’s provider with a recommendation for therapy.
In the first year after implementation of the RBRP, 2282 blood culture Gram stains and 2046 rapid diagnostic results were called to the pharmacy department. STAT antibiotics were ordered by the pharmacist per protocol in 781 (34.2%) cases. In patients not already on adequate antibiotics, median time from Gram stain to administration was 51 minutes (IQR 32-95 minutes). Prior to the RBRP, the average time to antibiotic therapy was approximately 10 hours. The fastest recorded time from Gram stain to antibiotics with the RBRP was seven minutes. From the pharmacist intervention on the rapid diagnostic result, antibiotic regimens were adjusted in 55.7% of cases.
To describe the clinical impact of the RBRP, patients with community acquired Staphylococcus aureus bacteremia were evaluated. Fifty random patients before the RBRP were compared to 100 patients after RBRP implementation. There was a reduced length of stay in the post-RBRP compared to the pre-RBRP, median 9 (IQR: 6-13) days vs. 9 (IQR: 6-15) days (Adjusted hazard ratio (aHR): 0.49; 95% CI: 0.26 – 0.92; p=0.026), respectively. While in hospital mortality was not affected by the RBRP, 30-day mortality was reduced by 93%. At 30 days, 9 (19%) patients were deceased pre-RBRP, compared to 3 (3%) patients post-RBRP (Adjusted odds ratio (aOR): 0.072, 95% CI: 0.009 – 0.365, p=0.004).
Our RBRP champions the pharmacy department through broad reaching services with Gram stain assessment, STAT antimicrobial doses, blood culture ordering, rapid diagnostic interpretation, patient isolation, and antimicrobial escalation or de-escalation all while being reproducible in most hospitals or health systems as it does not rely heavily on infectious diseases clinical coverage.