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Critical Care Team With Pharmacist Cuts Improper Antimicrobial Use

Kate Traynor

A preliminary report indicates that the round-the-clock availability of an intensivist-led critical care team with a clinical pharmacist can reduce inappropriate antimicrobial use in intensive care units (ICUs).

A poster presented Feb. 1 at the annual meeting of the Society of Critical Care Medicine in San Antonio described a 50 percent reduction in the inappropriate use of cefepime after a critical care team was created to support the 17-bed cardiothoracic ICU at Barnes-Jewish Hospital in St. Louis. The inappropriate use of vancomycin fell by 47 percent during the study period.

Clinical Pharmacist Jennifer R. Smith, Pharm.D., BCPS, a member of the critical care team, said that the reductions were apparently achieved simply because the team was present in the ICU to guide treatment decisions.

“We didn’t really have a set intervention that we did,” Smith said, adding that she was responsible for reviewing patient charts each day to determine whether a patient's clinical status or microbiological data indicated a need to continue antimicrobial therapy.

Inappropriate antimicrobial use was defined as more than 72 hours of treatment after the culture results were negative. Also considered inappropriate was antimicrobial therapy that continued unchanged after microbiological test results indicated a need for modification.

Smith pointed out that making a decision about antimicrobial use, such as saying no to a physician, is easier when done inside the ICU rather than elsewhere in the hospital.

“It’s hard if you’re somebody on the outside carrying a pager who gets a call saying, ‘I have a patient in the ICU who looks like they might not be doing well, and I want to start vancomycin or some broad-spectrum antibiotic,’ ” Smith said. “There are very few people who would say no in that situation.”

Smith said that antimicrobial use was monitored prospectively during a three-month period before the intensivist-led team was fully integrated into the workings of the ICU. During this time, 31 of 82 vancomycin orders and 19 of 53 orders for cefepime were deemed inappropriate.

Antimicrobial use was monitored again for a three-month period after the critical care team had been fully integrated into the ICU's work routine and was conducting patient rounds each day. During this follow-up period, inappropriate vancomycin use fell to 22 of 109 medication orders, and inappropriate cefepime orders decreased to 13 of 72 medication orders.

Smith said that inclusion of a clinical pharmacist on the critical care team is an important method for decreasing the inappropriate use of antimicrobial drugs. Her major role in this project, she added, was not the usual pharmacist function of determining when antimicrobial therapy should start or stop. Instead, she reminded the ICU staff that antimicrobial therapy needs to be monitored every day.