Effect of a pharmacist-driven management protocol on the ......implemented to automacally start...
1
Disclosure • The study with larger sample size is warranted in order to confirm this finding. • Combina:on of Lactobacillus strains probio:c has the poten:al to reduce AAD and hospital length of stay in hospitalized adult pa:ents. • Since the p-value for primary outcome is 0.884, there is no significant reduc:on in the rate of CDI using Lactobacillus strains probio:c. • For secondary outcomes, AAD rate is significantly less in the probio:c group as p-value = 0.021 and hospital length of stay is also shorter. • Limita:ons include single center and retrospec:ve study, extensive exclusion criteria, inclusion of only hospitalist’s pa:ents, and poten:al confounding factors. Piperacillin/ tazobactam 20% Ampicillin/ sulbactam 2% CePriaxone 29% Levofloxacin 30% Cefepime 8% Ciprofloxacin 3% Meropenem 5% Imipenem 0% Clindamycin 3% CePazidime 0% Piperacillin/ tazobactam 19% Ampicillin/ sulbactam 4% CePriaxone 16% Levofloxacin 17% Cefepime 18% Ciprofloxacin 9% Meropenem 9% Imipenem 0% Clindamycin 8% CePazidime 0% Effect of a pharmacist-driven management protocol on the probio9c combina9on of Lactobacillus strains for preven9on of Clostridium difficile infec9on (CDI) in hospitalized adult pa9ents Uyen Huynh, Pharm.D. 1.2 , Gregory K. Perry, Pharm.D., BCPS-AQID, BCIDP 2 , Young R. Lee, Pharm.D., BCPS, BCCCP 1 , Pete Palmere, Pharm.D. Candidate 1.2 1 Texas Tech University Health Sciences Center School of Pharmacy, Abilene, Texas, 2 Hendrick Medical Center, Abilene, Texas Background Results Conclusion • The authors of this study do not have any conflicts of interest. Pre-implementa9on • In 2011, an es:mate of 435,000 cases with CDI was reported and 29,000 deaths occurred as the result of the disease. • The financial burden of U.S. health care rela:ng to CDI was immense, cos:ng about $4.8 billion. • Probio:c has been a major debate in literature whether it should be recommended for primary preven:on of CDI. • The strain that was found to have the most prominent data in reducing CDI rate is Lactobacillus casei according to a meta-analysis. • Lactobacillus acidophilus, Lactobacillus casei, and Lactobacillus rhamnosus have been used in conjunc:on to standard protec:ve measures at a community hospital in the Quebec region to reduce the incidence of CDI. 1) Lessa et al. The New England Journal of Medicine. 2015, 372;9; 825-34. 2) Cai et al. UEG Journal 2018, 6(2), 169-180. 3) Maziade, P.; Pereira, P.; Goldstein, E. Clin. Infect. Dis. 2015, 60 (Suppl. 2), S144–S147. References Purpose • To determine if a pharmacist-driven protocol using combina:on strains of Lactobacillus acidophilus, Lactobacillus casei, and Lactobacillus rhamnosus would help to reduce the incidence of CDI Methods Study design • Single-center, observa:onal, retrospec:ve cohort pre-post study Data collec:on period • Pre-implementa:on data: October to February 2017 • Post-implementa:on data: October to February 2018 Inclusion criteria • Hospitalist’s pa:ent • Pa:ents who received probio:cs within 48 hours of administra:on of the following an:bio:cs: Piperacillin/ tazobactam, ampicillin/sulbactam, cePriaxone, levofloxacin, cefepime, ciprofloxacin, meropenem, imipenem, clindamycin, and cePazidime Pharmacist-driven protocol approved by Pharmacy & Therapeu:cs and Performance Improvement commikee was implemented to automa:cally start probio:c if pa:ent meets criteria and has no exclusion Table 1. Baseline characteris9cs Characteris9cs Pre- implementa9on (n = 218) Post- implementa9on (n = 239) Age (mean in years) 60.0 61.7 Weight (mean in kg) 85.7 88.2 BMI (%) • <18.5 kg/m 2 • 18.5 – 24.9 kg/m 2 • 25 – 29.9 kg/m 2 • ≥ 30 kg/m 2 5.1 23.9 30.7 40.0 5.4 28.9 25.5 40.2 Gender (%) • Male • Female 50.9 49.1 56.9 43.1 Prior history of CDI (n) 6 8 Number of previous CDI (n) 10 9 Hospitaliza:on or long-term care facility within 90 days (%) 28.0 28.9 Dura:on of an:bio:cs (mean in days) 6.9 5.51 Indica:ons of an:bio:c during hospitaliza:on (%) • Bone and joint infec:ons • Cardiovascular infec:ons • Central nervous system infec:ons • Intra-abdominal infec:ons • Skin and soP :ssue infec:ons • Upper and lower respiratory tract infec:ons • Urinary tract infec:ons 2.3 3.7 0.9 22.5 21.6 30.7 23.9 5.9 0.8 1.3 8.4 22.6 45.6 23.0 Acid-suppression therapy (AST) during hospitaliza:on (%) 64.7 49.4 Laxa:ve (s) used during hospitaliza:on (%) 53.7 47.7 Narco:c(s) used during hospitaliza:on (%) 79.4 63.2 Post-implementa9on Figure 1. Prescribed An9bio9cs Table 2. Outcomes 1 o &2 o Outcomes and Safety results Pre- implementa9on (n = 218) Post- implementa9on (n = 239) Primary outcomes Incidence of CDI during hospitaliza:on (n, %) • Mild to moderate (n, %) • Severe (n, %) • Severe, complicated (n, %) 6 (2.75) 3 (1.38) 2 (0.92) 1 (0.46) 6 (2.51) 2 (0.84) 4 (1.67) 0 (0.0) Secondary outcomes • An:bio:c-associated diarrhea (AAD) during hospitaliza:on (n, %) • Hospital length of stay (mean in days) 36 (15.5) 8.52 22 (9.21) 6.62 Safety • Lactobacillus bacteremia (n, %) 0 (0.0) 0 (0.0) Discussion n = 218 n = 239
Transcript of Effect of a pharmacist-driven management protocol on the ......implemented to automacally start...
Disclosure
• Thestudywithlargersamplesizeiswarrantedinordertoconfirmthisfinding.
• Combina:onofLactobacillusstrainsprobio:chasthepoten:altoreduceAADandhospitallengthofstayinhospitalizedadultpa:ents.
• Sincethep-valueforprimaryoutcomeis0.884,thereisnosignificantreduc:onintherateofCDIusingLactobacillusstrainsprobio:c.
• Forsecondaryoutcomes,AADrateissignificantlylessintheprobio:cgroupasp-value=0.021andhospitallengthofstayisalsoshorter.
• Limita:onsincludesinglecenterandretrospec:vestudy,extensiveexclusioncriteria,inclusionofonlyhospitalist’spa:ents,andpoten:alconfoundingfactors.
Piperacillin/tazobactam
20% Ampicillin/sulbactam
2%
CePriaxone29%
Levofloxacin30%
Cefepime8%
Ciprofloxacin3%
Meropenem5%
Imipenem0% Clindamycin
3%
CePazidime0%
Piperacillin/tazobactam
19%Ampicillin/sulbactam
4%
CePriaxone16%
Levofloxacin17%
Cefepime18%
Ciprofloxacin9%
Meropenem9%
Imipenem0%
Clindamycin8%
CePazidime0%
Effectofapharmacist-drivenmanagementprotocolontheprobio9ccombina9onofLactobacillusstrainsforpreven9onofClostridiumdifficile
infec9on(CDI)inhospitalizedadultpa9entsUyenHuynh,Pharm.D.1.2,GregoryK.Perry,Pharm.D.,BCPS-AQID,BCIDP2,YoungR.Lee,Pharm.D.,BCPS,BCCCP1,PetePalmere,Pharm.D.Candidate1.2
1TexasTechUniversityHealthSciencesCenterSchoolofPharmacy,Abilene,Texas,2HendrickMedicalCenter,Abilene,Texas
Background Results
Conclusion
• Theauthorsofthisstudydonothaveanyconflictsofinterest.
Pre-implementa9on
• In2011,anes:mateof435,000caseswithCDIwasreportedand29,000deathsoccurredastheresultofthedisease.
• ThefinancialburdenofU.S.healthcarerela:ngtoCDIwasimmense,cos:ngabout$4.8billion.
• Probio:chasbeenamajordebateinliteraturewhetheritshouldberecommendedforprimarypreven:onofCDI.
• ThestrainthatwasfoundtohavethemostprominentdatainreducingCDIrateisLactobacilluscaseiaccordingtoameta-analysis.
• Lactobacillusacidophilus,Lactobacilluscasei,andLactobacillusrhamnosushavebeenusedinconjunc:ontostandardprotec:vemeasuresatacommunityhospitalintheQuebecregiontoreducetheincidenceofCDI.
1) Lessaetal.TheNewEnglandJournalofMedicine.2015,372;9;825-34.2) Caietal.UEGJournal2018,6(2),169-180.3) Maziade,P.;Pereira,P.;Goldstein,E.Clin.Infect.Dis.2015,60(Suppl.2),
S144–S147.
References
Purpose• Todetermineifapharmacist-drivenprotocolusing
combina:onstrainsofLactobacillusacidophilus,Lactobacilluscasei,andLactobacillusrhamnosuswouldhelptoreducetheincidenceofCDI
MethodsStudydesign• Single-center,observa:onal,retrospec:vecohortpre-post
studyDatacollec:onperiod• Pre-implementa:ondata:OctobertoFebruary2017• Post-implementa:ondata:OctobertoFebruary2018Inclusioncriteria• Hospitalist’spa:ent• Pa:entswhoreceivedprobio:cswithin48hoursof
administra:onofthefollowingan:bio:cs:Piperacillin/tazobactam,ampicillin/sulbactam,cePriaxone,levofloxacin,cefepime,ciprofloxacin,meropenem,imipenem,clindamycin,andcePazidime
Pharmacist-drivenprotocolapprovedbyPharmacy&Therapeu:csandPerformanceImprovementcommikeewasimplementedtoautoma:callystartprobio:cifpa:entmeetscriteriaandhasnoexclusion
Table1.Baselinecharacteris9csCharacteris9cs Pre-
implementa9on(n=218)
Post-implementa9on
(n=239)Age(meaninyears) 60.0 61.7Weight(meaninkg) 85.7 88.2
BMI(%)• <18.5kg/m2
• 18.5–24.9kg/m2• 25–29.9kg/m2• ≥30kg/m2
5.123.930.740.0
5.428.925.540.2
Gender(%)• Male• Female
50.949.1
56.943.1
PriorhistoryofCDI(n) 6 8NumberofpreviousCDI(n) 10 9Hospitaliza:onorlong-termcarefacilitywithin90days(%) 28.0 28.9Dura:onofan:bio:cs(meanindays) 6.9 5.51Indica:onsofan:bio:cduringhospitaliza:on(%)• Boneandjointinfec:ons• Cardiovascularinfec:ons• Centralnervoussysteminfec:ons• Intra-abdominalinfec:ons• SkinandsoP:ssueinfec:ons• Upperandlowerrespiratorytractinfec:ons• Urinarytractinfec:ons
2.33.70.922.521.630.723.9
5.90.81.38.422.645.623.0
Acid-suppressiontherapy(AST)duringhospitaliza:on(%) 64.7 49.4Laxa:ve(s)usedduringhospitaliza:on(%) 53.7 47.7Narco:c(s)usedduringhospitaliza:on(%) 79.4 63.2
Post-implementa9on
Figure1.PrescribedAn9bio9csTable2.Outcomes
1o&2oOutcomesandSafetyresults Pre-implementa9on
(n=218)
Post-implementa9on
(n=239)PrimaryoutcomesIncidenceofCDIduringhospitaliza:on(n,%)• Mildtomoderate(n,%)• Severe(n,%)• Severe,complicated(n,%)
6(2.75)3(1.38)2(0.92)1(0.46)
6(2.51)2(0.84)4(1.67)0(0.0)
Secondaryoutcomes• An:bio:c-associateddiarrhea(AAD)during
hospitaliza:on(n,%)• Hospitallengthofstay(meanindays)
36(15.5)
8.52
22(9.21)
6.62
Safety• Lactobacillusbacteremia(n,%)
0(0.0)
0(0.0)
Discussion
n=218 n=239
