This article is more than 5 years old. Information may no longer be current.
Real-time AMS a predictor of faster time to optimal therapy
Click Here to Manage Email Alerts
Researchers identified real-time antimicrobial stewardship, or AMS, team response as an independent predictor of faster time to optimal treatment compared with the standard AMS practice of daily review of blood cultures.
Writing in Open Forum Infectious Diseases, Maya Beganovic, PharmD, MPH, an infectious diseases clinical pharmacy specialist at Advocate Lutheran General Hospital in Park Ridge, Illinois, and colleagues explained that rapid diagnostic tests (RDTs) may help improve patient outcomes, but a meta-analysis found that, without AMS programs, the technology may not have as great an impact.
“AMS team response to RDT results can lead to faster time to effective therapy (TTET), time to optimal therapy (TTOT), and is associated with reduced mortality, length of stay, and bacteremia recurrence,” they wrote.
To identify predictors of TTET and TTOT, Beganovic and colleagues conducted a cohort study at a tertiary care, teaching hospital during two time periods, November 2014 to February 2015 and November 2015 to February 2016. The AMS team conducted prospective audit and feedback on all patients with positive blood cultures on a daily, non-real-time basis in 2014 and early 2015. The team evaluated any adult and pediatric patients with at least one positive blood culture, but only the first positive blood culture per patient was included. The researchers defined optimal therapy as the most appropriate treatment option chosen based on an AMS program-approved bacteremia guideline. According to the study, patient blood cultures were used to determine predictors of TTOT and TTET.
The final analysis included 239 patients, of which 183 were infected with bacteremia or candidemia. According to the study, 54.4% of the blood cultures were positive for gram-positive organisms. The most commonly detected isolates were coagulase negative Staphylococcus at 46.1%, Streptococcus species at 19.2% and methicillin-sensitive Staphylococcus aureus at 16.1%. Moreover, 40.6% of cultures tested positive for gram-negative organisms, with Escherichia coli representing 49.5% and Klebsiella species representing 10.3%.
Beganovic and colleagues identified the most common sources of bacteremia as the urinary tract, abdomen and respiratory tract. For 13% of the cultures, the source of the bacteremia was unknown.
The only identifiable independent predictor of shorter time to optimal therapy was real-time AMS team response, Beganovic and colleagues reported. It was associated with a “significantly higher probability of receiving optimal therapy when compared to standard AMS intervention during pre-implementation period” (P < .05), they wrote. According to the researchers, having UTIs or pyelonephritis as a source of bacteremia or being infected with a gram-positive organism were independent predictors of faster TTET. The presence of a multidrug-resistant organism or bacteremia because of surgical site infections predicted longer TTET.
“While our data support a clear incremental benefit of integrating real-time AMS response with RDT, [they] also suggest that patients with severe disease and infections associated with immunosuppression, specifically febrile neutropenia, may prolong TTOT and require further attention as the safety of rapid streamlining in this population has yet to be determined, and AMS metrics remain to be standardized,” Beganovic and colleagues wrote. – by Marley Ghizzone
Disclosures: Beganovic reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
Back to Top
RDT has been nothing short of a revolution in clinical microbiology laboratories. As we have learned how to employ these new tests, it has become clear that their full clinical benefit is seldom realized without intervention from AMS practitioners, such as pharmacists, to transform laboratory results into prescriptive action.
Beganovic and colleagues’ article is a welcome addition to the existing body of literature on RDT outcomes with AMS intervention. Their article shines more light on the fact that the devil truly is in the details about which patients are most likely to benefit from RDT, as well as what modality of AMS intervention (standard vs. real time) best complements RDT. Their findings further clarify best practices in this arena, such as real-time communication of RDT results to an AMS practitioner, as opposed to passive notification, as well as outcomes most likely to be influenced, like TTOT, as opposed to TTET. Moreover, they identified patients who, possibly because of the complexity and severity of underlying illness and diagnostic uncertainty, such as those with febrile neutropenia or endocarditis, may have more difficulty in realizing the full benefits of RDT.
Click Here to Manage Email Alerts