Impact of a Standardized Pharmacist-Led Intervention to Promote Guideline-Directed Empiric Use of Vancomycin in Adult Patients with Febrile Neutropenia Ana Pellumbi, PharmD PGY1 Pharmacy Practice Resident Co-authors: Derick Miranda, Monika Totoraitis, Megan Musselman, Matt Baker, Jeremy John
Conflict of Interest Disclosure The speaker has no actual or potential conflict of interest in relation to this presentation 2
Background Febrile neutropenia (FN) Febrile Most common IDSA and NCCN complication of guidelines recommend + myelosuppressive empiric monotherapy ANC < 500 or < 1000 chemotherapy with an anti- neutrophils/mL and predicted pseudomonal beta- decrease to < 500 within 48 lactam hours ANC = absolute neutrophil count IDSA = Infectious Diseases Society of America NCCN = National Comprehensive Cancer Network 3
Background Exceptions • Suspected catheter- related infections • Recommend against • Skin or soft-tissue • Discontinue empiric use of infection after two days antimicrobials • Pneumonia if no positive targeting • Hemodynamic instability cultures gram positive • Positive blood cultures for aerobes gram positive cocci • Colonization with resistant Initiated gram positive organisms Empirically Guidelines 4
Consequences of Vancomycin Increased incidence of Acute kidney Unnecessary multidrug resistant injury antimicrobial organisms exposure 5
Study Rationale Adherence to recommendations Implementation of order sets or remains a challenge protocols may help guide clinicians 6
Objectives of the Study Evaluate the use of guideline-directed vancomycin for FN following a standardized intervention Assess the utilization of G-CSF during episodes of FN Analyze the rates of acute kidney injury related to vancomycin use G-CSF = Granulocyte-colony stimulating factor FN = Febrile neutropenia 7
Study Design Retrospective review of empiric vancomycin utilization prior to pharmacist-led intervention Order set update and pharmacist education on standardized-intervention Retrospective review of impact of intervention on empiric vancomycin utilization 8
Order Set Update Febrile neutropenia standard antibiotic regimen: Cefepime Vancomycin criteria for use +/- Vancomycin Hemodynamic instability Suspected catheter-related infection Skin or soft tissue infection Pneumonia Colonization with MRSA MRSA = methicillin resistant Staphylococcus aureus 9
Study Design January - July 2019 Pre-Intervention Vancomycin ordered per the ordering providers’ discretion November 2019 - March 2020 Pharmacist to intervene to Post-Intervention promote guideline-directed empiric vancomycin use 10
Pharmacist Intervention Vancomycin ordered for FN Meets criteria for Criteria for empiric use empiric use not met Contact ordering Verify order physician De-escalate vancomycin after 48 hours if appropriate FN = Febrile neutropenia 11
Study Design Inclusion Criteria Exclusion Criteria - Age > 18 years admitted for FN - Complete course of FN was not managed at our hospital - Hospitalization > 48 hours - Received anti-MRSA agent - Received at least two within 7 days of hospitalization consecutive doses of vancomycin or discontinued empirically - Documented vancomycin allergy FN = Febrile neutropenia MRSA = methicillin resistant Staphylococcus aureus 12
Outcomes Primary Outcome Secondary Outcomes - Guideline-directed empiric - Composite of guideline- vancomycin initiation directed empiric vancomycin initiation and discontinuation - Guideline-directed empiric vancomycin discontinuation - Length of stay - Incidence of acute kidney injury - Use of therapeutic G-CSF for FN G-CSF = Granulocyte-colony stimulating factor FN = Febrile neutropenia 13
Results - Demographics Pre-intervention Post-intervention Demographics n = 27 n = 15 Average age – years 67 61 Male gender – no. (%) 14 (52) 11 (73) Central line – no. (%) 19 (73) 14 (93) Received G-CSF outpatient – no. (%) 4 (15.3) 4 (26.7) Average baseline SCr – mg/dL 1.2 1.4 G-CSF = Granulocyte-colony stimulating factor No. = number SCr = Serum creatinine No = Number 14
Vancomycin Prescribing Pre-intervention Post-intervention n = 27 n = 15 ED – 11 (37) ED – 7 (46.7) Provider team ordering Primary – 11 (40.7) Primary – 3 (20) vancomycin – no. (%) Heme/Onc – 5 (18.5) Heme/Onc – 2 (13.3) ID – 1 (3.7) ID – 2 (13.3) Heme/Onc – 8 (29.6) ID – 4 (26.7) Primary – 6 (22.2) Pharmacist – 4 (26.7) Discipline who initiated Pharmacist – 6 (22.2) Primary – 3 (20) de-escalation of ID – 5 (18.5) Pulmonary – 2 (13.3) vancomycin – no. (%) ED – 1 (3.7) Heme/Onc – 1 (6.7) Other (patient expired) – 1 (6.7) ED = Emergency department Heme/Onc = Hematology/Oncology ID = Infectious diseases No = Number 15
Results - Outcomes Primary Outcome Composite of guideline-directed empiric initiation and discontinuation of vancomycin – no. (%) Pre-intervention Post-intervention P – value n = 27 n = 15 12 (44) 12 (80) 0.026 Secondary Outcomes Outcome Pre-intervention Post-intervention P – value n = 27 n = 15 Guideline-directed empiric initiation 15 (57.7) 14 (93.3) 0.089 of vancomycin – no. (%) Guideline-directed discontinuation 16 (61.5) 12 (80) 0.307 of vancomycin – no. (%) 7.6 8.3 0.82 Length of stay – days Acute kidney injury – no. 1 4 0.047 Therapeutic G-CSF – no. (%) 20 (76.9) 12 (80) 1 G-CSF = Granulocyte-colony stimulating factor No. = number 16
Limitations Retrospective, Small population Unbalanced groups single center size study Data collected from Duration of We could not account for different time of the study differences in AKI year between the groups AKI = Acute kidney injury 17
Conclusion Implementation of a Pharmacists can play standardized order set a role in limiting increases guideline- antibiotic exposure directed empiric vancomycin use Use of empiric vancomycin in Most patients received combination with other therapeutic G-CSF nephrotoxic agents should be further explored G-CSF = Granulocyte-colony stimulating factor 18
Next Steps RE-EVALUATE THE ENCOURAGE PROVIDERS PROMOTE GUIDELINE- APPROPRIATENESS OF TO UTILIZE THE FN DIRECTED MANAGEMENT THERAPEUTIC G-CSF ORDER SET AS GUIDANCE OF FN G-CSF = Granulocyte-colony stimulating factor FN = Febrile neutropenia 19
Ana Pellumbi PGY-1 Pharmacy Resident North Kansas City Hospital Ana.pellumbi@nkch.org 20
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