176 - Impact of pharmacist electronic communication on the appropriateness of antimicrobial therapy at renewal time

Background: Inappropriate antibiotic use increases the risk of antimicrobial resistance and adverse events. Our institution adopts all elements recommended by the CDC to improve antimicrobial stewardship (AMS). Compliance with such elements requires education, coaching and decision support tools. The objective of the study intervention is to engage prescribers to critically evaluate and improve antibiotic utilization through renewal communication in the electronic medical record (EMR).

Methods: This is a single center study with a retrospective phase and prospective phase. During the intervention period from October 1st, 2019 to January 1st, 2020 the pharmacist monitored targeted antibiotics and initiated an AMS EMR note. Prescribers were then requested to evaluate the appropriateness of therapy utilizing pre-defined criteria developed in agreement with the infectious disease (ID) service at 48 hours, in-line with the EMR time-out alert. Adults receiving vancomycin (VAN), piperacillin/tazobactam (TAZ), cefepime (CEF) or meropenem (MPN) for at least 48 hours were included. The historical group included patients on the targeted antibiotics between July 1st, 2019 and September 30th, 2019. The primary outcome was median days of therapy (DOT). Secondary outcomes were median DOT per antibiotic, percentage of ID consults and percentage of antibiotic optimization. Statistical analyses were conducted using T-test and chi-square test for continuous and categorical variables respectively.

Results: A total of 81 and 72 patients were included in the intervention and historical groups respectively. No statistical difference in the primary outcome of median DOT was observed (4.5 vs 4, p=0.5). However, Non-significant numerical reductions in DOT were observed for VAN (3 vs 3.5, p=0.5), CEF (3 vs 4, p=0.6) and TAZ (3 vs 4, p=0.3), but not for MPN (6 vs 5, p=0.6). The intervention resulted in more ID consults when prescribing targeted antibiotics (59.3% vs 41.6%, p=0.03). In the intervention group, antibiotic treatment was optimized in 87.7% of patient, in which 39.6% were treatment de-escalation and discontinuation. 

Conclusion: Pharmacist clinical guidance through the electronic medical record can provide a powerful educational tool to promote adherence to antimicrobials best practice