改善社区获得性肺炎重症患者的护理。

Improving care for critically ill patients with community-acquired pneumonia.

机构信息

Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI.

Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, and Department of Pharmacy Practice, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, MI.

出版信息

Am J Health Syst Pharm. 2019 Jun 3;76(12):861-868. doi: 10.1093/ajhp/zxz068.

DOI:10.1093/ajhp/zxz068

PMID:31361849

Abstract

PURPOSE

The purpose of this study was to improve antimicrobial management and outcomes of critically ill patients with community-acquired pneumonia (CAP) through implementation of a pharmacist-driven bundle for ordering evidence-based diagnostic tests in a medical intensive care unit (MICU).

METHODS

An inpatient collaborative practice agreement (CPA) was established for MICU pharmacists to order criteria-driven diagnostic testing for CAP from November 2017-March 2018. Adults admitted to the MICU and started on empiric antibiotics for CAP were included. The intervention arm was compared with a standard of care (SOC) group from November 2016-March 2017.

RESULTS

Ninety-one patients were included in each group. There was no difference in the median antibiotic duration between SOC and CPA, at 7 days (interquartile range [IQR], 6-10) versus 7 days (IQR, 6-8), respectively. The overall use of evidence-based diagnostic tests increased in the CPA group. Patients in the CPA group had more frequent pathogen identification (SOC and CPA, respectively: 31 [34%] versus 46 [51%], p = 0.035) and antimicrobial deescalation (24 [26%] versus 53 [58%], p < 0.001). There was no significant difference in length of intensive care unit stay, at 4 days for SOC (IQR, 2-10) versus 6 days for CPA (IQR, 3-10), and no significant difference in inpatient all-cause mortality (13 [14%] versus 7 [8%]), retreatment 14 [15%] versus 11 [12%]), or 30-day readmission 16 ([18%] versus 13 [14%]) for SOC and CPA, respectively. The CPA was the only variable that was independently associated with antimicrobial deescalation (odds ratio, 4.030; 95% confidence interval, 2.101-7.731) in a multiple logistic regression.

CONCLUSION

Implementation of a pharmacy-driven pneumonia diagnostic stewardship bundle improved the use of evidence-based diagnostics and increased the frequency of pathogen identification. This intervention was associated with increased antimicrobial deescalation without a negative impact on patient safety outcomes.

摘要

目的

本研究旨在通过在重症监护病房（MICU）实施药师主导的用于开具基于证据的诊断检测的捆绑包，改善社区获得性肺炎（CAP）危重症患者的抗菌药物管理和结局。

方法

2017 年 11 月至 2018 年 3 月，MICU 药师通过合作实践协议（CPA）为 CAP 开具基于标准的诊断检测。纳入入住 MICU 并开始接受 CAP 经验性抗生素治疗的成年人。干预组与 2016 年 11 月至 2017 年 3 月的标准护理（SOC）组进行比较。

结果

每组纳入 91 例患者。SOC 和 CPA 组的抗生素治疗持续时间中位数无差异，分别为 7 天（四分位距 [IQR]，6-10）和 7 天（IQR，6-8）。CPA 组中基于证据的诊断检测的总体使用率增加。CPA 组患者的病原体鉴定更为频繁（SOC 和 CPA 组分别为 31[34%]例和 46[51%]例，p=0.035），抗菌药物降阶梯更为频繁（SOC 和 CPA 组分别为 24[26%]例和 53[58%]例，p<0.001）。SOC 组 ICU 住院时间中位数为 4 天（IQR，2-10），CPA 组为 6 天（IQR，3-10），两组间差异无统计学意义；SOC 和 CPA 组患者的院内全因死亡率分别为 13[14%]例和 7[8%]例，差异无统计学意义；SOC 和 CPA 组患者的再治疗率分别为 14[15%]例和 11[12%]例，30 天再入院率分别为 16[18%]例和 13[14%]例，差异均无统计学意义。多因素逻辑回归分析显示，CPA 是抗菌药物降阶梯的唯一独立相关因素（比值比，4.030；95%置信区间，2.101-7.731）。