Prescribing trends and revisit rates following a pharmacist-driven protocol change for community-acquired pneumonia in an emergency department.

OBJECTIVE: To compare pharmacist-led prescribing changes and associated 30-day revisit rates across different regimens for patients discharged from an emergency department (ED) with a diagnosis of community-acquired pneumonia (CAP). METHODS: An observational, retrospective cohort analysis was conducted of patients who were discharged from an ED over a 4-year period with a diagnosis of CAP. Patient demographics, clinical characteristics, antibiotic selection and comorbidity and condition severity scores were collected for two cohorts: 2012-13 (before protocol change) and 2014-15 (post-protocol change). During January 2014, a pharmacist-led protocol change with prescriber education was implemented to better align ED treatment practices with clinical practice guidelines. The primary endpoint was the change in prescribing practices across the two cohorts. KEY FINDINGS: A total of 741 patients with CAP were identified, including 411 (55.5%) patients in 2012-13 and 330 (44.5%) in 2014-15. Prescribing of macrolide monotherapy regimens decreased significantly following protocol change (70.1% versus 42.7%; difference: 27.4%, 95% CI: 23.8-31.0%) with a reciprocal increase in macrolide/ß-lactam combination prescribing (6.3-21.8%; difference: 15.5%, 95% CI: 12.9-18.1%). A total of 12.2% of patients who received macrolide/ß-lactam combination treatment revisited a network ED within 30 days due to worsening pneumonia, compared to 8.6% of patients who received macrolide monotherapy treatment (P = NS). CONCLUSIONS: The current study showed a significant increase in antibiotic prescribing compliance following a pharmacist-driven protocol change and education, but no statistical difference in rates of return for macrolide monotherapy versus other regimens.

Defining the incidence and risk factors of colistin-induced acute kidney injury by KDIGO criteria.

BACKGROUND: Acute kidney injury (AKI) remains a treatment-limiting toxicity of colistin. Recently developed clinical practice guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) group have harmonized definitions of AKI, but have not been widely applied to patients receiving colistin. METHODS: We retrospectively defined AKI by KDIGO definitions among adult patients receiving intravenous colistin for ≥ 3 days. Risk factors for AKI within 48 hours and 7 days of initiating colistin were determined by multivariable logistic regression. RESULTS: Among 249 patients treated with colistin, rates of AKI were 12% and 29% at 48 hours and 7 days, respectively. At 48 hours, patients in the intensive care unit were at increased risk for AKI. Within 7 days, colistin daily doses >5mg/kg, chronic liver disease, and concomitant vancomycin were independent predictors. Seven percent of patients required renal replacement therapy at a median of 5 days (range: 3-7) following colistin initiation. CONCLUSION: Safe use of colistin is promoted by early detection of AKI with KDIGO criteria, avoiding nephrotoxins, and limiting duration of therapy.