Infection Control & Hospital Epidemiology
Table 6. Recommendations by Independent ID Physician, Trained Pharmacist, and ID Clinical Fellow Pharmacist (n=303)
ID Staff
Initial recommendation Approved
Temporarily approved Not approved
Antibiotic stopped before evaluation
Final recommendation Approved
Not approved
Antibiotic stopped before evaluation
Approved
57 3 1 0
Temporarily Approved
5
73 14 0
Not Approved
1 2
14 0
Stopped Before
Evaluation P Value Approved
0 0 0
133 <.001
72 4 2 0
1161
Fellow (n=307)
Temporarily Approved
5
79 6 0
Not Approved
0 0
27 0
Stopped Before
Evaluation
0 0 0
112 P Value <.001
105 0 0
NA NA NA
0
63 0
0 0
135
<.001
124 2 0
Note. ID, infectious diseases; NA, not applicable. Shading cells represent the number of concordant recommendations.
evaluated by the ID service consultation team; 21 of the 35 rejected prescriptions (60.0%) in the fellow PPRA group were later assessed by the ID service consultation team. Of the 40 ID service consultations, only 1 of 40 patients (2.5%) in the phar- macist PPRA group subsequently received approval from the ID service consultation team, and the targeted antibiotic was then continued. In the pharmacist PPRA group, the common reasons for rejected prescriptions were too broad antibiotic coverage (70.7%) and no clinical evidence of infection (13.8%). In the fellow PPRA group, the common reasons for rejected prescrip- tions were too broad antibiotic coverage (65.7%) and no clinical evidence of infection (18.6%). The agreement rates between the initial recommendation in
the pharmacist PPRA and fellow PPRA groups were 84.7% and 91.3% (P=.05), respectively. The final recommendations between the groups revealed nearly perfect agreement: 100% in the pharmacist PPRA group and 99.0% in the fellow PPRA group (P=.19). The details of the recommendations made by an inde- pendent ID physician, trained general pharmacist, and ID clinical fellows appear in Table 6.
Discussion
Several studies have demonstrated the benefits of ASP facilitated by ID clinical pharmacists.15,16 The Infectious Diseases Society of America has recognized the value of the pharmacist’s expertise and recommends including an ID clinical pharmacist in the ASP team.17 Thailand faces a shortage in ID specialists and ID clinical pharmacists; thus, the present investigation sought to determine whether trained general pharmacists could effectively implement an antibiotic approval program. The lower bound of the 95% CI of difference in all
favorable treatment outcomes (favorable clinical response and favorable microbiological response) and the upper bound of the 95% CI of difference in all unfavorable treatment out- comes (28-day overall mortality, 28-day ID-related mortality, superimposed infection, clinically diagnosed antibiotic asso- ciated colitis, and antibiotic allergy) did not include the +10%
noninferiority margin. These results confirmed that the recommendations of the pharmacist PPRA were not inferior to those of the fellow PPRA in terms of all treatment out- comes. Furthermore, 28-day overall mortality was slightly lower in the pharmacist PPRA group; however, the difference was not statistically significant. The upper bound of the 95% CI of difference in the targeted
antibiotic use (pharmacist PPRA minus fellow PPRA) was >1.5 DDDs; thus, this study failed to confirm noninferiority in targeted antibiotic consumption in the pharmacist PPRA group. Further- more, the mean DDD of targeted antibiotic use and all antibiotic use was slightly—but not significantly—higher in the pharmacist PPRA group. These findings may be explained in the following ways. First, the pharmacist PPRA group was less stringent than the fellow PPRA group. This possibility is supported by the slightly lower rate of disapproval on the initial evaluation. Second, with the pharmacist PPRA group, the targeted antibiotics were usually approved for a longer duration (eg, 14 days for upper urinary tract infection), especially if the initial diagnosis was bacteremia. Addi- tionally, the ID clinical fellows may have had more clinical experience and may have been more comfortable in discontinuing the target antibiotic as early as possible (eg, 7 days for upper urinary tract infection). Unfortunately, to confirm that hypothesis, we lacked data about the number of days of antibiotic therapy. Researchers comparing antibiotic recommendations by ID
clinical pharmacists versus ID clinical fellows reported that ID faculty agreement in antibiotic choice was higher among the former (87.0% vs 47.0%, respectively; P < .001).14 In contrast, we found a lower proportion of agreement with the initial recommendation among pharmacists. However, the pharmacists in the present study were general pharmacists without any formal ID training; they were not ID clinical pharmacists as in the earlier investigation. The present study has several strengths. First, to the best of our knowledge, this is the first randomized controlled trial to compare the effectiveness of an antibiotic approval program implemented by trained general pharmacists compared with ID clinical fellows. Second, this study was specifically designed to obtain not only aggregate data on antibiotic consumption and expenditure but also
NA NA NA
0
66 0
0 0
115
<.001
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