Improved Outcomes for Gram-positive Bacteremia with Rapid Diagnostics and On-call Pharmacy Residents

Background: Delay in appropriate antimicrobials in bacteremia is associated with mortality. Rapid blood culture diagnostics reduce time to pathogen identification. Studies demonstrate the need for active intervention on these results to improve outcomes, and ideas for sustainable intervention strategies are needed. The objective of this study was to determine the impact of the FilmArray Blood Culture Identification (BCID) Panel on time to optimal antibiotic (ABX) therapy in patients with blood cultures containing gram-positive cocci (GPC) with and without on-call pharmacy residents. 

Methods: This was an observational, single-center, before-and-after study. Patients were included if they met the following: at least 18 years of age, one or more positive blood cultures containing GPC, and located in an intensive care and/or oncology unit. Patients were excluded for death prior to organism identification, polymicrobial bacteremia, concomitant infection caused by another pathogen, or transfer from an outside hospital with a positive blood culture and/or receipt of prior ABX. Three study phases occurred sequentially (Figure 1). The PRE phase utilized traditional identification methods. The POST-1 phase used FilmArray BCID for identification. Results for PRE and POST-1 phases were called to nurses. POST-2 phase results were called to postgraduate year one pharmacy residents who communicated recommendations to physicians.

Results: The number of patients in each phase were 59 (PRE), 56 (POST-1), and 61 (POST-2). Median time (hours) to optimal ABX in the bacteremia group was less in the POST-2 versus PRE phase (23.4 vs. 68.8; P < 0.01) (Figure 2). Median time to de-escalation (hours) was less in the POST-2 (34.4) and POST-1 (42.3) phases compared to the PRE phase (78.3) (P < 0.01). For contaminants, median ABX duration (days) and defined daily doses/patient were less in the POST-2 (1 and 0.63) versus PRE (2 and 3) phase (P < 0.05), respectively. ICU length-of-stay (days) in the contaminant group was shorter in the POST-2 (5) and POST-1 (4) phases compared to the PRE phase (9) (P < 0.05).

Conclusion: Active intervention with rapid blood culture diagnostics improved ABX and clinical outcomes. Pharmacy residents are an effective stewardship intervention approach.