Study Highlights Role of Pharmacist Recommendations in Antibiotic Stewardship

Pharmacist recommendations are important to improving stewardship of broad-spectrum antibiotics when treating community-acquired pneumonia (CAP). Now, new research by Cleveland Clinic pharmacists examines whether clinicians are receptive to this advice.

The study found that clinicians are most open to recommendations for transitioning patients from IV to oral antibiotics, but less likely to follow guidance on the duration of therapy. Concerningly, researchers also found that around 50% of CAP patients receive broad-spectrum antibiotics, even though only 15% meet criteria for severe CAP.

“This truly points to overuse of broad-spectrum antibiotics,” says lead author Ramara Walker, PharmD, BCIDP, AAHIVP, an infectious diseases (ID) clinical pharmacy specialist at Cleveland Clinic.

Addressing antibiotic overuse

Community-acquired pneumonia is a leading cause of hospitalization and mortality. In most cases, a specific pathogen is never identified, and treatment is given empirically. However, prescribing broad-spectrum antibiotics over a long period of time raises concerns about antibiotic resistance and can also increase the risk of side effects.

The Infectious Diseases Society of America and American Thoracic Society released updated stewardship guidelines in 2019 that call for de-escalating extended-spectrum antibiotics (ESA) following negative cultures, making an early switch to oral antibiotics, and limiting the duration of therapy when possible. ID pharmacists often communicate these guidelines to clinicians when consulting on patient care.

For the prospective study, researchers studied how clinicians responded to this advice, tracking 685 patient encounters over a 15-month period. It was the first study to measure physician acceptance of multiple types of recommendations, ranking which recommendations were most likely to be accepted.

Longer courses a concern

Clinicians accepted pharmacist recommendations about 72% of the time overall.

They were most likely to follow suggestions to switch patients to oral antibiotics, with an 80% acceptance rate. Recommendations to de-escalate ESA therapy were accepted 78% of the time, and suggestions to discontinue antimicrobials due to non-bacterial etiologies were followed 73% of the time.

In contrast, recommendations on treatment duration were followed less often — only 65% of the time.

“Unfortunately, we continue to see providers prescribing extended courses of seven, 10, or even 14 days, despite growing evidence that shorter durations are often equally effective.”

She notes that, while current guidelines for steps like de-escalation are clear, the duration of therapy is more of a gray area.

“The guidelines say, ‘a minimum of five days is recommended,’” explains Walker. “Not five days, but a minimum. So that provides opportunity for different interpretations of that language.”

How hospitals can improve stewardship

Interestingly, researchers also noted that acceptance rates varied depending on the time of the year, with clinicians far more likely to accept pharmacist recommendations in June than in December. Walker says this may reflect a reluctance by clinicians to de-escalate or shorten the course of therapy during the respiratory illness season.

Medical centers can improve antibiotic stewardship by re-evaluating order sets to ensure they aren’t “tipping the scales” toward the use of broad-spectrum antibiotics unnecessarily. When broad-spectrum antibiotics are used, clinicians should reassess this approach after 48 hours and use available tools like blood and respiratory cultures to guide de-escalation.

“It’s important to just have those time-out moments to assess if care is still appropriate,” Walker notes.

The use of additional screening, such as the Staphylococcus aureus nasal polymerase chain reaction (PCR) test, can help to rule out pneumonia caused by methicillin-resistant S.aureus (MRSA). “This quick nasal swab has a high negative predictive value for NOT having MRSA pneumonia,” says Andrea Pallotta, PharmD, BCIDP, AAHIVP, an ID clinical pharmacy coordinator at Cleveland Clinic.

At Cleveland Clinic, pharmacists can order this test when vancomycin, a broad-spectrum antibiotic, is prescribed for pneumonia. “Our pharmacists work with prescribers to interpret the test and identify opportunities for antibiotic de-escalation,” she says.

Walker said the mode of communication can also make a difference in encouraging clinicians to accept pharmacist recommendations. Most recommendations are delivered electronically through the Cleveland Clinic’s EMR system, making it easy for pharmacists to pend and share orders directly to clinicians to quickly review and accept.

“It’s just one click, and then the order is processed,” she says.