Appropriateness of Empiric Antimicrobial Therapy for Community Onset Sepsis With Bacteremia in the Emergency Department: A Multidisciplinary Approach.

Background

Optimizing early antimicrobial therapy and incorporating clinical pharmacists into sepsis treatment strategies are essential for improving patient outcomes.

Objective

To examine the appropriateness of empiric antimicrobial selection for patients presenting with community onset sepsis with confirmed bacteremia, to characterize de-escalation practices, and to evaluate pharmacy involvement throughout the sepsis care process.

Methods

We conducted a retrospective review of adult patients with community-onset sepsis and confirmed bacteremia who presented to the Emergency Department (ED) between 9/2022 and 5/2023 at our hospital. The primary outcome was the percent of patients with ineffective empiric antimicrobials. Secondary outcomes included time to de-escalation, sepsis outcomes, sepsis guidelines adherence, and pharmacy interventions.

Results

109 patients were included. Median Charlson Comorbidity Index (CCI) was 6 (IQR 3-8) and Pitt bacteremia score 0 (IQR 0-1). Median time to first antibiotic administration was 29 minutes (IQR 15-50). Ineffective empiric antimicrobials occurred in 13.7% of cases, with median time to effective antibiotics at 24 h. De-escalation occurred in 84% of cases. The median time for discontinuation was 2 days for antimicrobial coverage against MRSA and atypical organisms and 4 days for coverage against P. aeruginosa. Initial therapy adhered to guidelines in 70.6% of cases, with deviation primarily due to vancomycin administration in the absence of MRSA risk factors. Antibiotic-related pharmacy recommendations were made in 40% (n = 44/109) of ED patients and 96% (n = 105/109) of hospitalized patients. In-hospital mortality, ICU admission, 30-day infection related re-admission and C. difficile infection within 6 months were 8.3% (n = 9), 42.2% (n = 46), 8.3% (n = 9), and 1.8% (n = 2), respectively.

Conclusion

Pharmacist involvement led to appropriate antimicrobial selection in the ED, effective de-escalation, and favorable sepsis outcomes.