The tangled relationship between sepsis and antimicrobial resistance (AMR) exacerbates these two persistent and troubling challenges for hospitals. It doesn't have to be that way. Each year sepsis afflicts 30 million adults and children globally, resulting in 6 million deaths; it accounts for 20% of U.S. hospital admissions and more than 50% of U.S. hospital deaths. Initial sepsis care demands the use of broad-spectrum antibiotics. Still, overuse of these drugs – 30% of those prescribed in U.S. hospitals are unnecessary – has contributed to one American dying every 15 minutes from an AMR infection.
These facts make clear the multi-faceted challenge. As more pathogens become resistant to antimicrobials, more people are at risk of developing sepsis – or AMR compromising the efficacy of their sepsis treatment. In addition, the overuse of antibiotics can lead to the emergence of more resistance and other healthcare-associated infections, such as C. difficile.
This dangerous relationship demands that sepsis improvement programs and antimicrobial stewardship (AMS) programs work hand in hand. Collaboration among clinical teams with the support of proven and integrated clinical surveillance can reduce care variation and costs while improving patient outcomes for these life-threatening concerns.
How top hospitals address balancing sepsis and antimicrobial stewardship
How can hospitals address both sepsis improvement programs and AMS programs? Let's consider two real-world cases.
In the first, a patient who presented with high fever and pneumonia rapidly decompensated into severe sepsis. Initially, the hospital implemented its severe sepsis protocol, which included vancomycin and meropenem. A rapid respiratory panel returned positive for Streptococcus pneumoniae two hours later but negative for other bacteria and viruses. In response, an AMS pharmacist recommended rapidly de-escalating the vancomycin to ceftriaxone, as methicillin resistant Staphylococcus aureus was not present. The patient steadily improved.
In the second, a patient with severe penicillin allergy who presented with cardiac symptoms received treatment at the cardiac catheterization lab before developing a high fever and early signs of sepsis. The hospital began its sepsis protocol, including vancomycin, but when an initial blood culture came back with gram-negative rods, the vancomycin was discontinued, and ciprofloxacin was added. However, the next day, the bacterium Enterobacter was identified, prompting the AMS pharmacist to suggest adding tobramycin while susceptibilities are pending. Again, the patient improved.
Both of these cases demonstrate that sepsis improvement and antimicrobial stewardship become complementary programs when the correct information gets to trained clinical teams in a timely fashion.
Data-driven support leads to sepsis and AMS collaboration
An intentional, well-informed effort is the key to successful collaborations like those described above. It begins with creating and training multidisciplinary clinical teams, including a pharmacy team that has developed AMS protocols rooted in best practices. However, the training and protocols are only effective when timely insights into each individual patient and into hospital, unit, and individual performance against vital benchmarks become available. Those insights emerge from the use of data and advanced analytics.
In the case of sepsis, surveillance technology that continuously monitors patients can identify early stages using complex algorithms to analyze multiple types of clinical data sources in real-time. When the probability of true sepsis is high, highly specific alerts establish credibility with clinical teams. In turn, those teams initiate appropriate treatment as early as possible – a key element in reducing mortality or serious complications.
In addition, surveillance technology that draws on data across systems can:
- Recommend the most appropriate treatment tailored to each patient's dynamic and specific condition.
- Direct recommendations to the appropriate care team member based on each hospital's unique protocols.
- Monitor adherence to best practices.
- Monitor patients as they transition between levels of care and clinical settings.
From an AMS perspective, clinical pharmacy teams can draw on the same data to identify when it might be appropriate to de-escalate, switch or discontinue antimicrobial use. To help ensure continuous improvement, the technology can also measure various important indicators and create reports that help enforce AMS policies throughout the hospital. Among the benefits, the technology can:
- Measure and trend days of therapy (DOTs) and duration by the prescriber and patient care area so individuals and units can understand how they perform and target improvements.
- Track clinical policy compliance throughout the hospital.
- Participate in antimicrobial use (AU) and resistance (AR) reporting for the National Health and Safety Network.
- Benchmark how the hospital is doing using the standardized antimicrobial administration ratio (SAAR) from NHSN.
- Draw on an antibiogram to inform the better selection of antimicrobials.
The result is that more patients throughout the hospital receive the right antibiotic and right dose at the right time and for a suitable duration. And for those patients with sepsis, reduced risk of mortality pairs with a dramatic reduction in the risk of long-term morbidity such as renal failure, liver failure, neurological deterioration, an overall decrease in the quality of the life of sepsis survivors.
For more information, view a webinar on this topic led by Itay Klaz, MD, MHCI, Medical Director and Steve Mok, PharmD, BCPS, BCIDP, Manager of Pharmacy Services and Fellowship Director on best practices for balancing sepsis care and antimicrobial stewardship.