309 Impact of Pharmacist-Led Stewardship Intervention on Appropriate Antibiotic Selection in the Emergency Department: A Systematic Review and Meta-analysis

Abstract

As many as 50% of antibiotics prescribed in outpatient settings are inappropriate, and antibiotics are prescribed in 16% of all emergency department (ED) visits. Clinical pharmacy practice in the ED improves overall patient outcomes, but the impact of pharmacy involvement on antibiotic stewardship in this setting is unknown. We performed this meta-analysis to analyze the impact of pharmacist-led stewardship intervention on appropriate antibiotic selection in the ED setting. This review followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. The search was conducted by an experienced medical librarian with input from the study team. Databases were searched from January 1st, 2000 through January 12th, 2021 and included Ovid Medline®, Embase, Cochrane Library, CINAHL, Web of Science, Scopus, and grey literature. Studies describing antimicrobial stewardship efforts in adult ED patients with pharmacists compared to an alternative practice were included. Appropriate antibiotic selection was determined by the definition within each study; all infection and intervention types were considered for inclusion. Two authors assessed risk of bias with the NIH Study Quality Assessment Tool and the Newcastle-Ottawa Scale for observational studies. Data was extracted by two authors and pooled using a random effects model with Mantel-Haenszel analysis. Cochrane's Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was used to assess quality of evidence across all studies. 24 studies were included and all were retrospective observational cohorts; 7 specifically were pre/post intervention assessments. Eighteen studies were fair quality and 3 had high risk of bias. The overall quality of evidence according to GRADE was low. Twenty-two studies had data for the primary outcome of appropriate antibiotic selection with a total of 5,062 patients. Comparator groups for intervention were hours without a pharmacist present in 6 studies, pre-protocol implementation in 9 studies, and alternative provider culture follow-up in 9 studies. Pharmacist involvement in stewardship was associated with a greater likelihood of receiving appropriate antibiotics (OR 3.23; 95% CI 1.98, 5.27). Among methods of intervention, pharmacist presence in the ED (OR 3.13; 95% CI 2.27, 4.32) and pharmacist-led algorithm and education (OR 6.13; 95% CI 2.85, 13.18) were associated with appropriate antibiotics. Pharmacist-led culture review was not significantly associated (OR 1.89; 95% CI 0.88, 4.06). Heterogeneity was high for all assessments. Though the overall quality of evidence was low, it appears that pharmacist involvement in antibiotic stewardship in the ED may significantly improve appropriate antibiotic selection. Pharmacist presence in the ED and pharmacist-led algorithm and education development may have a greater impact than pharmacist-led culture review.