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

Abstract

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.