Leah Nguyen is an Emergency Medicine Clinical Pharmacy Specialist at the Portland Veterans Affairs Health Care System in Oregon; Andrew Varker is an Infectious Disease Clinical Pharmacy Specialist; Pamela Slaughter and Daniel Boyle are Emergency Medicine Clinical Pharmacy Specialists; Negin Nekahi is an Infectious Disease Specialist; Leah Nguyen was a Pharmacy Resident at the time this article was written; all at Phoenix Veterans Affairs Health Care System in Arizona. Correspondence: Leah Nguyen (leah.nguyen1@va.gov)
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Seventy-three patients were included in the preintervention group and 77 in the postintervention group. The GOLD classification rates were similar between the groups (Table 1). In addition, > 90% of patients were White males and all patients were aged ≥ 50 years, which is characteristic of the US Department of Veterans Affairs (VA) population.
The percentage of antibiotic prescriptions decreased by 20% after implementation, falling from 83.6% before to 63.6% after the implementation (P =.01). The documented change in sputum color remained low compared with antibiotic prescriptions: 17.8% preimplementation and 16.9% postimplementation. The reduction in antibiotic prescriptions was associated with limited differences observed in 30-, 60-, and 90-day reexacerbation rates pre- and postintervention: 19.2% vs 23.4%, 12.3% vs 11.7%, and 4.1% vs 9.1%, respectively.
Prior to the education, introduction of the algorithm, and implementation of the PCT quick-order menu, PCT was ordered for 1.4% of AECOPD cases. Postintervention, PCT was ordered for 28.6% of mild-to-moderate AECOPD cases and used in clinical decision making per clinical documentation 81.8% of the time. PCT was used in 5 GOLD group B patients, 5 GOLD group C patients, and 7 GOLD group D patients. In all cases, PCT was < 0.25 ng/mL. In 4 cases PCT was ordered but not used: 1 GOLD group D patient refused traditional treatment with oral corticosteroids, which resulted in the clinician prescribing antibiotics, and the other 3 cases did not use PCT based on clinical decision making. The rate of PCT tests ordered for mild-to-moderate AECOPD over time is depicted in Figure 2.
The average duration of antibiotic therapy was about 6 days pre- and postintervention. This is longer than the PVAHCS recommended duration of 5 days but is consistent with the GOLD guidelines recommended duration of 5 to 7 days.1 Azithromycin is recommended as a first-line treatment option at the PVAHCS based on the local antibiogram, and it remained the most commonly prescribed antibiotic pre- and postintervention. Outcomes of interest are detailed in Table 2.
Discussion
The implementation of PCT-guided antibiotic prescribing for patients with mild and moderate AECOPD who presented to the ED resulted in a 20% reduction in antibiotic prescriptions, falling from 83.6% before the intervention to 63.6% afterward (P = .01). The measured decrease in antibiotic prescriptions is consistent with other studies evaluating the use of acute phase reactants to guide antibiotic prescribing for AECOPD.10,11 In addition, there was no observed difference in reexacerbation rates. This adds to the increasing body of evidence that antibiotics are overprescribed in mild and moderate AECOPD.12 This is exemplified in our data by the low percentage of patients who had a documented change in sputum color; symptoms that are well known to be highly specific and sensitive for a bacterial infection in AECOPD.
Many health care providers (HCPs) in the ED were unfamiliar with PCT prior to implementation. A primary concern with this study was its impact on diagnostic stewardship. Preimplementation, ED clinicians ordered PCT 8 times for any cause. Postintervention, ED clinicians ordered PCT 180 times for any cause: 36% of these orders were for patients with AECOPD who were discharged from the ED or who required hospital admission. The other orders were for other respiratory conditions, including asthma exacerbations, pneumonia, bronchitis, sinusitis, pharyngitis, nonspecific respiratory infections, and respiratory failure.
The early phase of the COVID-19 pandemic coincided with the postintervention phase of this project. PVAHCS started preparing for the pandemic in March 2020, and the first confirmed diagnosis at the facility occurred mid-March. COVID-19 may have contributed to the sharp increase in PCT tests. There is currently no well-defined role for PCT in the diagnosis or management of COVID-19, but ED clinicians may have increased their use of PCT tests to help characterize the etiology of the large influx of patients presenting with respiratory symptoms.13
