Assessment of Antibiotic Utilization

in Sepsis Order Sets Initiated in the

Emergency Department
Margo Whitehead, PharmD | PGY1 Resident
Preceptors: Brian Hazelrigg, PharmD, Joshua Blain, PharmD, 
Richard Lugar, PharmD, BCIDP, BCPS
Conflict of Interest Statement
Neither the speaker nor the preceptor mentors have anything to disclose regarding
relationships with commercial interests nor any other conflicts of interest related to the
subject of this presentation.

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 Indiana University Health (IUH) Ball Memorial Hospital

 325-bed community teaching hospital

 Partnership with Indiana University
School of Medicine
 Level III Trauma Center
 Located in Muncie, IN
 Delaware County, east central IN

Indiana University Health Ball Memorial Hospital. Indiana University Health, Inc. https://iuhealth.org/find-locations/iu-health-ball-memorial-hospital. 2023.
3
Accessed March 27, 2023.
Objective of Project

To determine the accuracy with which the order subphases

initiated in the emergency department at IU Health Ball
Memorial Hospital predict the antibiotics the patient will
continue to receive during their hospital stay

4
Audience Poll
In addition to a microbial source, how many systemic inflammatory response syndrome
(SIRS) criteria must be present for a patient to meet sepsis criteria?
A. 1
B. 2
C. 3
D. 4

5
Audience Poll
Which of the following patient factors warrants initiation of broad-spectrum antibiotic
therapy?
A. Penicillin allergy (unknown reaction)
B. Age greater than 75
C. Broad-spectrum antibiotic use within the last 90 days
D. Patient has one SIRS criteria element present

What if the patient has a cephalosporin allergy?

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Background

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 Background

SIRS (Any 2) WBC >12k/cumm or

Temp >38 or oC
RR >20 or PaCO2 HR >90 bpm <4k/cumm or Bands
<36oC <32mmHg >10%

Sepsis
SIRS + Microbial Source

Chakraborty RK, Burns B. Systemic Inflammatory Response Syndrome. [Updated 2023 Feb 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
8
Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547669/
 Background

Surviving Sepsis 2021

Guidelines recommend:

Tailoring empiric Daily assessment of

antibiotics based on antimicrobial de-
suspected source and escalation as part of
patient risk factors antimicrobial stewardship
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Images from Microsoft PowerPoint 2016.
 Tailoring Empiric Therapy
 Patient factors warranting broad-spectrum therapy
 Broad-spectrum antibiotic use within 90 days
 Multi-drug resistant organism (MDRO) isolated within previous year
 Local prevalence of MDROs
 Hospital-associated vs. community acquired infection

Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine:
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November 2021 - Volume 49 - Issue 11 - p e1063-e1143 doi: 10.1097/CCM.0000000000005337
 Ball Memorial Patient Population
 Community MRSA prevalence = ~50%1
 Delaware County – 5th in opioid-related deaths in Indiana (2020)2
 Emergency Department sees ~150-200 patients per day
 IUH order sets and subphases constructed with local and state-wide resistance patterns in
mind
 Subphases currently reviewed every 5 years

1. Lugar RG, Kfoury R, Tirmizi A, Zijoo R. 2021 Antibiogram IU Health Ball Memorial Hospital. 2021: p 5. Accessed January 15, 2023.
11
2. Deaths from Drug Poisoning Involving Any Opioid. Stats Explorer: Office of Data Analytics, Indiana Department of Health. 2020. Accessed March 30, 2023.
https://gis.in.gov/apps/isdh/meta/stats_layers.htm
Subphase Timeline

Patient presents
with sepsis in Decision made
the ED to admit

ED provider Admitting team

orders sepsis chooses to
order sets and continue orders
subphases or adjust
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Sepsis Subphases - Urinary
 Ampicillin and gentamicin
 System initiative based on susceptibility
patterns
 Piperacillin-tazobactam
 IV push access (critical access hospitals)

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Sepsis Subphases – Intra-abdominal
Piperacillin-tazobactam
For patients with non-anaphylactic PCN allergies:
Cefepime
⎻AND
Metronidazole
For patients with anaphylactic beta-lactam allergies:
Aztreonam
⎻AND
Vancomycin
If Pseudomonas or other gram-negative organism suspected consider adding
Tobramycin 14
Sepsis Subphases – Respiratory (Community Acquired)
Note: Ampicillin-sulbactam preferred over ceftriaxone
Ampicillin-sulbactam
⎻OR
Ceftriaxone
⎻AND
 Preferred azithromycin unless prolonged QT or allergy:
Azithromycin
⎻OR
Doxycycline

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Sepsis Subphases – Respiratory (Community Acquired) continued
Consider MRSA coverage if recent influenza, IVDA, necrotizing pneumonia,
homelessness, or previous MRSA infection:
Vancomycin
For patients with anaphylactic beta-lactam allergy:
Aztreonam
⎻AND
Vancomycin
⎻AND
Azithromycin

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Sepsis Subphases – Respiratory (Healthcare Acquired)
Cefepime
⎻AND
Vancomycin
⎻AND
Azithromycin
For patients with non-anaphylactic cephalosporin allergies:
Piperacillin-tazobactam
⎻AND
Vancomycin
⎻AND
Azithromycin 17
Sepsis Subphases – Respiratory (Healthcare Acquired) continued
For patients with anaphylactic beta-lactam allergy:
Aztreonam
⎻AND
Vancomycin
⎻AND
Azithromycin
If Pseudomonas or other resistant gram-negative organism suspected consider adding
Tobramycin

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Sepsis Subphases – Soft Tissue including Necrotizing Fasciitis
Piperacillin-tazobactam
⎻AND
Vancomycin
If necrotizing fasciitis, add:
Clindamycin
For patients with non-anaphylactic PCN allergies:
Cefepime
⎻AND
Metronidazole
⎻AND
Vancomycin 19
Sepsis Subphases – Soft Tissue including Necrotizing Fasciitis
continued
For patients with anaphylactic beta-lactam allergies:
Aztreonam
⎻AND
Vancomycin
⎻AND
Metronidazole

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Methods

21
Methods
 Retrospective data collection and chart review
 Quality improvement
 Exempt from institutional review board (IRB) review
 Timeframe: July – December 2022

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Methods

Inclusion criteria: Exclusion criteria:

• Patients with the following • Patients who did not initially

subphases active: receive antibiotics under the
• Respiratory (community- listed subphases
acquired) • Vulnerable populations
• Respiratory (healthcare- • Pediatrics
acquired) • Prisoners
• Urinary
• Soft tissue
• Intra-abdominal
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Endpoints

Primary • Probability that antibiotics from

Endpoint subphases will be continued

• Average inpatient antibiotic(s) duration

Secondary • Average time to de-escalation

Endpoints •
•
Antibiotic escalation incidences
Average length of stay
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De-Escalation Definition
 Considered de-escalation for the purpose of this project if at least one of the following
occurred:
 Switched to narrower spectrum (not including incidences where piperacillin-tazobactam was
changed to an agent such as cefepime)
 Discontinued one or more agents
 Switched to oral therapy
 Patient status change
⎻Left against medical advice (AMA)
⎻Hospice/comfort care

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Escalation Definition
 Considered escalation for the purpose of this project if at least one of the following
occurred:
 Switched to broader spectrum (ex. Piperacillin-tazobactam switched to meropenem)
 Initiated one or more additional agents to broaden coverage

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Data Analysis

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Data Analysis
 Binary logistical regression
 Recommendation from Ball State University statistics department – Dr. Munni Begum
 Likelihood that antibiotics from ED sepsis order subsets are continued throughout
admission based on the following:
⎻Antibiotic duration
⎻Length of stay
 Descriptive statistics
 Excel used for calculations

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Results and Discussion

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Population
 190 patient charts reviewed
 Average age: 60 years
 Range: 20 – 97 years
 Sex
 85 males
 105 females
 69 patients with at least one factor warranting broad-spectrum therapy
 Included intravenous drug abuse given community MRSA prevalence

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 Probability that Subphase Antibiotics Continue – Logistical Regression

Subphase Coefficient Standard Probabilit

Deviation y
Intra-abdominal -0.0074 0.2 0.5
Respiratory (Community Acquired) 0.53 0.24 0.63
Respiratory (Healthcare-Acquired 1.8 0.22 0.85
Soft Tissue including Necrotizing -1.4 0.22 0.19
Fasciitis
Urinary -0.85 0.17 0.3

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Average Length of Stay (days)
Respiratory Respiratory Soft Tissue
Intra- including
(Communit (Healthcare Urinary
abdominal Necrotizing
y Acquired) Acquired) Fasciitis

6.0 6.1 5.5 4.2 4.0

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Average Inpatient Antibiotic(s) Duration (days)
Respiratory Respiratory Soft Tissue
Intra- including
(Communit (Healthcare Urinary
abdominal Necrotizing
y Acquired) Acquired) Fasciitis

4.0 3.4 4.2 4.2 3.7

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Average Time to De-Escalation (days)
Respiratory Respiratory Soft Tissue
Intra- including
(Communit (Healthcare Urinary
abdominal Necrotizing
y Acquired) Acquired) Fasciitis

0.90 0.60 1.1 2.6 3.2

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Escalation Incidence
Respiratory Respiratory Soft Tissue
Intra- including
(Communit (Healthcare Urinary
abdominal Necrotizing
y Acquired) Acquired) Fasciitis

10% 26% 3.3% 0% 30%

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Limitations
 Chart review limited to Cerner (electronic medical record)
 No outside records
 Only able to review documented interventions

36
Conclusions and Future Direction

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 Conclusions

Respiratory (community-
Balancing SIRS criteria and acquired) and skin and soft
empiric antibiotic use tissue antibiotics were most
likely to be de-escalated

Urinary orders:
Respiratory (healthcare- • Longest average time to de-escalation
acquired) orders were most • Shortest average length of stay
likely to be continued • Highest escalation incidence

Images from Microsoft PowerPoint 2016.

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Future Directions

Provider and Outpatient data

pharmacist education analysis

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Audience Poll
In addition to a microbial source, how many systemic inflammatory response syndrome
(SIRS) criteria must be present for a patient to meet sepsis criteria?
A. 1
B. 2
C. 3
D. 4

40
Audience Poll
In addition to a microbial source, how many systemic inflammatory response syndrome
(SIRS) criteria must be present for a patient to meet sepsis criteria?
A. 1
B. 2
C. 3
D. 4

41
Audience Poll
Which of the following patient factors warrants initiation of broad-spectrum antibiotic
therapy?
A. Penicillin allergy (unknown reaction)
B. Age greater than 75
C. Broad-spectrum antibiotic use within the last 90 days
D. Patient has one SIRS criteria element present

42
Audience Poll
Which of the following patient factors warrants initiation of broad-spectrum antibiotic
therapy?
A. Penicillin allergy (unknown reaction)
B. Age greater than 75
C.Broad-spectrum antibiotic use within the last
90 days
D. Patient has one SIRS criteria element present

43
Reference
1. Indiana University Health Ball Memorial Hospital. Indiana University Health, Inc. https://iuhealth.org/find-
locations/iu-health-ball-memorial-hospital. 2023. Accessed March 27, 2023.
2. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management
of Sepsis and Septic Shock 2021. Critical Care Medicine: November 2021 - Volume 49 - Issue 11 - p e1063-
e1143 doi: 10.1097/CCM.0000000000005337
3. Chakraborty RK, Burns B. Systemic Inflammatory Response Syndrome. [Updated 2023 Feb 15]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK547669/
4. Lugar RG, Kfoury R, Tirmizi A, Zijoo R. 2021 Antibiogram IU Health Ball Memorial Hospital. 2021: p 5.
Accessed January 15, 2023.
5. Deaths from Drug Poisoning Involving Any Opioid. Stats Explorer: Office of Data Analytics, Indiana
Department of Health. 2020. Accessed March 30, 2023. https://gis.in.gov/apps/isdh/meta/stats_layers.htm
6. Images from Microsoft PowerPoint 2016.

44
Assessment of Antibiotic Utilization
in Sepsis Order Sets Initiated in the
Emergency Department
Margo Whitehead, PharmD | PGY1 Resident
Preceptors: Brian Hazelrigg, PharmD, Joshua Blain, PharmD, 
Richard Lugar, PharmD, BCIDP, BCPS