Impacto clínico y económico de las intervenciones del farmacéutico clínico sobre antimicrobianos en el paciente crítico

Up to 52% of the patients in acute care hospitals may receive an antibiotic, and 30-50% of the treatments are estimated to be inadequate. Pharmacists have an important role in their optimization. In addition, critically ill patients may benefit more from pharmacist interventions (PIs). Few comparative studies have evaluated the clinical and the economic impact of PIs on antimicrobials in these patients, and none of them was conducted in Europe. Moreover, there have been no reviews analyzing the clinical and economic impact of interventions on antimicrobials conducted specifically by pharmacists (not by a multidisciplinary group, even though it includes a pharmacist) in the hospital setting. Therefore, our main objective was to determine the clinical and economic impact of PIs related to antimicrobials in critical care. Firstly we conducted a review of the evidence in Pubmed from 2003 to March 2016 of the clinical and economic impact of PIs in the hospital setting, in general. Secondly, we developed a retrospective observational study in the Critical Care Area (CCA) of our university hospital to analyze the clinical and economic impact of the clinical pharmacist (CP) interventions (CPI) on antimicrobials over a 5-month period. Thirdly, we conducted another retrospective observational cohort study to determine the effectiveness of a specific intervention promoted by the CP, which consisted of adding inhaled antibiotics in critically ill patients with respiratory infections, as the role of this therapy in these patients remained uncertain. In the review, 23 studies were included. All of them had high risk of bias. Patient-specific recommendations were included in every study; five also included policy strategies and four education. Significant impact of PIs was found in 14 of the 18 studies (77.8%) that evaluated costs, 15 of the 20 (75.0%) that assessed treatment related outcomes, 12 of the 22 (54.5%) that analyzed clinical outcomes and 1 of the 2 studies (50.0%) that evaluated microbiological outcomes. None of the studies found significant negative impact of PIs. It could not be concluded that adding other strategies to patient-specific recommendations improves results. Acceptance of recommendations varied from 70 to 97.5%. Therefore, PIs on antimicrobials in the hospital setting improve clinical and treatment related outcomes, and decrease costs. This positive clinical and economic impact of the PIs was confirmed in our CCA. The CP performed 212 interventions in response to 212 Drug Related Problems (DRPs) detected during the study period, corresponding to 114 patients. Eighteen DRPs (8.5%) were medication errors. A total of 96.2% of the CPIs were considered important with improvement in patient care. None of the CPIs had any negative impact on patients. Physicians accepted 98% of the CPIs. We estimated a 10,905 decrease in costs as a result of CPIs (the estimation could vary from 374 to 127,772 in the worst and best case scenarios, respectively). This means that 4.8 were avoided per euro invested in the CP. The CP initiative of adding inhaled antibiotics to critically ill patients was also positive. We analyzed data from adults admitted to the CCA during a 2-year period with respiratory infections in which respiratory fluid samples were obtained. A total of 136 patients were included: 43 in the treated group (that received inhaled antibiotics in addition to systemic antimicrobials), 93 in the control group (that only received systemic antimicrobials). After adjusting for confounders, treated group had higher odds of clinical improvement (adjusted odds ratio: 7.13; 95% confidence interval: 1.17-43.3). There were no significant differences in creatinine clearance reduction between groups. In conclusion, clinical pharmacist interventions on antimicrobials in the hospital and critical care setting have a positive impact on clinical and treatment related outcomes, and decrease costs.