What quality indicator (qi) should be used when implementing antibiotics within 60 minutes?

From the Guidelines

The quality improvement (QI) measure to use when implementing antibiotics under 60 minutes is "Time to First Antibiotic Dose" or "Door-to-Antibiotic Time," with a target of administering empirical antibiotic therapy within 1 hour after recognition of septic shock, as recommended by the Surviving Sepsis Campaign 1. To implement this effectively, several strategies can be employed:

• Establish a clear protocol that includes rapid triage with early sepsis screening
• Use standardized order sets for common infections
• Dedicate pharmacy resources for antibiotic preparation
• Implement nurse-driven protocols allowing antibiotic administration before physician assessment in certain cases
• Track compliance using electronic medical record timestamps and create a dashboard to monitor performance Specific interventions should include:
• Storing common antibiotics like cefepime, piperacillin-tazobactam, and vancomycin in automated dispensing cabinets in the emergency department
• Implementing sepsis alerts in the EMR
• Conducting regular multidisciplinary huddles to review cases that missed the 60-minute target This metric is crucial because early antibiotic administration significantly improves outcomes in sepsis and other serious infections, with each hour of delay associated with increased mortality, particularly in septic shock where mortality increases by approximately 7-8% per hour of delay 1. In critically ill patients, therapeutic drug monitoring (TDM) of antibiotics is also recommended to ensure optimal antibiotic concentrations and minimize the risk of toxicity or clinical failure 1. Key recommendations for TDM include:
• Measuring the peak plasma concentration of aminoglycosides 30 min after the first dose
• Measuring the residual concentration of aminoglycosides to avoid toxicity associated with cumulative administrations
• Determining the steady-state vancomycin concentration in the case of continuous infusion after a loading dose, or the residual concentration in the case of discontinuous administrations
• Determining residual concentrations of broad-spectrum β-lactam antibiotics to assess efficacy and toxicity 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Infusion Time ... 5 to 60 minutes ...

The recommended infusion time for ceftaroline is 5 to 60 minutes.

• For ceftaroline, infusion times are between 5 to 60 minutes 2.
• For vancomycin, infusion times of 30 minutes or 60 minutes are mentioned, but the question is about implementing antibiotics under 60 min, which matches the infusion time for ceftaroline 3.

From the Research

Antibiotic Administration Under 60 Minutes

When implementing antibiotics under 60 minutes, the following points should be considered:

• The combination of vancomycin and piperacillin/tazobactam has been associated with an increased risk of acute kidney injury (AKI) compared to other broad-spectrum antibiotic combinations, such as vancomycin and cefepime or meropenem 4, 5, 6.
• Studies have shown that the incidence of AKI is higher in patients receiving vancomycin and piperacillin/tazobactam compared to those receiving vancomycin and cefepime or meropenem 4, 5, 6.
• Clinicians should be aware of the potential risks associated with combination antibiotic therapy, particularly when using vancomycin and piperacillin/tazobactam, and consider alternative regimens to minimize the risk of nephrotoxicity 7, 6.
• The appropriate use of broad-spectrum antibiotics, such as cefepime, piperacillin-tazobactam, and meropenem, is crucial to ensure optimal patient outcomes and minimize the risk of adverse effects 8.

Considerations for Antibiotic Selection

When selecting antibiotics for administration under 60 minutes, consider the following:

• Patient-specific characteristics, such as renal function and potential allergies, should be taken into account when choosing an antibiotic regimen 7.
• The potential risks and benefits of combination antibiotic therapy should be carefully evaluated, particularly when using vancomycin and piperacillin/tazobactam 4, 5, 6.
• Alternative antibiotic regimens, such as vancomycin and cefepime or meropenem, may be considered to reduce the risk of nephrotoxicity 6.