Jessica Ward, PharmD, BCCCP,
Cardiothoracic & Vascular Surgery ICU Pharmacy Clinical Specialist
Cleveland Clinic Foundation
Cleveland, Ohio
Disclosure information not submitted.
Jason Yerke, BCCCP, PharmD
Medical ICU Clinical Pharmacy Specialist
Cleveland Clinic Foundation
Cleveland, Ohio
Disclosure information not submitted.
Mollie Lumpkin, PharmD, BCPS, BCCCP
Clinical Pharmacy Specialist
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Aanchal Kapoor, MD
Associate Staff Physician
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Christina Lindenmeyer, MD
Staff Physician
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Stephanie Bass, BCCCP, BCPS, PharmD
Cleveland Clinic Foundation
Cleveland, Ohio
Disclosure information not submitted.
Title: Evaluation of rifaximin discontinuation in critically ill liver patients receiving antibiotics
Introduction: Rifaximin is frequently administered to critically ill patients with liver disease and infections as an off-label therapy. Administration with other broad-spectrum antibiotics may be unnecessary and associated with increased costs. A pharmacist-driven protocol was developed to reduce duplicative therapy through the discontinuation of rifaximin during broad-spectrum antibiotic treatment. This study aimed to evaluate the impact of the protocol on clinical, safety, and financial factors.
Methods: This was a single-center, quasi-experimental, non-inferiority study in critically ill patients with liver disease receiving broad-spectrum antibiotics with or without rifaximin in the Medical Intensive Care Unit (MICU). The primary outcome was days alive and free of delirium and coma to day 14. Safety outcomes included intensive care unit length of stay and mortality. Other secondary outcomes compared total treatment costs between groups and characterized protocol adherence. All outcomes-related data were collected by retrospective chart review.
Results: 32 patients were included in each group. The median (IQR) number of delirium and coma free days was 3 (0,8) in the pre-protocol group and 2 (0,9.5) in the post-protocol group (p-value for preliminary superiority analysis = 0.934). Differences in baseline characteristics included higher rates of norepinephrine, deep sedation, and paralytic use in the post-protocol group, and more frequent benzodiazepine use in the pre-protocol group. ICU mortality and length of stay were similar between the groups. Overall adherence to the protocol was 91.4%. Median days of MICU combination therapy were reduced with protocol implementation [6 (IQR 3,9.5) vs 1 (IQR 0,1); p< 0.001]. The median estimated total cost of rifaximin therapy per patient during the observation period was reduced from $494.64 (IQR 247.32,783.18) to $82.44 (IQR 0,82.44), p< 0.001.
Conclusions: This novel protocol for rifaximin discontinuation in critically ill liver patients receiving broad-spectrum antibiotics was associated with no differences in safety outcomes and significant cost savings. The results should be confirmed in a larger prospective study. The pharmacist-driven protocol described is applicable for centers throughout the United States though opportunities to optimize implementation exist.