Background/Purpose: Streptococcus pneumoniae is the most common cause of bacterial pneumonia.¹ Invasive pneumococcal infections carry a 10% mortality rate, which is higher in the immunosuppressed.¹ The Infectious Diseases Society of America recommends pneumococcal vaccination in patients planning to start or already on immunosuppression.² This project’s purpose is to improve the pneumococcal vaccination rate of patients on immunosuppression with the goal of decreasing morbidity and mortality from invasive pneumococcal disease.

Methods: In an adult rheumatology clinic in a tertiary care center, a best practice alert (BPA) was created within the electronic medical record (EMR). The BPA is triggered for patients taking an immunosuppressive medication who have not received both the pneumococcal conjugate vaccine and the pneumococcal polysaccharide vaccine within the last 5 years. Options within BPA include: a link to the Centers for Disease Control and Prevention website, an option to order either vaccine, and a link to document the vaccine if historically given. Educational sessions on vaccine guidelines were held periodically with both the clinic physicians and nursing staff. A survey of clinic physicians was conducted both prior to and after initiation of the BPA. Baseline data was collected prior to initiation of the BPA and quarterly thereafter to determine the rate of patients who had received 1, 2 or 3 vaccines. Fisher’s exact test was utilized.

Results: Baseline data from January to March 2016 found that of 741 patients, 335 (45.2 percent) had received 0 pneumococcal vaccines, 205 (27.6 percent) had received 1 pneumococcal vaccine, 168 (22.6 percent) had received 2 pneumococcal vaccines and 33 (4.4 percent) had received 3 pneumococcal vaccines. The BPA was implemented in May 2016. Repeat data from January to March 2017 showed that of 741 patients, 224 (30.2 percent) had received 0 pneumococcal vaccines, 219 (29.5 percent) had received 1 pneumococcal vaccine, 247 (33.3 percent) had received 2 pneumococcal vaccines and 51 (6.8 percent) had received 3 pneumococcal vaccines. The total number who had received at least 1 pneumococcal vaccine improved significantly after the intervention [406 (54.7 percent) to 517 (69.7 percent); (p = <0.0001)]. The rate of physicians surveyed who “usually” or “always” discussed vaccines with patients on immunosuppression improved from 50% (4/8) to 88.8% (8/9).

Conclusion: A BPA within the EMR was successful in significantly improving pneumococcal vaccination rates for patients on immunosuppression. A limitation of this study is that it was conducted in a tertiary care center and may not be generalizable to all care settings. Obtaining vaccination history was a challenge throughout the project. Future directions for this project include adding a patient education arm or expanding the BPA for use in other specialty clinics or additional vaccine types.

References:

1. Mirsaeidi, M. and D. E. Schraufnagel (2014). “Pneumococcal vaccines: understanding centers for disease control and prevention recommendations.” Ann Am Thorac Soc 11(6): 980-985.

2. Rubin, L. G., et al. (2014). “2013 IDSA clinical practice guideline for vaccination of the immunocompromised host.” Clin Infect Dis 58(3): e44-100.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pneumococcal-vaccination-rates-improving-safety-in-immunocompromised-patients/