Background
Pneumocystis jirovecii pneumonia (PJP) is a potentially severe illness affecting oncology patients on long-term high-dose steroid therapy as part of treatment regimens or symptom management.
Method
A retrospective audit was conducted of all medical oncology inpatients within three months at a major tertiary hospital in Sydney, Australia. In response to the results, a survey was conducted of prescribers in medical oncology and palliative care to clarify the clinical reasoning for omission and find effective interventions to improve PJP prophylaxis prescribing rates. Prescribers were asked to rank from least helpful to most helpful, interventions to improve PJP prophylaxis prescribing rates.
Results
183 inpatients were eligible. 33 were identified as high-risk patients based on steroid dose and duration as per the EviQ guidelines. 3 patients were on appropriate prophylaxis, 1 was being treated for PJP, and a further 29 were not on any prophylaxis. Within that group, 7 patients were on end-of-life care and did not require PJP prophylaxis as part of medication rationalisation. There was no documented reason for the absence of PJP prophylaxis in the remaining high-risk 22 patients.
23 prescribing clinicians were surveyed with 11 responses. The main reason identified for the low PJP prophylaxis rate was lack of clarity regarding the steroid plan at commencement. This was attributed to multiple prescribers across the inpatient and outpatient settings and poor documentation. There was also individual prescribers’ lack of certainty regarding intended dose and duration of the steroids. Of interventions to improve PJP prophylaxis, Pharmacist Reviews (25.0%) was ranked most helpful, then Technological Help (21.8%), Inclusion in Ward Meeting discussions (20.2%), Inclusion as a Clinical Quality Indicator (16.5%) and Education Sessions (16.5%). A repeat audit will be conducted after intervention implementation, to assess effectiveness and hopefully improve PJP prophylaxis prescribing rates.