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Published on: August 30, 2018
Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: A Prospective Cluster-Randomized Crossover
Jessica L Seidelman1,2, Nicholas A Turner1,2, Rebekah H Wrenn1,2
1Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.
Background:
Few groups have formally studied the effect of dedicated antibiotic stewardship rounds (ASRs) on antibiotic use (AU) in intensive care units (ICUs).
Methods:
We implemented weekly ASRs using a 2-arm, cluster-randomized, crossover study in 5 ICUs at Duke University Hospital from November 2017 to June 2018. We excluded patients without an active antibiotic order, or if they had a marker of high complexity including an existing infectious disease consult, transplantation, ventricular assist device, or extracorporeal membrane oxygenation. AU during and following ICU stay for patients with ASRs was compared to the controls. We recorded the number of reviews, recommendations delivered, and responses. We evaluated change in ICU-specific AU during and after the study.
Results:
Our analysis included 4683 patients: 2330 intervention and 2353 controls. Teams performed 761 reviews during ASRs, which excluded 1569 patients: 60% of patients off antibiotics, and 8% complex patients. Exclusions affected 88% of cardiothoracic ICU (CTICU) patients. The AU rate ratio (RR) was 0.97 (95% confidence interval [CI], .91-1.04). When CTICU was removed, the RR was 0.93 (95% CI, .89-.98). AU in the poststudy period decreased by 16% (95% CI, 11%-24%) compared to AU in the baseline period. Change in AU was differential among units: largest in the neurology ICU (-28%) and smallest in the CTICU (-2%).
Conclusions:
Weekly multidisciplinary ASRs was a high-resource intervention associated with a small AU reduction. The noticeable ICU AU decline over time is possibly due to indirect effects of ASRs. Effects differed among specialty ICUs, emphasizing the importance of customizing ASRs to match unit-specific population, workflow, and culture.
Insights
Dedicated antibiotic stewardship rounds (ASRs) in intensive care units (ICUs) showed a small reduction in antibiotic use (AU). However, a significant AU decline occurred post-study, suggesting indirect ASR effects and the need for tailored interventions.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Health Services Research
Background:
- Limited formal studies exist on the impact of dedicated antibiotic stewardship rounds (ASRs) on antibiotic use (AU) within intensive care units (ICUs).
- Understanding the effectiveness of ASRs is crucial for optimizing antimicrobial therapy in critically ill patients.
Purpose of the Study:
- To evaluate the effect of weekly multidisciplinary antibiotic stewardship rounds (ASRs) on antibiotic use (AU) in intensive care units (ICUs).
- To assess changes in AU during and after the implementation of ASRs in a real-world hospital setting.
Main Methods:
- A 2-arm, cluster-randomized, crossover study was conducted in 5 ICUs over 8 months.
- Antibiotic use (AU) was compared between patients exposed to ASRs and control patients, with exclusions for those off antibiotics or with high complexity markers.
- Data on reviews, recommendations, and responses were recorded to evaluate changes in ICU-specific AU.
Main Results:
- The study included 4683 patients, with 761 reviews conducted during ASRs, leading to the exclusion of 1569 patients (60% off antibiotics, 8% complex).
- Overall AU rate ratio was 0.97; however, excluding the cardiothoracic ICU (CTICU) showed a reduction (RR 0.93).
- A significant 16% decrease in AU was observed in the post-study period, with differential effects across ICUs, notably a 28% reduction in the neurology ICU.
Conclusions:
- Weekly multidisciplinary ASRs represent a high-resource intervention associated with a modest direct reduction in AU.
- The observed decline in ICU AU over time may be attributed to indirect effects of the ASRs.
- Tailoring ASRs to specific ICU populations, workflows, and cultures is essential for maximizing impact.
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