An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients

Abstract

IntroductionIncreasing antimicrobial costs, reduced development of novel antimicrobials, and growing antimicrobial resistance necessitate judicious use of available agents. Antimicrobial stewardship programs (ASPs) may improve antimicrobial use in intensive care units (ICUs). Our objective was to determine whether the introduction of an ASP in an ICU altered the decision to treat cultures from sterile sites compared with nonsterile sites (which may represent colonization or contamination). We also sought to determine whether ASP education improved documentation of antimicrobial use, including an explicit statement of antimicrobial regimen, indication, duration, and de-escalation.MethodsWe retrospectively analyzed consecutive patients with positive bacterial cultures admitted to a 16-bed medical-surgical ICU over 2-month periods before and after ASP introduction (April through May 2008 and 2009, respectively). We evaluated the antimicrobial treatment of positive sterile- versus nonsterile-site cultures, specified a priori. We reviewed patient charts for clinician documentation of three specific details regarding antimicrobials: an explicit statement of antimicrobial regimen/indication, duration, and de-escalation. We also analyzed cost and defined daily doses (DDDs) (a World Health Organization (WHO) standardized metric of use) before and after ASP.ResultsPatient demographic data between the pre-ASP (n = 139) and post-ASP (n = 130) periods were similar. No difference was found in the percentage of positive cultures from sterile sites between the pre-ASP period and post-ASP period (44.9% versus 40.2%; P = 0.401). A significant increase was noted in the treatment of sterile-site cultures after ASP (64% versus 83%; P = 0.01) and a reduction in the treatment of nonsterile-site cultures (71% versus 46%; P = 0.0002). These differences were statistically significant when treatment decisions were analyzed both at an individual patient level and at an individual culture level. Increased explicit antimicrobial regimen documentation was observed after ASP (26% versus 71%; P < 0.0001). Also observed were increases in formally documented stop dates (53% versus 71%; P < 0.0001), regimen de-escalation (15% versus 23%; P = 0.026), and an overall reduction in cost and mean DDDs after ASP implementation.ConclusionsIntroduction of an ASP in the ICU was associated with improved microbiologically targeted therapy based on sterile or nonsterile cultures and improved documentation of antimicrobial use in the medical record.

The need for cost-effectiveness analyses of antimicrobial stewardship programmes: A structured review

“…conversion (1). Of the 36 included studies, 2 were full CEAs [13,14]; 27 studies reported changes to costs and health outcomes separately [3,5,[8][9][10][12][13][14][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] and 9 reported only changes to costs [4,6,[15][16][17][18][19][20][21]. Table 1 presents the methods and results for studies that measured only cost outcomes and Table 2 presents the methods and findings of those studies that measured both a clinical as well as a cost outcome.…”

“…Costing studies that did not measure clinical outcomes Table 1 groups 9 of the 36 included studies that measured only the cost impact of AMS strategies [4,6,[15][16][17][18][19][20][21]. PAIF was the most commonly evaluated strategy in this group (5/9; 56%) [4,6,[15][16][17]; 2 studies focused on i.v.-to-p.o.…”

Time for a culture change? Suboptimal compliance with blood culture standards at a district hospital in Cape Town

“…It is also one of the cornerstones of antimicrobial stewardship, which has reduced the overuse of antibiotics and costs in hospitalised patients. [3] The interpretation of BC results may be complicated by the recovery of potential contaminants. The Clinical and Laboratory Standards Institute (CLSI)'s benchmark for the maximum acceptable percentage of contaminated BCs is 3%.…”

Antimicrobial Stewardship Programs: A Review of Recent Evaluation Methods and Metrics

“…There has been very little recent work regarding improving the time to adequate treatment [26]. As a potential prerequisite to appropriate antibiotic use, some ASPs have measured rates of chart documentation of antimicrobial regimens, indications and intended stop dates [21,34]. Finally, some ASPs have measured broader non-antimicrobial aspects of appropriateness related to infection management, such as ophthalmology consults for candidemia [14] and vaccination rates for at-risk patients [13].…”