Antibiotic stewardship programmes in intensive care units: Why, how, and where are they leading us

Abstract

Antibiotic usage and increasing antimicrobial resistance (AMR) mount significant challenges to patient safety and management of the critically ill on intensive care units (ICU). Antibiotic stewardship programmes (ASPs) aim to optimise appropriate antibiotic treatment whilst minimising antibiotic resistance. Different models of ASP in intensive care setting, include "standard" control of antibiotic prescribing such as "de-escalation strategies" through to interventional approaches utilising biomarkerguided antibiotic prescribing. A systematic review of outcomes related studies for ASPs in an ICU setting was conducted. Forty three studies were identified from MEDLINE between 1996 and 2014. Of 34 nonprotocolised studies, [1 randomised control trial (RCT), 22 observational and 11 case series], 29 (85%) were positive with respect to one or more outcome: These were the key outcome of reduced antibiotic use, or ICU length of stay, antibiotic resistance, or prescribing cost burden. Limitations of non-standard antibiotic initiation triggers, patient and antibiotic selection bias or baseline demographic variance were identified. All 9 protocolised studies were RCTs, of which 8 were procalcitonin (PCT) guided antibiotic stop/start interventions. Five studies addressed antibiotic escalation, 3 de-escalation and 1 addressed both. Six studies reported positive outcomes for reduced antibiotic use, ICU length of stay or antibiotic resistance. PCT based ASPs are effective as antibiotic-stop (de-escalation) triggers, but not as an escalation trigger alone. PCT has also been effective in reducing antibiotic usage without worsening morbidity or mortality in ventilator associated pulmonary infection. No study has demonstrated survival benefit of ASP. Ongoing challenges to infectious disease management, reported by the World Health Organisation global report 2014, are high AMR to newer antibiotics, and regional knowledge gaps in AMR surveillance. Improved AMR surveillance data, identifying core aspects of successful ASPs that are transferable, and further well-conducted trials will be necessary if ASPs are to be an effective platform for delivering desired patient outcomes and safety through best antibiotic policy.

Pros and cons of using biomarkers versus clinical decisions in start and stop decisions for antibiotics in the critical care setting

“…Key elements include aggressive microbiologic testing, rapid identification of patients requiring antimicrobials, optimal selection of antimicrobial agents and dosing based on pharmacokinetics and pharmacodynamics, antibiotic de-escalation and early discontinuation together with provider education, auditing, and feedback [64]. Various tools such as computerized decision support systems, biomarkers, antibiotic restriction and availability of infectious disease experts are applied as part of ABS [65]. Utilization of rapid testing such as MALDI-TOF significantly reduced time to optimal therapy in bacteremia and candidemia from 90 to 47 h [66].…”

“…Utilization of rapid testing such as MALDI-TOF significantly reduced time to optimal therapy in bacteremia and candidemia from 90 to 47 h [66]. Recent reviews showed success of at least one targeted outcome in 81 % of studies evaluating ABS in ICUs [65] and a reduction in antibiotic exposure and lower antibiotic costs [67]. In a mathematical model the impact on colonization rates with resistant Pseudomonas aeruginosa was highest with restricting treatment indications and optimizing antibiotic choices rather than shortening antibiotic courses [68].…”

Colonization and Antibiotic Resistance Dynamics of Patients at Intensive Care Unit (Icu)-Our Experience

“…Ongoing challenges to infectious disease management, reported by the WHO global report 2014, are high AMR to newer antibiotics, and regional knowledge gaps in AMR surveillance. Improved AMR surveillance data, identifying core aspects of successful ASPs that are transferable and further well-conducted trials will be necessary if ASPs are to be an effective platform for delivering desired patient outcomes and Safety through best antibiotic policy [45].…”

Intubated Trauma Patients Receiving Prolonged Antibiotics for Pneumonia despite Negative Cultures: Predictors and Outcomes

“…When more than two groups were being compared, the Bonferroni correction was employed to reduce the familywise error rate and avoid false-positive results. In the future, appropriate antibiotic management decisions may be supported by selective utilization of procalcitonin concentrations [41] and quantitative polymerase chain reaction of bronchoalveolar lavage samples, which has the potential to provide accurate diagnostic information within hours of sampling [42]. At our institution, strict adherence to protocolized management of intubated trauma patients with suspected pneumonia may abrogate unnecessary antibiotic administration.…”