Cluster randomized trial of an antibiotic time-out led by a team-based pharmacist

Abstract

Objective: Antibiotic time-outs (ATOs) have been advocated to improve antibiotic use without dedicated stewardship resources, but their utility is poorly defined. We sought to evaluate the effectiveness of an ATO led by a team-based pharmacist. Design: Cluster randomized controlled trial. Setting: Six medicine teams at an academic medical facility. Patients: Inpatients who received antibiotics and were cared for by a medicine team. Intervention: In phase A (2 months) pharmacist-led ATOs were implemented on 3 medicine teams (ATO-A) while 3 teams maintained usual care (UC-A). In phase B (2 months), ATOs were continued in the ATO group (ATO-B) and ATOs were initiated in the UC group (UC ATO-B). We targeted 2 ATO points: early (<72 hours after antibiotics were initiated) and late (after the early period but ≤5 days after antibiotic initiation). Results: In total, 290 ATOs were documented (181 early, 87 late, and 22 subsequent) among 538 admissions. The most common ATO recommendations were narrow therapy (148 of 290), no change (124 of 290), and change to oral (30 of 290). ATO initiation was lower in the UC ATO-B group than in either ATO group (21.8% UC ATO-B vs 69.2% ATO-A and -B). Overall antibiotic use was not different between the groups (P = .51), although intravenous (IV) levofloxacin use decreased in the UC group after ATO implementation (49 DOT/1,000 PD vs 20 DOT/1,000 PD; P = .022). The ratio of oral (PO) to intravenous (IV) DOT was lower in the UC group than in any of the ATO groups (P = .032). We detected no differences in mortality, length of stay, readmission, C. difficile infection, or antibiotic adverse events. Conclusions: Implementation of a pharmacist-led ATO was feasible and well accepted but did not change overall antibiotic use. An ATO may promote increased use of oral antibiotics, but more effective strategies for self-stewardship are needed.

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

“…We focused on prescribers who prescribed antimicrobial agents and thus were targeted by pharmacist interventions. Of J o u r n a l P r e -p r o o f the 52 studies, interventions were targeted at or delivered to junior or ward physicians (n=42) [23-31, 34-36, 38-41, 44-49, 51, 53-66, 68-72], specialist physicians (paediatricians, obstetricians, gynaecologists, anaesthetists, or surgeons) (n=12) [22,23,32,33,37,42,43,50,52,64,67,73], and nurses (n=5) [29,43,50,52,67]. The number of patients reviewed by pharmacists was clearly reported in 46 studies [22-33, 35-51, 54, 55, 57-60, 62-68, 70-73].…”

“…A total of 19 studies (2 RCTs and 17 NRS) reported mortality as an outcome. Interventions were not associated with increased mortality in any study [24,38,39,44,48,51,53,55,57,59,60,62,65,66,68,[70][71][72][73]. Three studies (all NRS) reported significant reductions in mortality [55,62,70].…”

“…Ten studies (1 RCT and 9 NRS) reported microbiological outcomes in terms of infections due to antimicrobial-resistant organisms or Clostridium difficile. Most studies (1 RCT and 6 NRS) did not show a statistically significant difference after pharmacist interventions had been delivered [26,48,50,53,60,65,73]. Of the remaining, one study reported a significant reduction in infections due to multi-drug resistant organisms from 31.7% to 23.8% [55].…”

Antimicrobial Time-Out for Vancomycin by Infectious Disease Physicians Versus Clinical Pharmacists: A Before-After Crossover Trial

“…[ 16 ]. Another study showed that a team-based, pharmacist-led, time-out strategy using an algorithm potentially promotes oral antimicrobial use [ 36 ]. Exploring more effective time-out strategies for antimicrobial use is needed to bolster the efficacy of time-out.…”

Effectiveness of an Electronic Automated Antibiotic Time Out Alert in the Setting of Gram-Negative Bacteremia

“…At this point, teams would be able to make an informed and confident decision to de-escalate, escalate, or appropriately continue antibiotics. A study conducted by Van Schooneveld et al [ 9 ] evaluated an ATO led by a pharmacist which was performed 72 h after antibiotic initiation and after ≤5 days of initiation. The authors did not find a significant difference in antibiotic use, which suggests that timing of the intervention may not be a significant factor.…”