De-escalation and discontinuation strategies in high-risk neutropenic patients: an interrupted time series analyses of antimicrobial consumption and impact on outcome

Abstract

Febrile neutropenia (FN) is the main reason for antibiotic prescription in hematology wards where, on the other hand, antibiotic stewardship (AS) is poorly explored. The objectives of the present study were to evaluate (1) the impact of an AS intervention on antibiotic consumption and (2) the applicability and acceptance rate of the intervention and its clinical impact. A persuasive AS intervention based on European Conference on Infection in Leukaemia (ECIL) guidelines for FN was implemented in a high-risk hematology ward in a tertiary referral public university hospital. This included the creation and diffusion of flow charts on de-escalation and discontinuation of antibiotics for FN, and the introduction in the team of a doctor dedicated to the implementation of flow charts and to antibiotic prescription revision. All consecutive patients receiving antibiotics during hospitalization were included. A segmented linear regression model was performed for the evaluation of antibiotic consumption, taking into account 1-year pre-intervention period and 6-month intervention period. Overall, 137 consecutive antibiotic prescriptions were re-evaluated, 100 prescriptions were for FN. A significant reduction of the level of carbapenem consumption was observed during the intervention period (level change (estimate coefficient ± standard error) = - 135.28 ± 59.49; p = 0.04). Applicability and acceptability of flow charts were high. No differences in terms of intensive care unit transfers, bacteremia incidence, and mortality were found. A persuasive AS intervention in hematology significantly reduced carbapenem consumption without affecting outcome and was well accepted. This should encourage further applications of ECIL guidelines for FN.

Persuasive antimicrobial stewardship intervention in the context of a KPC outbreak: a controlled interrupted time series analysis

“…Another study performed in our institution, in the Orthpaedics ward, also showed the impact of persuasive AMS interventions (local guideline plus audit and feedback) in antibiotic consumption [18]. Also, several studies in different settings and applying similar persuasive interventions have shown effect in reducing antimicrobial consumption, both globally and for specific antibiotic classes [9,19]. However, our intervention was designed and implemented in a particularly challenging setting, a KPC outbreak.…”

“…Antimicrobial stewardship (AMS) is one of the key strategies to combat resistance and implementation of such programs is recommended across the globe [7]. These programs aim to improve patient outcomes and safety by improving antimicrobials use and also to reduce emergence of antimicrobial resistance [8][9][10]. Different types of interventions can be used, namely restrictive and persuasive interventions.…”

“…However, robust evidence supporting different kinds of AMS interventions is still incomplete [14]. To fulfil this gap, in a pragmatic and realistic approach, the use of interrupted time series (ITS) analysis can be useful to evaluate complex interventions used in AMS programs [3,9,15].…”

Persuasive antimicrobial stewardship intervention in the context of a KPC outbreak: a controlled interrupted time series analysis

“…[7] These programs aim to improve patient outcomes and safety by improving antimicrobials use and also to reduce emergence of antimicrobial resistance. [8][9][10] Different types of interventions can be used, namely restrictive and persuasive interventions. The latter includes interventions like audit and feedback, educational outreach and formal or informal local consensus for clinical protocols, all of them aiming at change current behaviours in antibiotic prescription.…”

“…[14] To fulfil this gap, in a pragmatic and realistic approach, the use of interrupted time series (ITS) analysis can be useful to evaluate complex interventions used in AMS programs. [3,9,15] We conducted a controlled ITS to assess the impact of a set of persuasive AMS strategies implemented in a Vascular Surgery ward in the context of a KPC outbreak.…”