Frequency of empiric antibiotic de-escalation in an acute care hospital with an established Antimicrobial Stewardship Program

Abstract

BackgroundExpanding antimicrobial resistance patterns in the face of stagnant growth in novel antibiotic production underscores the importance of antibiotic stewardship in which de-escalation remains an integral component. We measured the frequency of antibiotic de-escalation in a tertiary care medical center with an established antimicrobial stewardship program to provide a plausible benchmark for de-escalation.MethodsA retrospective, observational study was performed by review of randomly selected electronic medical records of 240 patients who received simultaneous piperacillin/tazobactam and vancomycin from January to December 2011 at an 885-bed tertiary care medical center. Patient characteristics including antibiotic regimen, duration and indication, culture results, length of stay, and hospital mortality were evaluated. Antibiotic de-escalation was defined as the use of narrower spectrum antibiotics or the discontinuation of antibiotics after initiation of piperacillin/tazobactam and vancomycin therapy. Subjects dying within 72 h of antibiotic initiation were considered not de-escalated for subsequent analysis and were subtracted from the study population in determining a modified mortality rate.ResultsThe most commonly documented indications for piperacillin/tazobactam and vancomycin therapy were pneumonia and sepsis. Of the 240 patients studied, 151 (63%) had their antibiotic regimens de-escalated by 72 h. The proportion of patients de-escalated by 96 h with positive vs. negative cultures was similar, 71 and 72%, respectively. Median length of stay was 4 days shorter in de-escalated patients, and the difference in adjusted mortality was not significant (p = 0.82).ConclusionsThe empiric antibiotic regimens of approximately two-thirds of patients were de-escalated by 72 h in an institution with a well-established antimicrobial stewardship program. While this study provides one plausible benchmark for antibiotic de-escalation, further studies, including evaluations of antibiotic appropriateness and patient outcomes, are needed to inform decisions on potential benchmarks for antibiotic de-escalation.

Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey

“…Studies in acute care settings have found that ASPs can be effective at reducing these risks. [23][24][25][26] In 2014, the Centers for Disease Control and Prevention (CDC) published recommendations for hospitals to establish their ASPs around the core elements of leadership, accountability, drug expertise, action, tracking, reporting, and education. 27 These recommendations were also extended to the NH setting.…”

Impact of an automated antibiotic time-out alert on the de-escalation of broad-spectrum antibiotics at a large community teaching hospital

“…De-escalation of broad-spectrum antibiotics is a cornerstone of antimicrobial stewardship efforts, yet this practice has been inconsistently applied. 1,[6][7][8] This observational study provides the first evidence that automated antibiotic time-out alerts are effective in improving antibiotic de-escalation.…”

“…[3][4][5] Despite recognition of the utility and safety of antibiotic de-escalation, this practice has been inconsistently applied. 1,[6][7][8] The electronic medical record offers new opportunities to facilitate de-escalation with best practice alerts (BPAs) prompting evidence-based clinical decisions. 9,10 The impact of electronic alerts on antibiotic de-escalation, however, has not previously been examined.…”

Evaluating carbapenem restriction practices at a private hospital in Manila, Philippines as a strategy for antimicrobial stewardship

“…Lack of clinical confidence has been cited as a barrier to successful de-escalation [19] – if an antibiotic is noticeably improving a patient’s symptoms, there may be reluctance to change. Previous studies have shown that de-escalation strategies reduce antimicrobial resistance levels and patient mortality without compromising patient safety, but also acknowledge difficulties in implementation [19–21]. As our study corroborates, de-escalation policies should be supplemented by implementation support; providing physicians with additional support from ID specialists or clinical pharmacists at these key decision-making moments, perhaps through direct audit and feedback, or requiring follow up consults by phone or in-person, are essential.…”