Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: A Prospective Cluster-Randomized Crossover Study

Abstract

Background Few groups have formally studied the effect of dedicated antibiotic stewardship rounds (ASRs) on antibiotic use (AU) in intensive care units (ICUs). Methods We implemented weekly ASRs using a two-arm, cluster-randomized, crossover study in 5 ICUs at Duke University Hospital from 11/2017 to 6/2018. We excluded patients without an active antibiotic order, or if they had a marker of high complexity including an existing infectious disease consult, transplant, ventricular assist device, or ECMO. AU during and following ICU stay for patients with ASRs was compared to the controls. We recorded the number of reviews, recommendations delivered, and responses. We evaluated change in ICU-specific AU during and after the study. Results Our analysis included 4,683 patients: 2330 intervention and 2353 controls. Teams performed 761 reviews during ASRs, which excluded 1569 patients: 60% of patients off antibiotics, and 8% complex patients. Exclusions affected 88% the cardiac surgery ICU (CTICU) patients. AU rate ratio (RR) was 0.97 (0.91-1.04). When CTICU was removed, the RR was 0.93 (0.89-0.98). AU in the post-study period decreased by 16% (95% CI 11-24%) compared to the AU in the baseline period. Change in AU was differential among units: largest in the neurology ICU (-28%) and smallest in the CTICU (-2%). Conclusion Weekly multi-disciplinary ASRs was a high-resource intervention associated with a small AU reduction. The noticeable ICU AU decline over time is possibly due to indirect effects of ASRs. Effects differed among specialty ICUs, emphasizing the importance of customizing ASRs to match unit-specific population, workflow, and culture.

Exploring Antimicrobial Stewardship Influential Interventions on Improving Antibiotic Utilization in Outpatient and Inpatient Settings: A Systematic Review and Meta-Analysis

“…The included studies have been classified into four groups: 13 articles involved IP settings without a pharmacist as a part of an AMS-MDT intervention [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ], 19 were carried out in IP settings with the inclusion of a pharmacist as a part of the intervention team [ 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ], eight articles engaged OP without a pharmacist [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 ], while eight involved OP settings with a pharmacist [ 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ]. Forty-one articles were from d...…”

“…The risk of bias assessment for the included studies is presented in Figure 2 . There were 11 RCT studies assessed using the ROB-2 assessment tool [ 28 , 32 , 33 , 34 , 46 , 57 , 58 , 59 , 60 , 63 , 67 ]. Of those, seven scored high risk [ 33 , 34 , 46 , 57 , 59 , 63 , 67 ], three scored low risk [ 28 , 32 , 60 ], with one article only found to have some concerns [ 58 ].…”

“…There were 11 RCT studies assessed using the ROB-2 assessment tool [ 28 , 32 , 33 , 34 , 46 , 57 , 58 , 59 , 60 , 63 , 67 ]. Of those, seven scored high risk [ 33 , 34 , 46 , 57 , 59 , 63 , 67 ], three scored low risk [ 28 , 32 , 60 ], with one article only found to have some concerns [ 58 ]. On the other hand, the remaining 37 articles were non-randomized before and after methodology and were assessed using the ROBINS-1 assessment tool [ 24 , 25 , 26 , 27 , 29 , 30 , 31 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ...…”

“…One study was conducted in the OP setting and pharmacists did not take part in the intervention [ 62 ]. On the other hand, insignificant changes were reported by all the six studies conducted in the IP setting [ 29 , 34 , 35 , 38 , 52 , 55 ]. The data from four IP studies have been pooled to produce an overall effect.…”

Comments on “Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: A Prospective Cluster-Randomized Crossover Study”

“…As an infectious disease specialist struggling to propel the proper use of antibiotics, I have gone through the most recent article in your esteemed journal written by Seidelman et al [1]. In this age of antimicrobial resistance [2], promoting antimicrobial stewardship is increasingly highlighted worldwide [3].…”