Infectious Disease Team Review Using Antibiotic Switch and Discharge Criteria Shortens the Duration of Intravenous Antibiotic: A Single-Center Cluster-Randomized Controlled Trial in Thailand

Abstract

Background Strategies have been recommended to optimize early antibiotic (ATB) switching from intravenous (IV) to oral ATB. This study aimed to determine whether infectious disease (ID) team review using ATB switch and discharge criteria would shorten the duration of IV antibiotic and length of hospital stay (LOS). Methods This cluster randomized controlled trial was conducted in 8 general medical wards as cluster units at Siriraj Hospital during January-October 2019. ID team review with checklist criteria was performed on the third, fifth, and seventh day of IV-ATB treatment to determine the suitability of switching to oral ATB or outpatient parenteral ATB therapy, and early discharge for patients receiving IV-ATB versus control. The primary outcomes were LOS and the duration or days of therapy (DOT) or defined daily dose (DDD) of IV-ATB therapy. Results Four wards each were randomly assigned to the intervention and control groups (46 patients/cluster, 184 patients/arm). No significant difference was observed between intervention and controls for median duration of IV-ATB therapy (7 vs. 7 days) and LOS (9 vs. 10 days). A significantly shorter duration of IV-ATB was observed in patients without sepsis in the intervention group when measured by DOT (7 vs. 8 days, p=0.027) and DDD (7 vs. 9 days, p=0.017) in post-hoc analysis. Conclusions ID team review using checklist criteria did not result in a shorter duration of IV-ATB and LOS in overall patients. Further study is needed to determine if faster culture turnaround time or advanced testing will reduce the duration of IV-ATB therapy.

Criteria to Achieve Safe Antimicrobial Intravenous-to-Oral Switch in Hospitalised Adult Populations: A Systematic Rapid Review

“…The primary outcome of safety of antimicrobial IVOS was identified in eight of the included papers (50%), 12, 21, 23-28 with remaining papers focusing on outcomes classed as additional for the purposes of this study. All papers included measurable IVOS criteria.…”

“…The infection markers identified in the literature were temperature, 9, 12, 21, 23, 25-28, 30-35 heart rate, 9, 32-34 blood pressure, 12, 21, 23, 26-28, 31-35 respiratory rate, 9, 12, 32, 33 white cell count 9, 12, 24, 27, 28, 30, 32-34 or absolute neutrophil count 24, 30 and C-reactive protein. 32, 33…”

“…The most common criterion variance was that temperature must be between the 36-38°C range, appearing in 6 studies (38%). Of these 6 studies, three stated that 36-38°C must have been sustained for the past 24 hours – one of these studies was a clinical trial [H], 12 and one stated for the past 24-48 hours, also a clinical trial [H]. 9 Six studies (38%) [M] did not state a temperature range, but instead suggested that it must be less than 38°C, 27, 30, 31, 33, 34 or less than 37.6°C.…”

“…The preferred wording was divided between WCC must be normalising (n=3, 19%) 9, 27, 34 and WCC must be within 4-12 x10 9 /L (n=3, 19%). 12, 28, 33 Each of these criterion wordings appeared in clinical trials [H]. 9, 12…”

“…9, 10 Additionally, decreased medical equipment usage has the potential to reduce hospital’s carbon footprint. 11 In clinically stable patients, studies report that a timely IVOS is safe and of equal efficacy to the full course of IV therapy, 12 with no negative reports on patient outcome. 12 In the United Kingdom (UK), the national Start Smart – Then Focus AMS Toolkit recommends IVOS as an important outcome following review of prescribed antimicrobial within 48-72 hours.…”