Taking an Antibiotic Time-out: Utilization and Usability of a Self-Stewardship Time-out Program for Renewal of Vancomycin and Piperacillin-Tazobactam

Abstract

Background: Antibiotic time-outs can promote critical thinking and greater attention to reviewing indications for continuation. Objective: We pilot tested an antibiotic time-out program at a tertiary care teaching hospital where vancomycin and piperacillin-tazobactam continuation past day 3 had previously required infectious diseases service approval. Methods: The time-out program consisted of 3 components: (1) an electronic antimicrobial dashboard that aggregated infection-relevant clinical data; (2) a templated note in the electronic medical record that included a structured review of antibiotic indications and that provided automatic approval of continuation of therapy when indicated; and (3) an educational and social marketing campaign. Results: In the first 6 months of program implementation, vancomycin was discontinued by day 5 in 93/145 (64%) courses where a time-out was performed on day 4 versus in 96/199 (48%) 1 year prior (P = .04). Seven vancomycin continuations via template (5% of time-outs) were guidelinediscordant by retrospective chart review versus none 1 year prior (P = .002). Piperacillin-tazobactam was discontinued by day 5 in 70/105 (67%) courses versus 58/93 (62%) 1 year prior (P = .55); 9 continuations (9% of time-outs) were guideline-discordant versus two 1 year prior (P = .06). A usability survey completed by 32 physicians demonstrated modest satisfaction with the overall program, antimicrobial dashboard, and renewal templates. Conclusions: By providing practitioners with clinical informatics support and guidance, the intervention increased provider confidence in making decisions to de-escalate antimicrobial therapy in ambiguous circumstances wherein they previously sought authorization for continuation from an antimicrobial steward. 1-5 Inappropriate antimicrobial therapy leads to excess antimicrobial resistance, adverse events, and health care costs. Key6-13 Promotion of excess in antimicrobial resistance is particularly troubling in an age when multidrug-resistant organisms can no longer be effectively treated by any available antibiotics and few potentially effective agents are under development.14 Antimicrobial stewardship may be broadly defined as a program or series of interventions to improve the appropriateness of antimicrobial use, and it is a key strategy in combating antimicrobial resistance.9,15-17 Unfortunately, best practices in stewardship remain unclear.18 Whereas available data indicate that restrictive interventions (ie, limiting access to antibiotics through formulary or approval policies) have a significantly greater impact on prescribing practices in the short term than do persuasive measures such as dissemination of educational resources and/or outreach, reminders, or audit-feedback, these benefits do not persist, are less scalable, and can provoke negative reactions from providers who prefer to maintain autonomy in decision making. 19,20 Thus, stewardship must find a balance between restrictive and persuasive methods of influencing antimicrobial prescriptio...

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

“…Graber et al required users to enter a structured clinical note if vancomycin or piperacillin-tazobactam were continued for >3 days. 15 Vancomycin early discontinuation was more common after the ATO implementation, but piperacillin-tazobactam use was unchanged. Another center created an interruptive alert appearing after 72 hours for patients on empiric antibiotics with no defined duration.…”

SCAN: A novel approach for vancomycin time-out

“…5,6 Although there are reports of the successful use of automatic vancomycin stop orders in reducing inappropriate use, one concern frequently raised by clinicians is potential interruptions in therapy in cases where continuation is desired. 8,9 SCAN differs from an automatic stop order because the medication is not discontinued rather, a discussion regarding vancomycin use is initiated between the pharmacist and provider.…”

Results of the effectiveness of two piperacillin–tazobactam molecules in the real world

“…In general, the dose and the interval used in the two cohorts of patients were those recommended in the therapeutic guidelines. However, only half of the patients terminated or completed the piperacillin-tazobactam therapy, with a change to another antibiotic being most common, mainly by de-escalation to a lower spectrum (Graber et al, 2015). However, more than 15% of the cases were changed due to a suspicion of resistance or the presence of different etiological agents and types of infection, which is added evidence of the current difficulty in the use of broad-spectrum antibiotics as well as of resistance as an emerging problem in public health (Fasugba et al, 2016;Sonmezer et al, 2016;Villa et al, 2013).…”