Abstract
Early administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown. We used a modified Delphi approach to identify safety criteria for an opt-out protocol to guide de-escalation or discontinuation of antibiotic therapy after 72 hours in non-ICU patients with suspected sepsis. An expert panel with expertise in antimicrobial stewardship and hospital epidemiology rated 48 unique criteria across 3 electronic survey rating tools. Criteria were rated primarily based on their impact on patient safety and feasibility for extraction from electronic health record review. The 48 unique criteria were rated by anonymous electronic survey tools, and the results were fed back to the expert panel participants. Consensus was achieved to either retain or remove each criterion. After 3 rounds, 22 unique criteria remained as part of the opt-out safety checklist. These criteria included high-risk comorbidities, signs of severe illness, lack of cultures during sepsis work-up or antibiotic use prior to blood cultures, or ongoing signs and symptoms of infection. The modified Delphi approach is a useful method to achieve expert-level consensus in the absence of evidence suifficient to provide validated guidance. The Delphi approach allowed for flexibility in development of an opt-out trial protocol for sepsis antibiotic de-escalation. The utility of this protocol should be evaluated in a randomized controlled trial.
Highlights
Administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown
The 4 criteria identified as eligibility requirements for the proposed protocol were not included in the expert panel Delphi process: patient not located in intensive care unit, patient located on an adult medical or surgical unit, antibiotics initiated for suspected sepsis, and patient remained on any broad-spectrum antibiotics at 72 hours after the sepsis event
The primary finding of this protocol development program was that a multidisciplinary panel of experts in antimicrobial stewardship, critical care, and infectious diseases can achieve consensus through a modified Delphi approach to identify safety criteria for an opt-out protocol for antibiotic de-escalation in patients with suspected sepsis
Summary
Administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown. Methods: We used a modified Delphi approach to identify safety criteria for an opt-out protocol to guide de-escalation or discontinuation of antibiotic therapy after 72 hours in non-ICU patients with suspected sepsis. An expert panel with expertise in antimicrobial stewardship and hospital epidemiology rated 48 unique criteria across 3 electronic survey rating tools. The 48 unique criteria were rated by anonymous electronic survey tools, and the results were fed back to the expert panel participants. Results: After 3 rounds, 22 unique criteria remained as part of the opt-out safety checklist These criteria included high-risk comorbidities, signs of severe illness, lack of cultures during sepsis work-up or antibiotic use prior to blood cultures, or ongoing signs and symptoms of infection. The Delphi approach allowed for flexibility in development of an opt-out trial protocol for sepsis antibiotic de-escalation.
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