Abstract
BackgroundAntimicrobial decision making in intensive care units (ICUs) is challenging. Unnecessary antimicrobials contribute to the development of resistant pathogens, Clostridium difficile infection and drug related adverse events. However, inadequate antimicrobial therapy is associated with mortality in critically ill patients. Antimicrobial stewardship programs are increasingly being implemented to improve antimicrobial prescribing, but the optimal approach in the ICU setting is unknown. We assessed the impact of an audit and feedback antimicrobial stewardship intervention on antimicrobial use, antimicrobial costs, clinical outcomes and microbiologic outcomes in two ICUs with different patient populations.MethodsThe audit and feedback intervention was implemented in a trauma and neurosurgery ICU (TNICU) and a medical surgical ICU (MSICU) at a 465-bed teaching hospital in Toronto, Canada. ICU patients were reviewed Monday to Friday by a physician and pharmacist with infectious diseases training. Recommendations related to appropriate antimicrobial use were presented to ICU teams during a dedicated daily meeting. A controlled interrupted time series analysis was used to compare outcomes in the 12 months before and after the intervention. Cardiovascular and coronary care ICUs served as control units.ResultsMean total monthly antimicrobial use in defined daily doses (DDD) per 1000 patient days was reduced 28 % in the TNICU (1433 vs. 1037) but increased 14 % in the MSICU (1705 vs. 1936). In the time series analysis, total monthly antimicrobial use in the TNICU decreased by 375 DDD per 1000 patient days (p < 0.0009) immediately following the intervention, followed by a non-significant downward trend in use of −9 DDD per 1000 patient days (p = 0.56). No significant changes in antimicrobial use were identified in the MSICU. Antimicrobial use temporarily increased in one control unit and remained unchanged in the other. There were no changes in mortality, length of stay, readmission rate, incidence of C. difficile infection or resistance patterns of E. coli and P. aeruginosa in either intervention unit.ConclusionsAudit and feedback antimicrobial stewardship programs can lead to significant reductions in total antimicrobial use in the ICU setting. However, this effect may be context-dependent and further work is needed to determine the ingredients necessary for success.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1223-2) contains supplementary material, which is available to authorized users.
Highlights
Antimicrobial decision making in intensive care units (ICUs) is challenging
Patient Characteristics During the pre-intervention period, 1330 patients were admitted to the trauma and neurosurgery ICU (TNICU), corresponding to 6049 patient days, and 1305 patients were admitted to the medical surgical ICU (MSICU), corresponding to 7230 patient days
In the post-intervention period, there were 1387 patients admitted to the TNICU, making up 6254 patient days, and 1369 patients admitted to the MSICU, for a total of 7488 patient days
Summary
Antimicrobial decision making in intensive care units (ICUs) is challenging. Unnecessary antimicrobials contribute to the development of resistant pathogens, Clostridium difficile infection and drug related adverse events. Inadequate antimicrobial therapy is associated with mortality in critically ill patients. We assessed the impact of an audit and feedback antimicrobial stewardship intervention on antimicrobial use, antimicrobial costs, clinical outcomes and microbiologic outcomes in two ICUs with different patient populations. One of the most promising antimicrobial stewardship intervention strategies is prospective audit and feedback, a technique shown to reduce antimicrobial use in randomized-controlled trials [8, 9]. While most studies evaluating prospective audit and feedback programs have been conducted on medical and surgical wards, intensive care units (ICUs) may be the setting with the greatest potential impact [8,9,10]. We used interrupted time series analysis to evaluate the impact of our audit and feedback program on antimicrobial use in each of the two ICUs separately
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