Blood culture-guided de-escalation of empirical antimicrobial regimen for critical patients in an online antimicrobial stewardship programme

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Abstract

A blood culture-guided review strategy was applied to a hospital-wide computerised antimicrobial approval system (HCAAS) at a medical centre in Taiwan. The study aimed to evaluate the impact of this deployment on prescribers’ behaviours, antimicrobial consumption, antimicrobial expenditure and healthcare quality in adult intensive care units (ICUs). The HCAAS automatically identifies patients with positive blood cultures and notifies the pre-assigned infectious diseases (ID) physicians for an online second review of the current antimicrobial regimen. Patients from 16 adult ICUs were selected as a focus group. Descriptive analysis, McNemar's test, interrupted time-series analysis and univariate regression analysis were applied. The number of prescriptions assigned for second review increased from 304 in 2010 to 682 in 2012. The approval rate for the antimicrobial regimen in the second review exceeded 70%. In disapproved cases, prescribers accepted the recommendation from ID physicians in 66.1% of cases in the first year; the acceptance rate increased to 80.6% in 2012. Among the restricted antimicrobial agents, consumption gradients decreased for all eight drug classes. The overall antimicrobial expenditure gradient declined significantly following deployment of the second review strategy. The healthcare-associated infection rate continued to decrease over time, and the mortality and ICU re-admission rates remained stable after deployment. A blood culture-guided review of antimicrobial use based on clinical and microbiological evidence improves accuracy in choosing appropriate antimicrobial agents and encourages de-escalation. Consumption and expenditure gradients of antimicrobial agents decreased after the intervention, and healthcare quality was not compromised.

Introduction

Initial prescription of broad-spectrum antimicrobial agents to critically ill patients is supported by many studies as well as the latest Surviving Sepsis Campaign guidelines [1]. On the other hand, evidence has clearly shown that antimicrobial use is strongly related to the development and spread of antimicrobial-resistant pathogens [2], [3], [4]. Reckless de-escalation may cause unpredicted disease progression, especially for critically ill patients, and therefore hinder a reduction in antimicrobial use. De-escalation should be considered, however, when the clinical condition of a patient is stable or the causative pathogens and their antimicrobial susceptibilities are identified to prevent the development of antimicrobial resistance and adverse drug reactions and to reduce expenditure [1]. Several studies and an individual patient data meta-analysis have reported that procalcitonin-guided treatment can reduce antimicrobial exposure with no impact on the mortality rate and treatment failure in patients with acute respiratory infection [5], [6], [7], [8].

A hospital-wide computerised antimicrobial approval system (HCAAS) was developed in 2004 at Chang Gung Memorial Hospital (CGMH), a 3700-bed medical centre in northern Taiwan [9]. This antimicrobial stewardship programme (ASP) system built under the Health Information System (HIS) is an intranet-based interface. Infectious diseases (ID) physicians can access relevant information via the HCAAS and HIS, including the clinical course of patients, laboratory results and images, for real-time, on-line prescription vetting and then communicate with prescribers. De-escalation should be patient-specific and evidence-based, providing sufficient clinical credibility and timeliness. In April 2010, implementation of the HCAAS was extended with a blood culture-guided review strategy to provide clinical and microbiological evidence that can encourage and guide de-escalation. The system automatically identifies patients with positive blood culture results and notifies the assigned ID physicians for a second review of the previously approved prescription. This study aimed to evaluate the impact of the deployment of second review on prescribers’ responses, antimicrobial consumption, antimicrobial expenditure and healthcare quality in adult intensive care units (ICUs).

Section snippets

Intervention

The blood culture-guided second review strategy was implemented under the existing HCAAS (Fig. 1). Patients in 16 adult ICUs (223 beds) were selected as a focus group for this study. Antimicrobial agents were classified as ‘restricted’ or ‘non-restricted’ as described in previous studies [10], [11], [12]. Restricted antimicrobial agents in CGMH are: third- and fourth-generation cephalosporins (ceftriaxone, ceftazidime and cefepime); fluoroquinolones (ciprofloxacin, levofloxacin and

Process measurement

The second review strategy was implemented in April 2010, with the HCAAS identifying 1661 cases in the adult ICUs over 33 months following deployment. The number of prescriptions reviewed by the blood culture-guided system in the second review was 304 in 2010, 675 in 2011 and 682 in 2012. The second review approval rate was 80.6% in 2010, 74.2% in 2011 and 73.6% in 2012 (Fig. 2A). A total of 413 recommendations to change antimicrobial regimen were made by ID physicians in 1661 second review

Discussion

Clinical evidence increasingly suggests that ASPs are associated with positive outcomes for ICU patients [18]. For critically ill patients, timely administration of broad-spectrum antimicrobial agents is crucial to proper coverage of causative pathogens. When patients become stable and the causative pathogens have been identified, de-escalation should be carried out to avoid development of antimicrobial resistance in pathogens. The relatively high risk of litigation in Taiwan, however, has made

Acknowledgments

The authors would like to express their gratitude to all of the members of the Antimicrobial Stewardship Subcommittee at Chang Gung Memorial Hospital (Taoyuan, Taiwan) for their support in the execution of the programme.

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    1

    These three authors contributed equally to this work.

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