さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

Use of evidence-based recommendations in an antibiotic care bundle for the intensive care unit.

2017年 Int J Antimicrob Agentsに発表された、オランダとイタリアのICUにおけるantibiotic care bundle (ABC-Bundle) の開発に関する報告。

 

PURPOSE

To drive decisions on antibiotic therapy in the intensive care unit (ICU), we developed an antibiotic care bundle (ABC-Bundle) with evidence-based recommendations (EBRs) for antibiotic prescriptions.

 

METHODS

We conducted a 3-step prospective study. First, a systematic review of the literature reporting EBRs for antibiotic usage in the ICU was performed. Second, we developed an ABC-Bundle through a 2-round, RAND-modified Delphi method with an international expert panel, including the most relevant EBRs on a 9-point Likert scale. Those EBRs that were considered mandatory by >50% of the experts were included in the bundle. Third, we assessed the adherence to and applicability of the bundle in 2 mixed university ICUs.

RESULTS

Out of 1,190 potentially relevant articles, 14 (4 guidelines, 4 randomised controlled trials and 6 systematic reviews) fulfilled the eligibility criteria. Six EBRs were classified as relevant: 1. Provide rationale for antibiotic start; 2. Perform appropriate microbiological sampling; 3. Prescribe empirical antibiotic therapy according to guidelines (Day 1); 4. Review diagnosis; 5. Evaluate de-escalation based on microbiological results (Days 2-5); and 6. Consider discontinuation of treatment (Days 3-5). Daily adherence to the ABC-Bundle, prospectively assessed in 861 days of therapy in 142 ICU patients, ranged from 2% to 37%.

CONCLUSIONS

The ABC-Bundle is a novel tool to improve delivery of appropriate antibiotic therapy to ICU patients. The low adherence in the prospective cohorts confirms the significant role that the ABC-Bundle could play in an antibiotic stewardship programme in the ICU setting.

 

HIGHLIGHTS

  • Antibiotic prescription bundle using evidence-based recommendations (EBR) was developed EBRs were retrieved from a systematic literature review including >1100 articles
  • Bundle was assessed in 142 ICU patients in the Netherlands & Italy
  • Novel tool to improve delivery of appropriate antibiotic therapy to ICU patients

 

 limitations

 

There are no guidelines for determining consensus, sample size and sampling techniques for the Delphi approach, and some concerns have been raised about the reliability of the technique. However, the lack of drop-outs of our respondents as well the selection of experts through 2 different societies and backgrounds should have reduced the risk of bias. The analysis of EBRs was restricted to guidelines and RCTs that, although considered the sources for the best evidence, could have missed some data from cohort studies that could play a role in antibiotic prescription primarily in community settings. The testing of adherence and feasibility was only performed in 2 ICUs. However, the 2 settings  were selected in 2 countries with different epidemiology of antibiotic resistance and health systems to increase the generalisability and transferability of our results. At the time of the study, both hospitals had local antibiotic therapy indications and formularies but not an antimicrobial stewardship programme. The goal of the study was to provide antimicrobial stewardship with a further tool to increase effectiveness and results. The ABC bundle was not developed to work without guidelines for empiric antibiotic therapy or appropriate microbiological stewardship. A prospective RCT is needed to define the cost-effectiveness of the bundle.

 

f:id:akinohanayuki:20170725061319p:plain

 

f:id:akinohanayuki:20170725061329p:plain

 

感想

ABCバンドルという名前はいいですね。

しかし、内容は微妙かな。