Effectiveness of an Antimicrobial Stewardship Program in Critical Care: A Before-and-After Study.

AACに発表された、バロセロナにある総合病院のICUによるASPの効果。

Abstract

We evaluated the use of antimicrobials expressed as defined daily doses (DDDs) per 1,000 patient days and days of therapy (DOT) per 100 occupied bed-days in a intensive care unit (UCI) of a general hospital in Barcelona, Spain, before and after implementation of an antimicrobial stewardship (AMS) program (2007-2010 versus 2011-2015). The quarterly costs of antimicrobials used in the ICU and its weight in the overall hospital costs of antimicrobials were calculated. The effect of the applied AMS program on DDDs and DOT time series data was analyzed by means of intervention time series analysis. A total of 5,002 patients were included (1,971 for the first [before] period and 3,031 for the second [after] period). The percentage of patients treated with one or more antimicrobials decreased from 88.6% to 77.2% (P< 0.001). DDDs decreased from 246.8 to 192.3 (mean difference -54.5, P = 0.001) and DOT from 66.7 to 54.6 (mean difference -12.1, P = 0.066). The mean cost per trimester decreased from 115,543[euro] to 73,477[euro] (mean difference -42,065.4[euro], P< 0.001) and the percentage of ICU antimicrobials cost with respect to the total cost of hospital antimicrobials decreased from 28.5% to 22.8% (mean difference -5.59, P = 0.023). Implementation of an AMS program in the ICU was associated with a marked reduction of the use of antimicrobials, with cost savings close to one million euros since its implementation. An AMS program can have a significant impact on optimizing antimicrobial use in critical care practice.

Antimicrobial stewardship (AMS) program.
Between January 1 and March 31, 2011, a program for optimizing the use of antimicrobials
was implemented in the hospital.
Prior to the application of the AMS program, each attending physician or medical team
decided on which antimicrobials had to be administered to their patients and the
duration of treatment. No restriction programs for the use of antimicrobials have been
implemented before 2011. In the hospital and in the ICU, there were some guidelines
for the use of antibiotics but these recommendations have not been subjected to
audits or assessments of adherence.
The AMS program included the following characteristics:
a) establishment of a multidisciplinary working group with specialists in
infectious diseases, pharmacy, microbiology, and intensive care medicine who were
responsible for the design and implementation of the AMS program;
b) development of a computer application for the specific prescription of antimicrobials which was
added to the patient’s computerized medical record;
c) selection of 10 antimicrobial agents, which due to their greater environmental and economic impact, underwent special control measures, including the need to justify their indications in writing
through the application form of the program, compulsory detailed information of the
duration of treatment, immediate information of the cost of prescription, and
automatic discontinuation of drug administration on the day set by the prescriber
physician, with reassessment of indications during the next 24-72 hours by a member
of the working group.
These antimicrobials were carbapenems (imipenem,meropenem), tigecycline, linezolid, voriconazole, candins (caspofungin, anidulafungin,micafungin), and lipid-associated amphotericin B (liposomal, lipid complex).
In the ICU setting, an expert intensivist in infectious diseases was responsible for implementation
of the program. Actions included daily review of antibiotics regimens of all patients
during the shift change (8:00 AM, 3:00 PM, 9:00 PM), obligation to include the number
of days of antimicrobial administration in the computerized clinical course record, and
reasonable proposals of dose adjustment, de-escalation, or withdrawal in the daily
clinical sessions of the ICU staff (2:00-3:30 PM).
The AMS program was well accepted in the ICU setting, with no rejections by
the ICU personnel. Details of the implementation of the recommendations were
discussed at daily sessions and final decisions were taken by consensus of the ICU
team. In case of disagreement, the expert’s opinion prevailed who had received
empowerment by the medical director of the hospital and the chief of the ICU.