March 6, 2021
Long-Term Sustainability and Acceptance of Antimicrobial Stewardship in Intensive Care
Reviewed by Milana Bogorodskaya, MD
Antimicrobial stewardship programs (ASPs) have been shown to effectively reduce unnecessary antibiotic use, the rise in multidrug-resistant organisms, and Clostridium difficile rates. However, a recent retrospective study by Sehgal et al. published in Critical Care Medicine is the first study to evaluate the long-term effects and sustainability of ASP implementation within intensive care units (ICUs) over a 10-year period.
The ICUs included level 2 and 3 general medicine/surgery, neurosurgery/stroke, cardiovascular surgery, trauma, and burn units in a tertiary care center in Toronto, Canada. The study aimed to (1) evaluate long-term trends in suggestion and acceptance rates of ASP interventions, (2) identify predictors of ASP suggestions being offered, and (3) identify predictors of acceptance versus rejection of ASP suggestions.
In total, 14% of ICU patients qualified for review by the ASP team, with 7,749 antibiotic assessments made during 5,569 ICU patient encounters during 2010-2019. The ASP suggested a change in antibiotic management in 36% of the encounters (63% to discontinue, 13% to narrow, and 9% to change dose). The most assessed antibiotics were piperacillin-tazobactam (24%), ceftriaxone (21%), and fluoroquinolones (12%). Admission to the cardiovascular surgery or burn surgery service, a urogenital indication for therapy, and receipt of aminoglycosides or intravenous vancomycin were associated with increased odds of receiving an ASP suggestion. Admission to a level 3 ICU, vasopressor use, and a primary central nervous system, intra-abdominal, or skin/soft-tissue infection were associated with decreased odds of receiving an ASP suggestion.
The overall acceptance rate of ASP suggestions was 67% and did not change over time. Admission to a level 3 ICU was associated with higher acceptance rates of ASP suggestions while admission to burn surgery service, treatment for community- and ventilator-associated pneumonia, and unknown source of infection were associated with lower acceptance rates of ASP suggestions. A suggestion to narrow, change agent, or change formulation were also all associated with lower acceptance rates of ASP suggestions.