Major article
Prospective audit for antimicrobial stewardship in intensive care: Impact on resistance and clinical outcomes

This work was presented in part at the 47th Meeting of the Infectious Diseases Society of America (October 2009, Philadelphia, PA).
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Background

The impact of antimicrobial audit and feedback on outcomes of critically ill adults is unclear.

Methods

A prospective study was performed in the intensive care units (ICU) of a public hospital in Atlanta, GA. Critically ill adults receiving empiric imipenem or piperacillin-tazobactam were eligible. Outcomes for 3 periods were compared: baseline (B, February to May 2006), model 1 (M1, October 2006 to July 2008), and model 2 (M2, September 2008 to February 2009). No audit was performed during B. During M1, an infectious diseases physician evaluated patients, and a critical care pharmacist communicated recommendations to the treating team. During M2, an infectious diseases physician directly participated in interdisciplinary rounds with the medical ICU team.

Results

One hundred ninety-four patients were included during B, 415 during M1, and 83 during M2. M1 and M2 were associated with appropriate antimicrobial selection (B, 70%; M1, 78%; M2, 82%; P = .042) and with lower rates of resistance (B, 31%; M1, 25%; M2, 17%; P = .033). Logistic regression analysis confirmed that audit and feedback were independently associated with appropriate antimicrobial selection and prevention of resistance. The association remained strongest for M2.

Conclusion

Audit and feedback had an influence on antimicrobial prescription patterns in the ICU with a favorable impact on the emergence of resistance.

Section snippets

Setting

Grady Memorial Hospital is a 1,000-bed, community teaching hospital in Atlanta, GA. An antimicrobial stewardship program was established at Grady Memorial Hospital in 2001. Since then, both an ID physician and an ID clinical pharmacist have been core members of the program. PAIF for the ICUs is performed by the ID physician with the support of the critical care (non-ID) pharmacists. In general, audit is triggered by the prescription of targeted antimicrobials, which is followed by case

Results

A total of 692 patients was prospectively included in the study: 194 during the baseline period, 415 during M1, and 83 during M2. During M1, 196 patients (47%) were evaluated by the antimicrobial utilization physician. Although imipenem and piperacillin-tazobactam were the antibiotics targeted for determining patient eligibility, 90% of included patients were concurrently exposure to other antimicrobial classes (75%, 26%, and 23% were coexposed to vancomicin, amikacin, and fluoroquinolones,

Discussion

Both M1 and M2 are in line with the recommendations by the Society of Critical Care Medicine Outcomes Task Force guidelines on how to implement, evaluate, and maintain an interdisciplinary quality improvement program in the intensive care unit.11 According to these guidelines, leadership, motivation, and teamwork are the foundation for a successful quality improvement intervention, which should introduce strategies likely to change behavior. Behavioral change in physicians is difficult to

Acknowledgment

The author thanks Stephanie Burton, Evan Tiderington, Stephen Causey, and Scott Dahlgren (MPH) for their assistance in data collection, entry, and management; Prasad Abrams, PharmD, and Marina Rabinovich, PharmD, for their assistance with AS in the ICUs; and Henry M. Blumberg, MD, for scientific and operational advice.

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This study was funded by the Emory Medical Care Foundation and the Emory University Research Committee.

Conflicts of interest: None to report.

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