Benefit of In-Person Antibiotic Consultation in the ICU
Thomas Glück, MD
Two reports showed substantial savings and improvements in antibiotic management associated with regular infectious diseases consultations or daily prompting on antibiotic treatment issues.
In intensive care units (ICUs), many patients receive antibiotics, sometimes despite low likelihood of infection. Several previous reports have suggested that unnecessary antibiotic use may lead to superinfection, selection of resistant pathogens, and — eventually — worse outcomes. But what is the effect of daily in-person counseling or prompting on the optimization of antibiotic therapy in critically ill medical patients? Two recent studies conducted in U.S. hospitals addressed this issue.
Rimawi and coworkers prospectively compared antibiotic use during a 3-month pre-intervention period (July–September 2011) with that during a 3-month intervention period (July–September 2012) in which an infectious diseases (ID) specialist made daily visits to the medical ICU and interacted directly with the staff. During the period with daily consultation, nearly all of the ID specialists' suggestions were followed for 88% of the patients, and significantly more patients received guideline-concordant antibiotic therapy (88% vs. 63%). Patient-days of antibiotic therapy dropped by 11%, and total antibiotic costs fell by 35%. Significant reductions in days of therapy were seen for carbapenems (–49%), piperacillin/tazobactam (–5%), vancomycin/linezolid (–5%), and metronidazole (–89%). In contrast, the use of narrow-spectrum penicillins increased 17-fold. The all-cause ICU mortality rate was similar between periods, but both the number of mechanical-ventilation days and the ICU length of stay were significantly lower during the period with daily ID consultation (–40% and –24%, respectively).
Weiss and colleagues compared use of empirical antibiotics between medical ICU patients whose caregivers received daily face-to-face prompting on various aspects of antibiotic treatment during rounds and those who were managed using a computerized checklist embedded in the electronic health record. Empirical antibiotic therapy was discontinued, or narrowed in spectrum, on 44% of patient-days in the prompted group compared with 10% of patient-days in the checklist group. Patients in the prompted group had 10% fewer days of empirical antibiotic treatment. Length of ICU stay and ICU mortality were similar between groups.
Citation(s):
Rimawi RH et al. Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med 2013 Jul 18; [e-pub ahead of print].
Weiss CH et al. A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization. Crit Care Med 2013 Aug 9.
