Long-Term Effects of Phased
Implementation of Antimicrobial Stewardship in Academic ICUs: 2007–2015*
by Morris, Andrew M.;
Bai, Anthony; Burry, Lisa; Dresser, Linda D.; Ferguson, Niall D.; Lapinsky,
Stephen E.; Lazar, Neil M.; McIntyre, Mark; Matelski, John; Minnema, Brian;
Mok, Katie; Nelson, Sandra; Poutanen, Susan M.; Singh, Jeffrey M.; So, Miranda;
Steinberg, Marilyn; Bell, Chaim M.
Objectives:
Antimicrobial stewardship is advocated to reduce antimicrobial resistance in
ICUs by reducing unnecessary antimicrobial consumption. Evidence has been
limited to short, single-center studies. We evaluated whether antimicrobial
stewardship in ICUs could reduce antimicrobial consumption and costs.
Design: We
conducted a phased, multisite cohort study of a quality improvement initiative.
Setting: Antimicrobial stewardship was implemented in four academic ICUs in
Toronto, Canada beginning in February 2009 and ending in July 2012. Patients:
All patients admitted to each ICU from January 1, 2007, to December 31, 2015,
were included. Interventions: Antimicrobial stewardship was delivered using
in-person coaching by pharmacists and physicians three to five times weekly,
and supplemented with unit-based performance reports. Total monthly
antimicrobial consumption (measured by defined daily doses/100 patient-days)
and costs (Canadian dollars/100 patient-days) before and after antimicrobial
stewardship implementation were measured.
Measurements and Main Results: A total of 239,123 patient-days (57,195 patients)
were analyzed, with 148,832 patient-days following introduction of
antimicrobial stewardship. Antibacterial use decreased from 120.90 to 110.50
defined daily dose/100 patient-days following introduction of antimicrobial
stewardship (adjusted intervention effect –12.12 defined daily dose/100
patient-days; 95% CI, –16.75 to –7.49; p < 0.001) and total antifungal use
decreased from 30.53 to 27.37 defined daily doses/100 patient-days (adjusted
intervention effect –3.16 defined daily dose/100 patient-days; 95% CI, –8.33 to
0.04; p = 0.05). Monthly antimicrobial costs decreased from $3195.56 to
$1998.59 (adjusted intervention effect –$642.35; 95% CI, –$905.85 to –$378.84;
p < 0.001) and total antifungal costs were unchanged from $1771.86 to
$2027.54 (adjusted intervention effect –$355.27; 95% CI, –$837.88 to $127.33; p
= 0.15). Mortality remained unchanged, with no consistent effects on
antimicrobial resistance and candidemia.
Conclusions:
Antimicrobial stewardship in ICUs with coaching plus audit and feedback is
associated with sustained improvements in antimicrobial consumption and cost.
ICUs with high antimicrobial consumption or expenditure should consider
implementing antimicrobial stewardship programs.
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