Todd C. Lee, MD, MPH; Charles Frenette, MD; Dev Jayaraman, MD, MPH; Laurence Green, MD; Louise Pilote, MD, MPH, PhD (*)
Disclosures: None. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-3016.
Reproducible Research Statement:Study protocol: Available from Dr. Lee (e-mail, firstname.lastname@example.org). Statistical code and data set: Not available.
Requests for Single Reprints: Todd C. Lee, MD, MPH, Division of Internal Medicine, Royal Victoria Hospital, 687 Pine Avenue West, Room A4.21, Montreal, Quebec H3A 1A1, Canada; e-mail, email@example.com.
Current Author Addresses: Drs. Lee, Frenette, Jayaraman, Green, and Pilote: Division of Internal Medicine, Royal Victoria Hospital, 687 Pine Avenue West, Room A4.21, Montreal, Quebec H3A 1A1, Canada.
Author Contributions: Conception and design: T.C. Lee, C. Frenette.
Analysis and interpretation of the data: T.C. Lee, C. Frenette, D. Jayaraman, L. Pilote.
Drafting of the article: T.C. Lee, C. Frenette, D. Jayaraman.
Critical revision of the article for important intellectual content: T.C. Lee, C. Frenette, D. Jayaraman, L. Pilote.
Final approval of the article: T.C. Lee, C. Frenette, L. Green, L. Pilote.
Provision of study materials or patients: T.C. Lee, C. Frenette, L. Green.
Statistical expertise: T.C. Lee.
Administrative, technical, or logistic support: T.C. Lee, C. Frenette.
Collection and assembly of data: T.C. Lee, C. Frenette.
Lee TC, Frenette C, Jayaraman D, Green L, Pilote L. Antibiotic Self-stewardship: Trainee-Led Structured Antibiotic Time-outs to Improve Antimicrobial Use. Ann Intern Med. 2014;161:S53-S58. doi: 10.7326/M13-3016
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Published: Ann Intern Med. 2014;161(10_Supplement):S53-S58.
Antibiotic use is an important quality improvement target. Nearly 50% of antibiotic use is unnecessary or inappropriate. To combat overuse, the Centers for Disease Control and Prevention (CDC) proposed “time-outs” to reevaluate antibiotics.
To optimize antibiotic use through trainee-led time-outs.
Internal medicine (2 units, 46 beds) at a university hospital.
Inpatients (n = 679).
From January 2012 until June 2013, while receiving monthly education on antimicrobial stewardship, resident physicians adjusted patients' antibiotic therapy through twice-weekly time-out audits using a structured electronic checklist.
Antibiotic costs were standardized and compared in the year before and after the audits. Use was measured as World Health Organization defined daily doses (DDDs) per 1000 patient-days. Total antibiotic use and the use of moxifloxacin, carbapenems, antipseudomonal penicillins, and vancomycin were compared by using interrupted time series. Rates of nosocomial Clostridium difficile infection were compared by using incidence rate ratios.
Total costs in the units decreased from $149 743CAD (January 2011 to January 2012) to $80 319 (January 2012 to January 2013), for a savings of $69 424 (46% reduction). Of the savings, $54 150 (78%) was related to carbapenems and $15 274 (22%) was due to other antibiotic classes. Adherence with the auditing process was 80%. In the time-series analyses, the only reliable and statistically significant change was a reduction in the rate of moxifloxicin use, by −1.9 DDDs per 1000 patient-days per month (95% CI, −3.8 to −0.02; P = 0.048). Rates of C. difficile infection decreased from 24.2 to 19.6 per 10 000 patient-days (incidence rate ratio, 0.8 [CI, 0.5 to 1.3]).
Other temporal factors may confound the findings.
An antibiotic self-stewardship bundle to implement the CDC's suggested time-outs seems to have reduced overall costs and targeted antibiotic use.
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