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, email@example.com). 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, firstname.lastname@example.org.
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.
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.
Table 1. Antibiotic Changes Made During the First and Subsequent Audits
Table 2. Antibiotic Changes Made During the First Audit, by Initial Antibiotic Choice
Total antibiotic use, by fiscal period.
The fiscal period started in April 2010. There are 13 fiscal periods in the financial year. The vertical line represents the first fiscal period of the intervention. The dashed and dotted lines represent the time-series model–predicted lines of best fit before and after the intervention. DDD = defined daily dose; P = period.
Antibiotic use, by fiscal period.
Combined macrolide and tetracycline use, by fiscal period.
The fiscal periods started in April 2010. There are 13 fiscal periods in the financial year. The vertical line represents the first fiscal period of the intervention. The dashed and dotted lines represent the time-series model–predicted lines of best fit before and after the intervention. DDD = defined daily dose; P = period.
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Celine Pulcini, MD, Philippe Lesprit, MD
Université de Lorraine
December 2, 2014
Lee et al. should be commended for their very interesting prospective study, showing that an antibiotic self-stewardship bundle to implement the CDC’s suggested time-outs did significantly decrease costs (78% related to carbapenem use) and moxifloxacin use, but did not reduce total antibiotic use, as measured using DDDs/1000 patient-days (1). This before-and-after uncontrolled multifaceted interventional study was conducted on internal medicine wards in the Montreal General Hospital (Canada), using interrupted time-series analyses. All senior residents attended a 30-minute teaching session, and were invited to perform ‘antibiotic self-stewardship’, meaning self-reassessment of all antibiotic prescriptions twice weekly using a very detailed structured electronic checklist. They also received monthly feedback about their antibiotic use. Adherence with auditing was good (80%), and 12.5% of prescriptions were modified. It would have been interesting to have some details regarding the changes made (particularly if some unnecessary prescriptions were stopped) and the quality of antibiotic prescriptions.
Apart the Weiss study cited by the authors (2), post-prescription review using a a self-administered checklist has also been studied by others. In a before-and-after uncontrolled study conducted in one French hospital on all medical and surgical wards, Lesprit et al. showed that distributing a questionnaire aimed at reminding physicians to reassess therapy did not lead to more modifications of antibiotic therapy at day 4 (discontinution, de-escalation, oral switch or decreased duration of therapy), whereas systematic infectious diseases specialist intervention (IDS) significantly improved the modification rate (3). In another before-and-after uncontrolled French study using interrupted time-series analyses conducted in a medical intensive care unit, Pulcini et al. showed that a better documentation of antibiotic prescriptions’ reassessment was achieved, using a previously validated ‘day 3 bundle’, but that it did not improve the quality of antibiotic prescriptions (4). The bundle was made up of four process measures: antibiotic plan, reviewing the diagnosis, adapting to positive microbiological results, and IV-per os switch (5). All these studies assessed a single-component intervention, and used a less detailed checklist than the one designed by Lee et al.
In conclusion, we agree with Lee et al. that self-stewardship might be a ‘low-hanging fruit’ and merits further study in different settings. Self-stewardship certainly ensures better documentation of antibiotic prescriptions in medical records, but it might need to be associated with other measures such as IDS-driven review of prescriptions to really have an impact on quality and quantity of antibiotic use.
1. 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 Nov 18;161(10 Suppl):S53-8. doi: 10.7326/M13-3016.
2. Weiss CH, Dibardino D, Rho J, Sung N, Collander B, Wunderink RG. A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization. Crit Care Med. 2013;41:2563-9.
3. Lesprit P, Landelle C, Girou E, Brun-Buisson C. Reassessment of intravenous antibiotic therapy using a reminder or direct counselling. J Antimicrob Chemother. 2010 Apr;65(4):789-95. doi: 10.1093/jac/dkq018.
4. Pulcini C, Dellamonica J, Bernardin G, Molinari N, Sotto A. Impact of an intervention designed to improve the documentation of the reassessment of antibiotic therapies in an intensive care unit. Med Mal Infect. 2011 Oct;41(10):546-52. doi: 10.1016/j.medmal.2011.07.003.
5. Pulcini C, Defres S, Aggarwal I, Nathwani D, Davey P. Design of a 'day 3 bundle' to improve the reassessment of inpatient empirical antibiotic prescriptions. J Antimicrob Chemother. 2008 Jun;61(6):1384-8. doi: 10.1093/jac/dkn113.
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. ;161:S53–S58. doi: 10.7326/M13-3016
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Published: Ann Intern Med. 2014;161(10_Supplement):S53-S58.
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