Antibiotic Stewardship is Tough in Hospital Wards, But Even Tougher in ICU

Antibiotic stewardship in the intensive care unit setting poses unique challenges to intensivists and other ICU clinicians, recent research indicates.

Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

Research co-author Richard Wunderink, MD, FCCP, of Northwestern University Feinberg School of Medicine in Chicago, told HealthLeaders that there are three primary unique aspects of antibiotics stewardship in the ICU.

• Severity and acuity of illness requires early administration of antibiotics
• Diagnostic uncertainty in a patient who presents with multiple potential sites of infection prompts multiple potential antibiotic treatment regimens
• There is a tendency for patients with risk factors for multidrug-resistant, extensively drug-resistant, and pan-drug-resistant infections to require transfer to the ICU

As a result of these challenges, ICU clinicians often deal with the negative impact of excess antibiotic therapy, Wunderink and his co-authors wrote in the journal CHEST.

“Many ICUs become sinks for multi-drug resistant pathogens, accumulating patients with treatment failure due to antibiotic resistance. Prolonged duration of mechanical ventilation also predisposes to recurrent ventilator-associated pneumonias (VAPs), with each pathogen more resistant than the previous.”

The research team found there are three main barriers to good antibiotics stewardship in the ICU: diagnostic uncertainty, fear of not adequately covering the causative pathogen, and underestimation of antibiotics toxicity. Wunderink said there are approaches to overcome these barriers.

• Developing new rapid diagnostic tests as opposed to culture-based techniques—the greatest needs are for direct-from-blood samples and accurate samples from respiratory secretions
• Promoting better clinical research with more accurate tests to determine the true incidence of “missed” pathogens
• Raising awareness about antibiotic toxicity and the difficulty of separating drug toxicity from the underlying infection; for example, both often can cause fever

Antibiotic stewardship program

Implementing a formal antibiotic stewardship program is essential in the ICU setting, the researchers wrote.

“Judicious use of antibiotics in the ICU is essential to control development of resistant organisms and the benefits of implementing an ASP in the intensive care unit are well-documented. Studies have shown that ASPs reduce rates of antibiotic resistance, duration of ventilation, days of antibiotic use, and healthcare costs in critically ill patients.”

An ASP in the ICU setting should have seven elements, according to the researchers.

• Leadership: An infectious disease pharmacist and infectious physician should responsible for administering the ASP along with the ICU leadership.
• Audit and feedback: Antibiotics administration should be reviewed and revised in response to changing circumstances such as new diagnostic results. Revised courses of treatment include de-escalation of medication.
• Antibiotic time out: This physician-trainee approach reviews antibiotic indications on a bi-weekly basis and includes monthly trainee instruction.
• Rapid diagnostics: The ICU should be equipped with a viral multiplex polymerase chain reaction platform, rapid PCR for methicillin-resistant Staphylococcus aureus, and serial procalcitonin.
• Clinical pathways: These guidelines require physicians to document signs and symptoms, then provide antibiotics recommendations. Some pathways stratify patients based on risk factors for multi-drug resistance, which can determine the length of antibiotics treatment.
• Computerized decision support: Electronic analysis of antibiograms and patient data generate antibiotics recommendations. Computerized decision support can provide an individualized approach to antibiotic decision-making for each patient.
• Infection control: ICU staff should take preventive measures such as hand washing.