title: Impact of antimicrobial stewardship in critical care: a systematic review.
abstract: OBJECTIVE
  To evaluate the current state of evidence for antimicrobial stewardship interventions in the critical care unit.
  
  
  METHODS
  We performed a systematic search of OVID MEDLINE, Embase and Cochrane electronic databases from 1996-2010. Studies were included if they involved any experimental intervention to improve antimicrobial utilization in the critical care setting.
  
  
  RESULTS
  Thirty-eight studies met the inclusion criteria, of which 24 met our quality inclusion criteria. The quality of research was poor, with only 3 randomized controlled trials, 3 interrupted time series and 18 (75%) uncontrolled before-and-after studies. We identified six intervention types: studies of antibiotic restriction or pre-approval (six studies); formal infectious diseases physician consultation (five); implementation of guidelines or protocols for de-escalation (two); guidelines for antibiotic prophylaxis or treatment in intensive care (two); formal reassessment of antibiotics on a pre-specified day of therapy (three); and implementation of computer-assisted decision support (six). Stewardship interventions were associated with reductions in antimicrobial utilization (11%-38% defined daily doses/1000 patient-days), lower total antimicrobial costs (US$ 5-10/patient-day), shorter average duration of antibiotic therapy, less inappropriate use and fewer antibiotic adverse events. Stewardship interventions beyond 6 months were associated with reductions in antimicrobial resistance rates, although this differed by drug-pathogen combination. Antibiotic stewardship was not associated with increases in nosocomial infection rates, length of stay or mortality.
  
  
  CONCLUSIONS
  More rigorous research is needed, but available evidence suggests that antimicrobial stewardship is associated with improved antimicrobial utilization in the intensive care unit, with corresponding improvements in antimicrobial resistance and adverse events, and without compromise of short-term clinical outcomes.
authors: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors: Reham
authors: R
authors: Kaki
authors: Marion
authors: M
authors: Elligsen
authors: Sandra
authors: S
authors: Walker
authors: Andrew
authors: A
authors: Simor
authors: Lesley
authors: L
authors: Palmay
authors: Nick
authors: N
authors: Daneman
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness; D024881:Drug Resistance, Bacterial; D004363:Drug Utilization / Q000592:standards*; D006801:Humans; D007362:Intensive Care Units; D016896:Treatment Outcome; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents