title: Blood culture-guided de-escalation of empirical antimicrobial regimen for critical patients in an online antimicrobial stewardship programme.
abstract: A blood culture-guided review strategy was applied to a hospital-wide computerised antimicrobial approval system (HCAAS) at a medical centre in Taiwan. The study aimed to evaluate the impact of this deployment on prescribers' behaviours, antimicrobial consumption, antimicrobial expenditure and healthcare quality in adult intensive care units (ICUs). The HCAAS automatically identifies patients with positive blood cultures and notifies the pre-assigned infectious diseases (ID) physicians for an online second review of the current antimicrobial regimen. Patients from 16 adult ICUs were selected as a focus group. Descriptive analysis, McNemar's test, interrupted time-series analysis and univariate regression analysis were applied. The number of prescriptions assigned for second review increased from 304 in 2010 to 682 in 2012. The approval rate for the antimicrobial regimen in the second review exceeded 70%. In disapproved cases, prescribers accepted the recommendation from ID physicians in 66.1% of cases in the first year; the acceptance rate increased to 80.6% in 2012. Among the restricted antimicrobial agents, consumption gradients decreased for all eight drug classes. The overall antimicrobial expenditure gradient declined significantly following deployment of the second review strategy. The healthcare-associated infection rate continued to decrease over time, and the mortality and ICU re-admission rates remained stable after deployment. A blood culture-guided review of antimicrobial use based on clinical and microbiological evidence improves accuracy in choosing appropriate antimicrobial agents and encourages de-escalation. Consumption and expenditure gradients of antimicrobial agents decreased after the intervention, and healthcare quality was not compromised.
authors.affiliation: Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Hsiu-Yin
authors.initials: HY
authors.lastname: Wang
authors.affiliation: Molecular Infectious Disease Research Centre, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan. Electronic address: chchiu@adm.cgmh.org.tw.
authors.forename: Cheng-Hsun
authors.initials: CH
authors.lastname: Chiu
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Ching-Tai
authors.initials: CT
authors.lastname: Huang
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Chun-Wen
authors.initials: CW
authors.lastname: Cheng
authors.affiliation: Biostatistical Centre for Clinical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Yu-Jr
authors.initials: YJ
authors.lastname: Lin
authors.affiliation: Department of Management Information System, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Ying-Jen
authors.initials: YJ
authors.lastname: Hsu
authors.affiliation: Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Chi-Hua
authors.initials: CH
authors.lastname: Chen
authors.affiliation: Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Shin-Tarng
authors.initials: ST
authors.lastname: Deng
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Hsieh-Shong
authors.initials: HS
authors.lastname: Leu
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D006761:Hospitals; D006801:Humans; D007362:Intensive Care Units; D065186:Interrupted Time Series Analysis; D008826:Microbial Sensitivity Tests; D018805:Sepsis / Q000188:drug therapy*; D013624:Taiwan; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antimicrobial stewardship; Blood culture; De-escalation; Hospital-wide computerised antimicrobial approval system