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Abstract
Background There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country.
Methods We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training.
Results We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: −17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: −12.3 to 100.0), p=0.1413).
The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).
The infection prevention control (IPC) assessment framework was increased in eight ICUs.
Conclusion Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.
- Quality improvement methodologies
- Antibiotic management
- Critical care
- Collaborative, breakthrough groups
Data availability statement
Data are available in a public, open access repository. https://osf.io/5v7xa/?view_only=111e421428c5463385190685e6fa1cca.
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- Quality improvement methodologies
- Antibiotic management
- Critical care
- Collaborative, breakthrough groups
Data availability statement
Data are available in a public, open access repository. https://osf.io/5v7xa/?view_only=111e421428c5463385190685e6fa1cca.
Footnotes
X @jorrobox, @emilsevi
Collaborators Collaborative Group COST: Natalí Ini, Juan Pedro Alonso, (Institute for Clinical Effectiveness and Health Policy -IECS- Buenos Aires, Argentina). Marisol García Sarubbio, Agustina Paglia, María Cecilia García, Silvia Laura Fernández, (HIGA San Martín de La Plata - Buenos Aires, Argentina). Olga Zulema Tejerina, Cristian Efrain Tejerina, Dalma Fabian, Aylén Gutierrez, Julián Vercellone, Susana Noemi Tejerina, (Hospital Pablo Soria - Jujuy, Argentina). Viviana Chediack, María Julieta Ochoa, Cintia Hernaiz, Cecilia Domínguez, (Hospital Muñiz - CABA, Argentina). Alicia Sirino, Cecilia del Valle Barrios, Ana Valeria Lugo, Flavia Nitto, Fernando Luna, (Hospital Pirovano – CABA, Argentina). Laura Valeria Aldana, María Fernanda Formiga Fresser, (Hospital Francisco López Lima - Río Negro, Argentina). Ainoa Echegoyen, Nelson Linares, (Hospital Castro Rendón – Neuquén, Argentina). Luciano Inowlocki Calejman, Mariana Casas Alvarez, Johnny Rodríguez Galán, Graciela Farfan, Luz Torrico García, (Hospital Rivadavia - CABA, Argentina). Eva Rodríguez Caicedo, Verónica Bortoli, Eliseo Velasquez Chambi, Vanesa Arce Villanueva, Eduardo Zamora Mendizabal, Gustavo Figueroa Ojeda, Ángeles Rodríguez Altamirano, Ytala Talamas Hurtado, (Hospital Simplemente Evita - Buenos Aires, Argentina). Carlos Gustavo Ruiz Pulgar, Edson Gozales Aguilar, Carla Daniela Bautista Numbela, Lilia Elisa Müller, Virginia Soledad Quiroga, (Hospital Evita de Lanús - Buenos Aires, Argentina).
Contributors FJ-B had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, also is responsible for the overall content as guarantor. FJ-B conducted the study as data and implementation coordinator planned, reported and submitted the study for publication. CIL, WC and VR conducted the study as subject matter experts, planned and reported the study. JR conducted the formative research as coordinator, planned and reported the study. EG-E planned and reported the study. LG and EV conducted the study as data experts and reported the study. APR and MG conducted the study as data coordinators and reported the study. PA-L and MER conducted the study as data coordinators. IS-A, ML, CM and VMR conducted the study as coaching for improvement. CB, LC, EC, PRJC, GI, CO, FP, MR and PRV conducted the study as centre coordinators. Natalí Ini and Juan Pedro Alonso conducted the formative research as interviewers. People in the COST Collaborative group conducted the study as data collectors or facilitators of implementation.
Funding This study was funded by Pfizer Foundation (PFIZER COMPETITIVE GRANT PROGRAM ID: 68339261).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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