Use of evidence-based recommendations in an antibiotic care bundle for the intensive care unit

Mutters NT, De Angelis G, Restuccia G, Di Muzio F, Schouten J, Hulscher M, Antonelli M, Tacconelli E.

Int J Antimicrob Agents. 2018 Jan;51(1):65-70. doi: 10.1016/j.ijantimicag.2017.06.020., 01/2018.

Purpose: To  drive decisions on antibiotic therapy in the intensive care unit (ICU),  we developed an antibiotic care bundle (ABC-Bundle) with evidence-based  recommendations (EBRs) for antibiotic prescriptions.

Methods: We  conducted a three-step prospective study. First, a systematic review  was performed of the literature reporting EBRs for antibiotic usage in  the ICU. Second, we developed an ABC-Bundle through a two-round,  RAND-modified Delphi method with an international expert panel,  including the most relevant EBRs on a 9-point Likert scale. Those EBRs  that were considered mandatory by >50% of the experts were included  in the bundle. Third, we assessed the adherence to and applicability of  the bundle in two mixed university ICUs.

Results: Out  of 1190 potentially relevant articles, 14 (four guidelines, four  randomised controlled trials and six systematic reviews) fulfilled the  eligibility criteria. Six EBRs were classified as relevant: 1. Provide  rationale for antibiotic start; 2. Perform appropriate microbiological  sampling; 3. Prescribe empirical antibiotic therapy according to  guidelines (Day 1); 4. Review diagnosis; 5. Evaluate de-escalation based  on microbiological results (Days 2-5); and 6. Consider discontinuation  of treatment (Days 3-5). Daily adherence to the ABC-Bundle,  prospectively assessed in 861 days of therapy in 142 ICU patients,  ranged from 2% to 37%.

Conclusion: The ABC-Bundle  is a novel tool to improve delivery of appropriate antibiotic therapy  to ICU patients. The low adherence in the prospective cohorts confirms  the significant role that the ABC-Bundle could play in an antibiotic  stewardship programme in the ICU setting.

Keywords: Antibiotic prescription; Antimicrobial resistance; Antimicrobial therapy; Care bundle; ICU; Infectious diseases.