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Audit and feedback does not increase ICU mortality

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July 7, 2018

Photo of Matthew P. Muller, 2018
Matthew P. Muller

Audit and feedback as part of antimicrobial stewardship programs has no impact on mortality rates in the ICU and can be safely implemented in this setting, according findings from a systematic review and meta-analysis published in Clinical Infectious Diseases.

“The best available data does not suggest that antimicrobial stewardship, in the form of audit and feedback, significantly increases or decreases mortality in the ICU setting,” Matthew P. Muller, MD, PhD, FRCPC, associate professor in the department of medicine at the University of Toronto and medical director for infection prevention and control at St. Michael's Hospital, told Infectious Disease News. “As with many systematic reviews, there are some important limitations of the data that we used and future studies should continue to look at mortality as an outcome and attempt to generate better data on how antimicrobial stewardship may impact mortality, in either a positive or negative direction.”

According to Muller and colleagues, antibiotic overuse in ICUs can lead to adverse drug events, increased Clostridium difficile infection risk, antimicrobial resistance and organ-specific injury. Antimicrobial stewardship — in particular, prospective audit and feedback — “has been recommended as a strategy to reduce inappropriate antibiotic use, prevent antibiotic-related adverse events, and improve patient outcomes and has been associated with reduced antibiotic usage in randomized controlled trials,” they wrote.

The primary outcome in most studies about antimicrobial stewardship programs is a change in antibiotic use, with mortality rates often reported as a secondary outcome, Muller and colleagues noted. For their study, they reviewed 2,447 citations and found 11 that evaluated a prospective audit and feedback antimicrobial stewardship program intervention and reported any measure of mortality for all patients in the ICU or for the subset of patients reviewed by the program. Audit and feedback interventions were defined as ICU clinical teams receiving written or oral recommendations on patient patient-specific antimicrobial use by antimicrobial stewardship program experts on a regular basis.

They analyzed mortality using an uncontrolled before-and-after study design for all 11 studies, but a variety of study designs assessed the rate of reduction in antibiotic use.

In five studies, Muller and colleagues observed that audit and feedback was directed at all or most ICU patients on antibiotics. Moreover, these five studies also measured overall ICU mortality. According to a meta-analysis of the studies, the pooled RR of ICU mortality was 1.03 (95% CI, 0.93-1.14). A second meta-analysis on three smaller studies that evaluated mortality solely in patients assessed by the antimicrobial stewardship program showed a pooled RR of ICU mortality of 1.06 (95% CI, 0.80-1.4), according to Muller and colleagues. In the three remaining studies, meta-analysis was not feasible, but Muller and colleagues reported that their results were consistent with the overall findings.

They said their findings “provide the strongest evidence to date that implementing audit and feedback in the ICU setting does not increase patient mortality.”

“ID physicians should continue to actively engage in antimicrobial stewardship and should work toward ensuring that all patients receive antibiotics appropriately. The potential benefits in terms of reduced adverse events, reduced C. difficile infection and reduced antimicrobial resistance are extremely important,” Muller said. – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

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