Shaun Johnson is a Medical Student at Case Western Reserve University School of Medicine in Cleveland, Ohio. Steven Waisbren is a Surgeon and Assistant Service Chief at the Minneapolis Veterans Affairs Health Care System in Minnesota and an Assistant Professor of Surgery at the University of Minnesota. Correspondence: Steven Waisbren (steven.waisbren@va.gov)
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
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Another finding within this investigation was the statistically significantly shorter response mean (SD) time when deescalating in response to pathogen identification (8 [7.3] h) than to sensitivity profile (10.4 [7] h). Overall when deescalating, the time of each individual response to antibiotic changes was highly irregular. There was no noticeable time point where a change was more likely to occur within the 24 hours after notification of a culture result. This erratic distribution further exemplifies the complexity of deescalation as it underscores the unique nature of each case. The timing of the dosage of previous antibiotics, the health status of the patient, and the individual physician attitudes about the progression and severity of the infection all likely played into this distribution.
Due to the lack of a regular or even skewed distribution, a Wilcoxon nonparametric rank sum test was performed (P = .049). Although this result was statistically significant, the 2.5-hour time difference is likely clinically irrelevant as both times represent fairly prompt physician responsiveness.50 Nonetheless, it suggests that it was more important to rapidly escalate the breadth of coverage for a patient with a positive blood culture than to deescalate as identified pathogens may have been left untreated with the prescribed antibiotic.
Future Study
Similar studies designed using the spectrum score methodology would allow for more meaningful interinstitutional comparison of antibiotic administration through the use of a unified definition of deescalation and escalation. Comparison of deescalation and escalation rates between hospital systems with similar patient populations with and without prompt infectious disease review and phone notification of blood culture results could further verify the value of such a protocol. It could also help determine which empiric antibiotics may be most effective in individual patient morbidity and mortality outcomes, length of stay, costs, and the development of antibiotic resistance. Chou and colleagues found that only 49 of 130 responding VA facilities had antimicrobial stewardship teams in place with even fewer (29) having a formal policy to establish an antimicrobial stewardship program.11 This significant variation in the practices of VA facilities across the nation underscores the benefit to be gained from implementation of value-added protocols such as daily infectious disease case monitoring and microbiology laboratory phone notification of positive blood culture results as it occurs at MVAMC.
They also noted that systems of patient-level antibiotic review, and the presence of at least one full-time infectious disease physician were both associated with a statistically significant decrease in the use of antimicrobials, corroborating the results of this analysis.11 Adapting the current system of infectious disease specialist review of positive blood culture results to use remote monitoring through the EHR could help to defer some of the cost of needing an in-house specialist while retaining the benefit of the oversite.
Another option for study would be a before and after design to determine whether the program of infectious disease specialist review led to increased use of deescalation strategies similar to studies investigating the efficacy of antimicrobial subcommittee implementation.13,20,23,24,26
Conclusions
This analysis of empiric antibiotic use at the MVAMC indicates promising rates of deescalation. The results indicate that the medical service may be right and that positive blood culture results appear to affect clinical decision making in an appropriate and timely fashion. The VAis the largest health care organization in the US. Thus, identifying and propagating effective stewardship practices on a widespread basis can have a significant effect on the public health of the nation.
These data suggest that the program implemented at the MVAMC of phone notification to the primary care team along with daily infectious disease staff monitoring of blood culture information should be widely adopted at sister institutions using either in-house or remote specialist review.
