SAN DIEGO – A “time-out” to review antibiotic therapy 72-96 hours into treatment increased appropriate discontinuations of vancomycin by 31%, researchers said at an annual scientific meeting on infectious diseases.
The practice fit into hospital work flow, streamlined other antibiotic stewardship practices, and respected provider autonomy, said Dr. Christopher Graber of VA Greater Los Angeles Healthcare System and the University of California, Los Angeles. It also was durable, persisting into the second 6 months of the program even though active research support had ended, he and his associates said.
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The Centers for Disease Control and Prevention endorses the antibiotic time-out as a way to encourage providers to switch from empirical treatment with broad-spectrum antibiotics to a more tailored plan after culture and other laboratory results become available. The Veterans Affairs teaching hospital in greater Los Angeles created a self-directed time-out program to encourage reconsideration of broad-spectrum therapy with vancomycin and piperacillin-tazobactam after the first 3 days of empirical treatment. The program included an antimicrobial “dashboard” report, an electronic template to document time-outs, and a marketing program consisting of educational documents, lectures, “clinical champions,” and reminder notes and fliers posted near computers.
To evaluate early and late responses to the program, Dr. Graber and his associates tracked discontinuations of vancomycin and piperacillin-tazobactam, as well as decisions to continue these antibiotics through day 5 when doing so contradicted guidelines. Among 276 vancomycin episodes during the program, clinicians discontinued 175 (63%) – significantly more than before the program started (96 of 199; 48%; P = .001). They documented vancomycin time-outs 46% of the time, continued patients on vancomycin through day 5 without a time-out in 7.6% of cases, and allowed vancomycin to expire without a time-out 46% of the time.
The rate of inappropriate discontinuations of vancomycin during the program exceeded baseline (4.7% vs. none; P = .001), but this trend was balanced out by the overall rise in vancomycin discontinuations, the researchers said. Furthermore, providers documented vancomycin time-outs more often during the second 6 months, compared with the first (54% vs. 37%; P = .005). The increase in vancomycin discontinuations also was durable (about 63% throughout the two 6-month periods), and inappropriate continuations remained stable at about 4.5%.
“Piperacillin-tazobactam did not see any change in discontinuations between the two study periods,” said the researchers. The discontinuation rate was about 62% before and during the program. Clinicians performed time-outs about half the time, and inappropriately continued the antibiotics beyond day 5 in 10% of cases, compared with 2% before the program started (P = .02). Clinicians continued performing piperacillin-tazobactam time-outs at the same rate in the second 6 months of the program as during the beginning, and rates of discontinuation and inappropriate continuations also remained similar.
The investigators reported these results at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
CDC funded the research with a grant to the University of Utah. The researchers reported no conflicts of interest.