Literature Update - October 2009
Compiled by Dr Leon Worth, ID Physician
Experience of using an Antimicrobial Utilisation Program for Improving Antimicrobial Prescribing
A range of approaches to reduce the development of antimicrobial resistance in healthcare facilities have been reported –
hospital formulary restriction of antimicrobials, development of prescribing guidelines, and education of physicians. Another
important mechanism for improving antimicrobial usage is the establishment of multidisciplinary antimicrobial utilisation teams
(AUT), including clinicians, pharmacy and microbiology personnel. Camins BC et al (Infect Control
Hosp Epidemiol 2009; 30:931-938) performed a randomised controlled trial comparing indication-based antimicrobial prescribing
guidelines (standard of care) with AUT review at a single-centre.
The study centre was comprised of 12 internal medical teams, responsible for delivery of general medical care but not ICU
services to inpatients. An AUT was established, comprised of an ID physician, and an ID clinical pharmacist who worked closely
with microbiology personnel. For each month during the 10 month study period (October 2002 – July 2003), 6 internal medicine
teams were randomly assigned to the intervention arm and 6 teams were assigned to the control group. Prescribing physicians
belonging to teams in the intervention arm received structured feedback on the appropriateness of antimicrobial use (short
phone conversation or face-to-face meeting). Each antimicrobial prescription for levofloxacin, piperacillin-tazobactam and
vancomycin was assessed by blinded review by the director of the AUT to determine 'appropriateness'.
In total, 784 new prescriptions were reviewed during the study period. Initial antimicrobial use was appropriate in 78% of
cases in the intervention group, compared to 58% for the control group (p < 0.001). In addition,
empirical and definitive antimicrobial use were also significantly more likely to be appropriate in the intervention arm
compared with the control group (82% compared with 73% (p = 0.0.005) and 82% compared with 43%
(p < 0.001), respectively). End antimicrobial usage was deemed appropriate in 94% of prescriptions
in the intervention group, compared to 70% of prescriptions in the control arm. Multivariate analysis identified AUT
intervention and ID consultation to be independent predictors for appropriate end antimicrobial use.
These findings support the establishment of multidisciplinary AUTs for improving antimicrobial use. Future studies are required
to examine the impact of this intervention upon the development of drug resistance, and to what degree this intervention will
influence outcomes in healthcare facilities with existing ID consulting services.
Simulation-based Education of Hospital Medical Officers can Reduce Catheter-related Bloodstream Infections in ICU
Simulation-based education has been used to improve procedural competence for central venous catheter (CVC) insertion. The effect
of simulation-based education in CVC insertion on the incidence of catheter-related bloodstream infection (CRBSI) has not
previously been evaluated. Barsuk JH et al (Arch Intern Med 2009; 169:1420-1423) performed a
single-centre observational education cohort study of second- and third-year hospital medical officers to determine the
impact of simulation-based training in CVC insertion on CRBSI rates.
The educational module included a one hour videotaped lecture on the technique, indications, contraindications and complications
of CVC insertion, emphasising evidence-based guidelines for CRBSI reduction – hand washing, full sterile barrier technique,
chlorhexidine skin asepsis, avoidance of the femoral site and removal of unnecessary CVCs. Pre- and post-intervention CRBSI
rates were determined, and rates in a comparison ICU (same hospital, without intervention) were also determined to exclude a
hospital-wide effect.
Over the period December 2006 to March 2008, 92 residents completed the simulation-based learning program in CVC insertion
skills. In the pre-intervention period, the rate of CRBSI was 3.2 per 1000 CVC days. Following the intervention, the CRBSI rate
fell to 0.50 per 1000 CVC days (p = 0.001). In the comparison ICU, rates were 4.86 and 5.26 per
1000 CVC days for the equivalent periods, suggesting that a hospital-wide reduction in infection was not responsible.
Outcomes of this study suggest that an educational intervention in CVC insertion can significantly improve patient outcomes –
in this instance, components of previously described 'bundle' interventions for CRBSI reduction were used as the basis for
the educational content. From a practical standpoint, the rotating nature of ICU staff and requirement for allocated time to
complete the module may limit the widespread uptake of this and similar initiatives.