Addressing the aftermath of the COVID-19 pandemic: A quality improvement collaborative to optimize the use of antibacterials in Argentine Intensive Care Units
Authors: Jorro-Barón Facundo , Loudet Cecilia , Cornistein Wanda , Suárez-Anzorena Inés , Arias-López Pilar , Balasini Carina , Cabana Laura , Cunto Eleonora , Corral Rodrigo , Gibbons Luz , Guglielmino Marina , Izzo Gabriela , Lescano Marianela , Meregalli Claudia , Orlandi Cristina , Perre Fernando , Ratto María Elena , Rivet Mariano , Rodríguez Ana Paula , Rodríguez Viviana M. , Villegas Paula Romina , Vitar Emilse , Roberti Javier , García-Elorrio Ezequiel , Rodriguez Viviana E. 
Published: December 2023

Background

Reducing antimicrobial resistance is a global priority that become even more important after the COVID-19 pandemic. To date there is a scarce volume of evidence from antimicrobial stewardship programs from less resourced settings where this phenomenon is bigger. Our aim was to improve the quality of antibacterials prescription in intensive care units (ICUs) in a middle-income country.

Methods

We established a quality improvement collaborative (QIC) model involving nine ICUs over an 11-month period, with a 16-week baseline (BP) and 32-week Intervention (IP) periods. Our co-designed intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions, and education. The intervention was delivered in two learning sessions with three action periods, along with coaching support and basic quality improvement training.

Results

We enrolled 912 patients, with 357 in baseline period (BP) and 555 in implementation period (IP). The latter had higher APACHE II (17 (12, 21) vs. 15 (11, 20); p=0.036) and SOFA scores (6 (4, 9) vs. 5 (3, 8); p=0.006), sepsis (36.1% vs. 31.6%, p<0.001), and septic shock (40.0% vs. 33.8%, p<0.001). Days of antibacterial therapy were similar between groups (IP 1112.2, BP 1133.4, RR 0.98 (0.95-1.02); p=0.2973) and the antibacterial Daily Define Dose was lower in IP group (IP, 1193.0; BP, 1301.0; RR, 0.92 (0.89, 0.95); p=0.0001). The rate of adequate antibacterial adjustment was higher during the IP (62.0% vs. 45.3%, p<0.001). We observed a lower rate of ventilation-associated pneumonia and catheter-associated urinary tract infections related to multidrug-resistant organisms (MDRO) in the IP. There was a noticeable improvement in the Infection Prevention and Control (IPC) Assessment Framework compared to baseline.

Conclusion

The implementation of a post pandemic antimicrobial stewardship program in ICUs via a QIC demonstrated success in improving antibacterials utilization, reducing HAIs related to MDRO while also enhancing IPC measures.

What is already known on this topic

Healthcare-associated infections represent a global healthcare issue, particularly prevalent in low- and middle-income countries, where their occurrence is nearly three times higher.

Approximately 50% of antimicrobial use is deemed unnecessary or inappropriate, necessitating the development of widely accessible stewardship methods.

The misuse and overuse of antibacterials adversely affect patients admitted to intensive care units (ICUs).

Further research is urgently required to determine the most effective ways to implement ASPs in LMICs.

What this study adds

By establishing a quality improvement collaborative (QIC), we showcased an improvement in antibacterial utilization within ICUs in a low- to middle-income country.

Additionally, a reduction in healthcare-associated infections is evident.

Moreover, the QIC effectively strengthened the capabilities of infection control and prevention in participating ICUs.

How this study might affect research, practice, or policy

This study is among the initial endeavors in a middle-income country to evaluate the efficacy and essential strategies for establishing antimicrobial stewardship programs.

This study could serve as a foundational reference for upcoming teams aiming to introduce similar programs in the region.