Infection Control & Hospital Epidemiology (2019), 40, 491–499 doi:10.1017/ice.2019.34
Letter to the Editor
Reduction in antimicrobial use among medical intensive care unit patients during a cluster randomized crossover trial of palliative care consultation
Jason P. Burnham MD1 — , Stephen Chi MD2, Jessica Ma MD3, Maria C. Dans MD4 and Marin H. Kollef MD5
1Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, 2Department of Medicine, Washington University School of Medicine, St Louis, Missouri, 3Department of Medicine, Duke University and Health System, Durham, North Carolina, 4Department of Palliative Care, Barnes-Jewish Hospital, St Louis, Missouri and 5Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri
To the Editor Intensive care units (ICUs) are one of the largest
consumers of antimicrobials, with >70% of patients of receiving antimicrobials on a given day.1 With the continuing emergence of difficult to treat, costly, and deadly multidrug-resistant patho- gens, antimicrobial stewardship strategies to reduce antimicrobial use are urgently needed.2,3 Patients at the end of life are often cared for in ICUs and frequently receive antimicrobials4 with uncertain benefits.5 We recently conducted a cluster randomized crossover trial of
early palliative care consultation in our medical ICUs,6 with the goal of determining the impact of early palliative care interventions on outcomes of medical ICU patients. The purpose of the current investigation was to determine whether palliative-care consulta- tion in our medical ICU resulted in reduced antimicrobial use at the end of life.
Methods
The details of the trial have recently been described.6 Briefly, the trial was a single-center cluster randomized crossover trial (August 2017– May 2018) at Barnes-Jewish Hospital (1,250 beds). The study included a 6-week washout period halfway through the study, fol- lowed by crossing over to intervention or usual care of the 2medical ICUs. The Washington University School of Medicine Human Studies Committee approved this investigation, and the need for informed consent was waived (Institutional Review Board no. 201707067;
ClinicalTrials.gov Identifier:NCT03263143).All patients admitted on weekdays that were ≥18 years of age and at high risk for morbidity and mortality based on predetermined palliative- care screening criteria could be enrolled as long as they did not meet exclusion criteria.6 Patients in the intervention arm received palliative-care consultation within 48 hours of ICU admission, and the control arm received standard of care with palliative-care consultation at the discretion of the treating physicians. Collected data included sociodemographic data; medical co-
morbidities; laboratory results; changes in resuscitation preferences; length of stay; duration and use of mechanical ventilation,
Authors for correspondence: Jason P. Burnham or Marin H. Kollef, Email address:
burnham@wustl.edu,
kollefm@wustl.edu Cite this article:BurnhamJP, et al. (2019). Reduction in antimicrobial useamongmedical
intensive care unit patients during a cluster randomized crossover trial of palliative care consultation. Infection Control & Hospital Epidemiology, 40: 491–492,
https://doi.org/ 10.1017/ice.2019.34
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
vasopressors, and antimicrobials; place of discharge; mortality dur- ing the hospital stay; and antimicrobial prescriptions at discharge. Days of antimicrobial therapy were calculated by adding the total number of calendar days of each administered antimicrobial agent. Only antimicrobials with antibacterial properties were considered. The primary outcome of the current investigation was the pro-
portion of patients receiving antimicrobial prescriptions at hospital discharge among those who did and did not change their resusci- tation preference. Our secondary outcomes were total duration of inpatient and outpatient antimicrobials. We compared discharge on antimicrobials between groups using the χ2 test and duration of inpatient antimicrobials using the Mann-Whitney U test. All statistical analyses were performed using SPSS version 25 software (IBM, Armonk, NY).
Results
In the original trial, 242 patients were enrolled, but only 199 were eligible for the primary outcome.6 Of these patients, only 132 survived to hospital discharge and had not been on suppressive antimicrobials or active treatment for a previous infection at the time of hospital admission. Of 132 patients, 36 patients (27.3%) changed their code status to do not resuscitate/do not intubate. Of the patients that changed their code status, 6 (16.7%) were discharged on antibiotics compared to 36 patients (37.5%) that did not change their code status. For the 23 patients discharged alive to hospice, none was discharged on antimicrobials. The proportion of patients discharged on antimicrobials was
significantly lower among those having a change in code status (P = .022) (Table 1). Of the 132 patients, 116 (87.9%) either died within 30 days of hospital discharge or had at least 30 days of avail- able follow-up data. From these 116 patients, there was no signifi- cant difference in the proportion discharged on antimicrobials between those that died within 30 days and those that did not (P = .14). Among the cohort of 132 patients, the median total duration of antimicrobial therapy (inpatient plus outpatient) was significantly different (P = .044) between the group that changed their code status and those that did not (Table 1). The median duration of in- patient antimicrobials was not statistically different between those that did and did not change their code status (Table 1). Patients discharged on hospice (n = 23) had significantly (P = .018) shorter durations of inpatient antimicrobial therapy (median, 5 days;
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