A Practical Approach to Clinical Antibiotic Stewardship in the ICU Patient With Severe Infection

Jan Fierens, MD; Pieter O. Depuydt, MD, PhD; Jan J. De Waele, MD, PhD


Semin Respir Crit Care Med. 2019;40(4):435-446. 

In This Article

Clinical Decision Support Systems are Useful Adjuncts in ASP

Monitoring is one of the most important features in hospital ASP.[72] As the ICU is a data-driven location, where the integration of clinical parameters and examination, microbiological and radiological data, and medication prescriptions is daily practiced, information technology, data science, and the use of clinical decision support systems (CDSS) create new opportunities to support daily decisions in this data-rich environment.[128] These systems allow day-to-day individual antibiotic tracking, allowing clinicians to answer several questions during the daily routine: what was the chosen therapy? Are there cultures? Why is it changed, etc.? CDSS can also facilitate the implementation of the ATO. The system can alert the clinician or the ASP team when cultures become available or when 72 hours after an antibiotic prescription has passed. It also allows for a collective audit, enabling feedback both to the individual prescriber and on an ICU-wide level. A recent Cochrane review illustrated that these feedbacked interventions are more effective in creating effective ASP interventions.[129] Ushering in antibiotic behavioral changes initially requires a definition of adequate antibiotic use and measurements of current antibiotic use.[130] Several electronic surveillance systems have been developed to integrate resistance data, rate of nosocomial infection, quantity and quality of antibiotic usage.[131–133] These longitudinal data collections are not only a time-consuming job, but also require adequate insight to analyze, interpret, and formulate conclusions and possible working points. Fortunately, evidence has shown that this kind of analysis is capable of investigating prescription patterns and subsequent formulation of ASP goals.[134] Literature evaluating the effect of CDSS on patient outcomes in the ICU is rather limited (Table 2). While it seems logical that implementation of these systems, both in daily workflow and prospective long-term feedback, will enhance ASP, technological and financial hurdles need to be overcome before CDSS will gain widespread acceptance. This role will be particularly relevant in the patient with severe infections, where antibiotic prescriptions can be complex and an integration of all available information may be of particular value.