In this episode, I’ll discuss an opt-out protocol for antibiotic de-escalation.
Current guidelines for sepsis recommend a daily review of antibiotic therapy to de-escalate or discontinue antibiotics when appropriate. This however is an opt-in process that requires the provider to either make the assessment or for a different healthcare discipline such as a pharmacist to make a recommendation and obtain provider agreement. With an opt-in process, it is reasonable to expect some inefficiencies such as the provider or pharmacist not performing the daily review of antibiotic therapy for de-escalation.
Therefore a group of researchers examined the effects of an opt-out Antibiotic De-escalation in Patients with Suspected Sepsis in the form of a multicenter randomized controlled trial.
This was a randomized multi-center trial at 10 US hospitals, and just under 800 patients were enrolled and randomized to the opt-out protocol vs. usual care.
The primary outcome was 30-day post-enrollment antibacterial days of therapy (DOT). The providers for patients in the intervention group were contacted about de-escalation using opt-out language, and if antibiotics were continued, clinicians were asked to discuss their rationale for continuing antibiotics in addition to a de-escalation plan.
Patients who received the intervention had 32% lower odds of antibiotic continuation, however, the days of antibiotic therapy were similar between groups when counting only the interventions patients who did not have antibiotics stopped. There was less exposure to broad-spectrum therapy in the intervention group with only 36% of patients receiving broad-spectrum antibiotics vs 44% in the control group.
The authors concluded:
An antibiotic opt-out protocol targeting patients with suspected sepsis resulted in more antibiotic discontinuations, similar DOT when antibiotics were continued, and no evidence of harm.
Using opt-out strategies for antibiotic stewardship represents a novel approach and one that is effective in increasing the number of patients who have antibiotics discontinued. However, this strategy is likely to apply to only a very small proportion of the patients that need antibiotic stewardship efforts. For example, in this study, there was a 23-point safety screen that had to be performed to identify patients that did not have ongoing signs of systemic infection, concerning or inadequate microbiologic data or high-risk conditions. 9606 patients needed to be screened to come up with the group of 767 patients involved in the study, suggesting that if this were to be implemented in a real-world setting over 90% of patients would not qualify.
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