Skip to main content Accessibility help

Audit and Feedback to Reduce Broad-Spectrum Antibiotic Use among Intensive Care Unit Patients A Controlled Interrupted Time Series Analysis

  • Marion Elligsen (a1), Sandra A. N. Walker (a1) (a2) (a3), Ruxandra Pinto (a4), Andrew Simor (a3) (a5), Samira Mubareka (a4) (a3) (a5), Anita Rachlis (a3) (a5), Vanessa Allen (a3) (a5) (a6) and Nick Daneman (a4) (a3) (a5) (a7)...



We aimed to rigorously evaluate the impact of prospective audit and feedback on broad-spectrum antimicrobial use among critical care patients.


Prospective, controlled interrupted time series.


Single tertiary care center with 3 intensive care units.

Patients and Interventions.

A formal review of all critical care patients on their third or tenth day of broad-spectrum antibiotic therapy was conducted, and suggestions for antimicrobial optimization were communicated to the critical care team.


The primary outcome was broad-spectrum antibiotic use (days of therapy per 1000 patient-days; secondary outcomes included overall antibiotic use, gram-negative bacterial susceptibility, nosocomial Clostridium difficile infections, length of stay, and mortality.


The mean monthly broad-spectrum antibiotic use decreased from 644 days of therapy per 1,000 patient-days in the preintervention period to 503 days of therapy per 1,000 patient-days in the postintervention period (P < .0001); time series modeling confirmed an immediate decrease (± standard error) of 119 ± 37.9 days of therapy per 1,000 patient-days (P = .0054). In contrast, no changes were identified in the use of broad-spectrum antibiotics in the control group (nonintervention medical and surgical wards) or in the use of control medications in critical care (stress ulcer prophylaxis). The incidence of nosocomial C. difficile infections decreased from 11 to 6 cases in the study intensive care units, whereas the incidence increased from 87 to 116 cases in the control wards (P = .04). Overall gram-negative susceptibility to meropenem increased in the critical care units. Intensive care unit length of stay and mortality did not change.


Institution of a formal prospective audit and feedback program appears to be a safe and effective means to improve broad-spectrum antimicrobial use in critical care.


Corresponding author

Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 2M5, Canada (


Hide All
1. Pakyz, AL, MacDougall, C, Oinonen, M, Polk, RE. Trends in antibacterial use in US academic health centers: 2002 to 2006. Arch Intern Med 2008;168:22542260.
2. Ansari, F, Erntell, M, Goossens, H, Davey, P. The European surveillance of antimicrobial consumption (ESAC) point-prevalence survey of antibacterial use in 20 European hospitals in 2006. Clin Infect Dis 2009;49:14961504.
3. Hecker, MT, Aron, DC, Patel, NP, Lehmann, MK, Donskey, CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003;163:972978.
4. Dellit, TH, Owens, RC, McGowan, JE Jr., et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159177.
5. Gould, LM. Minimum antibiotic stewardship measures. Clin Microbiol 2001;7(suppl 6):2226.
6. Lawrence, KL, Kollef, MH. Antimicrobial stewardship in the intensive care unit: advances and obstacles. Am J Respir Crit Care Med 2009;179:434438.
7. Brown, EM, Nathwani, D. Antibiotic cycling or rotation: a systematic review of the evidence of efficacy. J Anrimicrob Chemother 2005;55:69.
8. Vincent, JL, Relio, J, Marshall, J, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009;302:23232329.
9. Kaki, R, Elligsen, M, Walker, S, Simor, A, Palmay, L, Daneman, N. Impact of antimicrobial stewardship in critical care: a systematic review. J Antimicrob Chemother 2011;66:12231230.
10. Fan, E, Laupacis, A, Pronovost, PJ, Guyatt, GH, Needham, DM. How to use an article about quality improvement. JAMA 2010; 304:22792287.
11. Polk, RE, Fox, C, Mahoney, A, Letcavage, J, MacDougall, C. Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis 2007;44:664670.
12. Anderson, DJ, Kaye, KS, Classen, D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51S61.
13. Hussey, MA, Hughes, JP. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials 2007;28:182191.
14. Gibbs, L, Kakis, A, Weinstein, P, Conte, JE Jr. Bone wax as a risk factor for surgical-site infection following neurospinal surgery. Infect Control Hosp Epidemiol 2004;25:346348.
15. Geissler, A, Gerbeaux, P, Granier, I, Blanc, P, Facon, K, Durand-Gasselin, J. Rational use of antibiotics in the intensive care unit: impact on microbial resistance and costs. Intensive Care Med 2003;29:4954.
16. Marra, AR, de Almeida, SM, Correa, L, et al. The effect of limiting antimicrobial therapy duration on antimicrobial resistance in the critical care setting. Am J Infect Control 2009;37:204209.
17. Brahmi, N, Biel, Y, Kouraichi, N, Ben, HR, Thabet, H, Amamou, M. Impact of antibiotic use and prescribing policy in a Tunisian intensive care unit [in French]. Med Mai Infect 2006;36:460465.
18. Starr, JM, Campbell, A, Renshaw, E, Poxton, IR, Gibson, GJ. Spatio-temporal stochastic modelling of Clostridium difficile . J Hosp Infect 2009;71:4956.
19. Valiquette, L, Cossette, B, Garant, MP, Diab, H, Pepin, J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007; 45(suppl 2):S112S121.
20. Ntagiopoulos, PG, Paramythiotou, E, Antoniadou, A, Giamarellou, H, Karabinis, A. Impact of an antibiotic restriction policy on the antibiotic resistance patterns of gram-negative microorganisms in an intensive care unit in Greece. Int J Antimicrob Agents 2007; 30:360365.
21. Brahmi, N, Biel, Y, Kouraichi, N, et al. Impact of ceftazidime restriction on gram-negative bacterial resistance in an intensive care unit. J Infect Chemother 2006;12:190194.
22. Elligsen, M, Walker, S, Simor, A, Daneman, N. Antimicrobial prospective-audit and feedback in critical care: program implementation, experience and challenges. Can J Hosp Pharm (forthcoming).

Audit and Feedback to Reduce Broad-Spectrum Antibiotic Use among Intensive Care Unit Patients A Controlled Interrupted Time Series Analysis

  • Marion Elligsen (a1), Sandra A. N. Walker (a1) (a2) (a3), Ruxandra Pinto (a4), Andrew Simor (a3) (a5), Samira Mubareka (a4) (a3) (a5), Anita Rachlis (a3) (a5), Vanessa Allen (a3) (a5) (a6) and Nick Daneman (a4) (a3) (a5) (a7)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed