Impact of an antibiotic checklist on antibiotic prescription in an adult medical intensive care unit: a before-after study

The increase in antimicrobial resistance is a major public health concern. Antimicrobial stewardship (AMS) programs are being developed to manage this situation. Among them, checklists are an interesting tool for use in Intensive Care Unit (ICU). This study aimed to assess the impact of an antibiotic checklist on antibiotic prescription in an adult medical ICU. This prospective before-after study, approved by our local research ethics committee ( Commission de qualification des projets de recherche) , enrolled adult patients with infectious episodes who received antibiotic therapy for more than 48 hours in the adult medical ICU of Rouen University Hospital (France). Two periods were compared: before (June 2020 to February 2021) and after (June 2021 to February 2022) implementation of a daily paper antibiotic checklist. During the intervention period, only patients for whom the checklist had been initiated were included. The primary outcome was the rate of appropriate antibiotic therapy, a composite of four criteria: guideline-concordant choice of empirical molecules, appropriate antibiotic dose, appropriate antibiotic re-evaluation and guideline-concordant antibiotic duration. Secondary outcomes included appropriate antibiotic dose, guideline-concordant antibiotic duration, therapeutic drug monitoring (TDM), ICU mortality, ICU length of stay (LOS), and ICU antibiotic consumption and costs. Overall, 385 infectious episodes were analyzed in 347 patients. The main reason for ICU hospitalization was respiratory failure. The checklist completion rate during the intervention period was 51%. No difference was observed in the rate of appropriate antibiotic therapy between the baseline and the intervention periods (23% versus 22%, p = 0.9). Statistically significant differences were observed in appropriate antibiotic dose (81% versus 91%, p = 0.006), guideline-concordant antibiotic duration (59% versus 69%, p = 0.037) and TDM (31% versus 49%, p < 0.001), but not in ICU mortality (19% versus 27%, p = 0.062) or ICU LOS (8 days [5–18] versus 11 days [6–28], p = 0.063). ICU antibiotic consumption (1,350 versus 1,271 Daily Defined Doses/1,000 patient-days) and costs (€22 versus €18 per patient-days) decreased after checklist implementation. In this study, an antibiotic checklist in an adult medical ICU was associated with improvements in antibiotic prescription quality markers and decreased antibiotic costs suggesting that it could be used to improve AMS in ICU.