Antibiotic time-out as an effective antimicrobial stewardship strategy: reduced duration, preserved clinical outcomes

Abstract

Background. Prolonged antibiotic therapy remains common, despite shorter guideline durations. Overexposure to antibiotics has reported negative impacts in patients, such as an increase in resistant, invasive fungal infections and mortality. Given the issue, the WHO has recommended the implementation of antimicrobial stewardship programs (ASPs) that provide for re-evaluation of the efficacy, routes of administration, and spectrum of action after 48-72 hours. We evaluated antibiotic time-out intervention impact on antibiotic use and clinical outcomes. Materials and Methods. Conducted a pre-poststudy including 4236 antibiotic courses. The primary outcome: median days of therapy (DOT) per course. Secondary outcomes: proportion of guideline-exceeding courses, rates of de-escalation/ discontinuation, broad-spectrum antibiotic use, C.difficile incidence, and clinical outcomes. Results. Median DOT decreased by 25%, from 8.0 to 6.0 days (95% CI −2.3 to −1.7; P<0.001). Guideline-exceeding courses declined from 42% to 26% (RR 0.62; P<0.001), driven by reductions in community-acquired pneumonia (47% to 28%) and urinary tract infections (39% to 24%). Time-out implementation increased de-escalation/ discontinuation (37% vs 18%; OR 2.6; P<0.001), preventing an average of 2.1 excess antibiotic days per patient across 1,892 reviewed courses. Broad-spectrum DOT/ 1,000 patient-days declined by 22%, and C. difficile incidence decreased by 15% (1.2 to 1.0/ 10,000 patient-days). Clinical outcomes were unchanged: 30-day readmission (8.5% vs 9.0%), inhospital mortality (3.4% vs 3.2%), and length of stay (6.9 vs 7.1 days). Hospitals integrating the timeout into electronic health record duration-default order sets achieved greater DOT reductions (32% vs 18%; P=0.02). In multivariable analysis, the intervention independently predicted shorter DOT (HR 0.73; 95% CI 0.68–0.79; P<0.001). Conclusions. Implementation of an antibiotic time-out significantly reduced antibiotic duration and broad-spectrum use without adversely affecting clinical outcomes. Integration into electronic health record order sets enhanced effectiveness, supporting time-out strategies as scalable ASPs intervention.