Clinical impact of a multidisciplinary remote-based hybrid antibiotic stewardship program in critically ill patients during COVID-19 pandemic in Korea: a prospective pilot implementation study.

BACKGROUND: Antimicrobial stewardship programs (ASPs) are recommended to optimize antibiotic use in intensive care units (ICUs); however, many institutions lack infectious disease specialists and pharmacy expertise for full implementation. The COVID-19 pandemic further disrupted conventional stewardship. While tele-stewardship models have shown promise, evidence for hybrid programs operating without infectious disease specialist leadership remains limited, particularly outside high-income countries. We developed a hybrid ASP (hASP) collaboratively led by an on-site intensivist and an off-site faculty clinical pharmacist to reduce inappropriate antibiotic use and improve outcomes in a resource-constrained ICU.

METHODS: This prospective, single-center, pre-post study was conducted in the medical ICU of a 733-bed university teaching hospital in Seoul, South Korea. The pre-intervention period (August to October 2017) with no ASP was compared with the post-intervention period (August to October 2020) following hASP implementation. Stewardship activities were primarily performed off-site by trained clinical pharmacists via secured messaging, telephone, and video conferencing, with on-site rounds every other weekday. Key outcomes were inappropriate antibiotic prescriptions per 100 patient-days, 30-day all-cause mortality, ICU length of stay, preventable adverse drug events, and days of therapy, assessed using Delphi-derived appropriateness criteria.

RESULTS: Thirty-three and 37 admissions were analyzed (364 and 251 patient-days). On-site activities were limited to three hours daily or less. Inappropriate prescriptions declined from 83.8 to 20.7 per 100 patient-days (p < 0.001), ICU length of stay from 14 to 6 days (p < 0.05), and preventable adverse drug events from 4.4 to 2.8 per 100 patient-days (p < 0.05). Thirty-day all-cause mortality was comparable (24.2% vs. 24.3%). The most frequent pharmacist interventions were dose optimization (47.8%) and antimicrobial discontinuation (40.6%), with an overall acceptance rate of 62.3%. Days of therapy for broad-spectrum antibiotics targeting multidrug-resistant organisms declined while those for narrower-spectrum agents increased, suggesting a shift toward targeted therapy.

CONCLUSION: The hASP, collaboratively led by an intensivist and a faculty clinical pharmacist with off-site pharmacist-led interventions via virtual communication, significantly reduced inappropriate prescribing, ICU length of stay, and preventable adverse drug events. Hybrid stewardship models may serve as a feasible alternative to on-site programs in resource-limited settings.