Antimicrobial Timeout

Concept of Antimicrobial Time Out

Empiric antibiotic choice should take into account local antibiograms, drug cost, and formulary restrictions.

Once the causative agent and antibiotic susceptibilities have been identified, restriction of the number of antibiotics and narrowing the spectrum of antimicrobial therapy is an important and responsible strategy for minimizing the development of resistant pathogens and containing costs.

The antimicrobial regimen should always be re-assessed after 48-72 hours on the basis of  microbiological and clinical data, with the aim of using a narrow spectrum antibiotic to prevent the development of resistance, to reduce toxicity, and to reduce costs. Empiric combination therapy should not be administered for more than 3-5 days. Once a causative pathogen has been identified, there is no evidence that combination therapy is more effective than monotherapy. The duration of therapy should be typically 5-10 days and guided by clinical response. Longer courses may be required in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus, some fungal and viral infections, or immunologic deficiencies, including neutropenia. (2012 Surviving Sepsis Campaign Guidelines)

Antimicrobial Time Out should occur 48-72 hours after antibiotics are initiated. (Center for Disease Control Recommendations)

Antibiotic timeouts should be practiced at least daily as long as the patient is receiving antibiotics. Antibiotic timeouts can result in cessation on antibacterial agents.

  • Step 1    Review the available clinical and laboratory data, especially the microbiological results
  • Step 2    Determine the likelihood that the patient has an infection that is likely to be effectively treated with antibiotics
  • Step 3    Determine the appropriate antibiotic and necessary duration of therapy
      • Prolonged treatment courses are associated with:
        • increased antibiotic resistance
        • increased cost
        • increased collateral damage, such as C. dificile infections
  • Step 4    Document these elements of care

Antimicrobial Time Out - Key Principles
  • Treat infection, not colonization or contamination
  • Target pathogens as narrowly as possible
  • Resolve any bug-drug mismatches
  • Eliminate redundant coverage
  • Optimize dosing
  • In some cases, consider converting from intravenous to oral administration
    • patient clinically improving, hemodynamically stable, tolerating oral intake well, no malabsorption concerns
    • orally bioavailable antibiotic (serum and tissue concentrations comparable to IV)
      • includes all flouroquinolones, doxycycline, azithromycin, trimethoprim/sulfamethoxazole, metronidazole, fluconazole, cephalexin, and linezolid
      • other antibiotics with good and in most cases adequate bioavailability when dosed appropriately include amoxicillin, amoxicillin/clavulanate, and cefpodoxime
    • decreases costs
    • facilitates discharge
    • saves patients from complications from indwelling intravenous catheters, including infection and clots
  • Choose the least expensive antimicrobial regimen that effectively treats the underlying infection
  • If no pathogen is identified and the patient is clinically improving 
    • Consider the possibility that the patient does not have a bacterial infection
    • This may constitute a reason for antibiotic discontinuation
  • If microbiological studies are negative and the patient has clinically deteriorated
    • Search for sources such as an abscess requiring drainage or infected hardware