Antimicrobial Stewardship Adherence and Resistant Pathogens in a High Dependency Unit

Abstract

Aims
To evaluate antimicrobial prescribing adherence to local guidelines, implementation of microbiology recommendations, and documentation and execution of escalation plans in a tertiary hospital High Dependency Unit (HDU).

Methods
A concurrent audit was conducted on a random sample of 50 adult HDU patients who received antimicrobial therapy, excluding those stepped down from Intensive Care. The HDU functions as an open unit, with antimicrobial suggestions made by both the core HDU multidisciplinary team (MDT) and prescriptions by visiting specialty teams. Data collected included patient demographics, antimicrobial prescriptions, adherence to local guidelines, microbiology multidisciplinary team (MDT) input and implementation, and escalation plan documentation.

Results
Of the 50 patients included, 28 (56%) were medical, 15 (30%) surgical, and 7 (14%) had mixed admissions. Antimicrobial prescriptions were fully guideline-adherent in 15 cases (30%), partially adherent in 15 (30%), and non-adherent in 11 (22%). In 9 cases (18%), no local guidelines were identified, and prescribing was based on microbiology advice. A total of 33 patients (66%) received input from the Microbiology multidisciplinary team, generating 50 recommendations. Of this subgroup of 33 patients, 28 (56%) were fully implemented, 4 (8%) partially implemented, and 1 (2%) not implemented. A history of infection or colonisation with resistant organisms were isolated in 7 patients (14%), including 2 cases each of carbapenemase-producing Enterobacterales (CPE), extended-spectrum β-lactamase producers (ESBL), methicillin-resistant Staphylococcus aureus (MRSA), and 4 cases of vancomycin-resistant Enterococcus (VRE). Of the 10 microbiology-issued escalation plans, 6 (60%) were enforced during clinical deterioration.

Discussion
Antimicrobial guideline adherence in the HDU was suboptimal, but microbiology recommendations were largely accepted. Regular microbiology rounds, prescriber education, and targeted surveillance would enhance antimicrobial stewardship and patient safety in critical care.