Use of evidence-based recommendations in an antibiotic care bundle for the intensive care unit

•Antibiotic prescription bundle using evidence-based recommendations (EBRs) was developed.•EBRs were retrieved from a systematic literature review including >1100 articles.•Bundle was assessed in 142 intensive care unit (ICU) patients in the Netherlands and Italy.•Novel tool to improve delivery of appropriate antibiotic therapy to ICU patients. To drive decisions on antibiotic therapy in the intensive care unit (ICU), we developed an antibiotic care bundle (ABC-Bundle) with evidence-based recommendations (EBRs) for antibiotic prescriptions. We conducted a three-step prospective study. First, a systematic review was performed of the literature reporting EBRs for antibiotic usage in the ICU. Second, we developed an ABC-Bundle through a two-round, RAND-modified Delphi method with an international expert panel, including the most relevant EBRs on a 9-point Likert scale. Those EBRs that were considered mandatory by >50% of the experts were included in the bundle. Third, we assessed the adherence to and applicability of the bundle in two mixed university ICUs. Out of 1190 potentially relevant articles, 14 (four guidelines, four randomised controlled trials and six systematic reviews) fulfilled the eligibility criteria. Six EBRs were classified as relevant: 1. Provide rationale for antibiotic start; 2. Perform appropriate microbiological sampling; 3. Prescribe empirical antibiotic therapy according to guidelines (Day 1); 4. Review diagnosis; 5. Evaluate de-escalation based on microbiological results (Days 2–5); and 6. Consider discontinuation of treatment (Days 3–5). Daily adherence to the ABC-Bundle, prospectively assessed in 861 days of therapy in 142 ICU patients, ranged from 2% to 37%. The ABC-Bundle is a novel tool to improve delivery of appropriate antibiotic therapy to ICU patients. The low adherence in the prospective cohorts confirms the significant role that the ABC-Bundle could play in an antibiotic stewardship programme in the ICU setting.