Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 28 , ISSUE 7 ( July, 2024 ) > List of Articles

Original Article

Investigating the Variability among Indicators for Quantifying Antimicrobial Use in the Intensive Care Units: Analysis of Real-world Evidence

Prity R Deshwal, Pramil Tiwari

Keywords : Antimicrobial use, Days of therapy, Defined daily dose, Length of therapy, Prescribed daily dose, Real-world evidence

Citation Information : Deshwal PR, Tiwari P. Investigating the Variability among Indicators for Quantifying Antimicrobial Use in the Intensive Care Units: Analysis of Real-world Evidence. Indian J Crit Care Med 2024; 28 (7):662-676.

DOI: 10.5005/jp-journals-10071-24745

License: CC BY-NC 4.0

Published Online: 29-06-2024

Copyright Statement:  Copyright © 2024; The Author(s).


This study investigated variability among four indicators for quantifying antimicrobial use in intensive care units (ICUs): defined daily doses (DDD), prescribed daily doses (PDD), duration of therapy (DOT), and length of therapy (LOT) and recommended the most clinically relevant approach. Retrospective data from patients who had received at least one antimicrobial was analyzed. Patients whose records were incomplete or expired were excluded. Duration of therapy (24433/1000 PDs) and LOTs (12832/1000 PDs) underestimated the overall consumption of antimicrobials compared with DDD of 28391/1000 PDs. Whereas PDD (46699/1000 PDs) overestimated it. Comparison analysis detected % differences of 13.94, 23.92, and 54.80% between DDD and DOT, DDD and PDD, and DDD and LOT, indicators respectively. Linear regression revealed stronger (r2 = 0.86), moderate (r2 = 0.50), and moderate (r2 =0.60) correlation between DDD and DOT, DDD and PDD and DDD and LOT indicators respectively. According to findings, combining DOT and DDD is a more practical method to quantify antimicrobial consumption in hospital ICUs.

Supplementary file

PDF Share
  1. Gould I. Controversies in infection: Infection control or antibiotic stewardship to control healthcare-acquired infection? J Hosp Infect 2009;73(4):386–391. DOI: 10.1016/j.jhin.2009.02.023.
  2. Shlaes DM, Gerding DN, John JF Jr, Craig WA, Bornstein DL, Duncan RA, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997;18(4):275–291. DOI: 10.1086/647610.
  3. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44(2):159–177. DOI: 10.1086/510393.
  4. Bronzwaer SL, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, et al. The relationship between antimicrobial use and antimicrobial resistance in Europe. Emerg Infect Dis 2002;8(3):278. DOI: 10.3201/eid0803.010192.
  5. Kubin CJ, Jia H, Alba LR, Furuya EY. Lack of significant variability among different methods for calculating antimicrobial days of therapy. Infect Control Hosp Epidemiol 2012;33(4):421–423. DOI: 10.1086/664770.
  6. Pollack LA, Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014;59(suppl_3):S97–S100. DOI: 10.1093/cid/ciu542.
  7. World Health Organization. WHO Collaborating Centre for Drug Statistics Methodology: ATC classification index with DDDs and Guidelines for ATC classification and DDD assignment. Oslo Nor Inst Public Health. Published online 2006:15.
  8. Muller A, Monnet DL, Talon D, Hénon T, Bertrand X. Discrepancies between prescribed daily doses and WHO defined daily doses of antibacterials at a university hospital. Br J Clin Pharmacol 2006;61(5):585–591. DOI: 10.1111/j.1365-2125.2006.02605.x.
  9. Stanic Benic M, Milanic R, Monnier AA, Gyssens IC, Adriaenssens N, Versporten A, et al. Metrics for quantifying antibiotic use in the hospital setting: results from a systematic review and international multidisciplinary consensus procedure. J Antimicrob Chemother 2018;73(suppl_6):vi50–vi58. DOI: 10.1093/jac/dky118.
  10. ATC-DDD toolkit. World Health Organization. Available from:
  11. Morris AM. Antimicrobial stewardship programs: Appropriate measures and metrics to study their impact. Curr Treat Options Infect Dis 2014;6(2):101–112. DOI: 10.1007/s40506-014-0015-3.
  12. World Health Organization. Guidelines for ATC classification and DDD assignment. Published online 1996.
  13. Polk RE, Fox C, Mahoney A, Letcavage J, MacDougall C. Measurement of adult antibacterial drug use in 130 US hospitals: Comparison of defined daily dose and days of therapy. Clin Infect Dis 2007;44(5):664–670. DOI: 10.1086/511640.
  14. Kern WV, Steib-Bauert M, de With K, Reuter S, Bertz H, Frank U, et al. Fluoroquinolone consumption and resistance in haematology–oncology patients: Ecological analysis in two university hospitals 1999–2002. J Antimicrob Chemother 2005;55(1):57–60. DOI: 10.1093/jac/dkh510.
  15. Mandy B, Koutny E, Cornette C, Woronoff-Lemsi MC, Talon D. Methodological validation of monitoring indicators of antibiotics use in hospitals. Pharm World Sci 2004;26(2):90–95. DOI: 10.1023/b:phar.0000018595.78732.1c.
  16. Shetka M, Pastor J, Phelps P. Evaluation of the defined daily dose method for estimating antiinfective use in a university hospital. Am J Health Syst Pharm 2005;62(21):2288–2292. DOI: 10.2146/ajhp 050140.
  17. Zagorski BM, Trick WE, Schwartz DN, Wisniewski MF, Hershow RC, Fridkin SK, et al. The effect of renal dysfunction on antimicrobial use measurements. Clin Infect Dis 2002;35(12):1491–1497. DOI: 10.1086/344753.
  18. Först G, de With K, Weber N, Borde J, Querbach C, Kleideiter J, et al. Validation of adapted daily dose definitions for hospital antibacterial drug use evaluation: A multicentre study. J Antimicrob Chemother 2017;72(10):2931–2937. DOI: 10.1093/jac/dkx244.
  19. Zarb P, Amadeo B, Muller A, Drapier N, Vankerckhoven V, Davey P, et al. Antimicrobial prescribing in hospitalized adults stratified by age. Drugs Aging 2012;29(1):53–62. DOI: 10.2165/11597870-000000000-00000.
  20. Schön T, Sandelin LL, Bonnedahl J, Hedebäck F, Wistedt A, Brudin L, et al. A comparative study of three methods to evaluate an intervention to improve empirical antibiotic therapy for acute bacterial infections in hospitalized patients. Scand J Infect Dis 2011;43(4):251–257. DOI: 10.3109/00365548.2010.544326.
  21. Gagliotti C, Ricchizzi E, Buttazzi R, Tumietto F, Resi D, Moro M. Hospital statistics for antibiotics: Defined vs prescribed daily dose. Infection 2014;42(5):869–873. DOI: 10.1007/s15010-014- 0649-6.
  22. Vallès J, Fernández S, Cortés E, Morón A, Fondevilla E, Oliva JC, et al. Comparison of the defined daily dose and days of treatment methods for evaluating the consumption of antibiotics and antifungals in the intensive care unit. Med Intensiva 2020;44(5):294–300. DOI: 10.1016/j.medin.2019.06.008.
  23. Momattin H, Al-Ali AY, Mohammed K, Al-Tawfiq JA. Benchmarking of antibiotic usage: An adjustment to reflect antibiotic stewardship program outcome in a hospital in Saudi Arabia. J Infect Public Health 2018;11(3):310–313. DOI: 10.1016/j.jiph.2017.08.008.
  24. Balkhy HH, El-Saed A, El-Metwally A, Arabi YM, Aljohany SM, Al Zaibag M, et al. Antimicrobial consumption in five adult intensive care units: a 33-month surveillance study. Antimicrob Resist Infect Control 2018;7(1):1–9. DOI: 10.1186/s13756-018-0451-9.
  25. Kallen MC, Natsch S, Opmeer BC, Hulscher MEJL, Schouten JA, Prins JM, et al. How to measure quantitative antibiotic use in order to support antimicrobial stewardship in acute care hospitals: A retrospective observational study. Eur J Clin Microbiol Infect Dis 2019;38(2):347–355. DOI: 10.1007/s10096-018-3434-0.
  26. Danaher PJ, Milazzo NA, Kerr KJ, Lagasse CA, Lane JW. The antibiotic support team—A successful educational approach to antibiotic stewardship. Mil Med 2009;174(2):201–205. DOI: 10.7205/milmed-d-00-1408.
  27. Panditrao A, Shafiq N, Kumar-M P, Sekhon AK, Biswal M, Singh G, et al. Impact of an antimicrobial stewardship and monitoring of infection control bundle in a surgical intensive care unit of a tertiary-care hospital in India. J Glob Antimicrob Resist 2021;24:260–265. DOI: 10.1016/j.jgar.2021.01.003.
  28. Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62(10):e51–e77. DOI: 10.1093/cid/ciw118.
  29. Morris AM, Brener S, Dresser L, Daneman N, Dellit TH, Avdic E, et al. Use of a structured panel process to define quality metrics for antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2012;33(5):500–506. DOI: 10.1086/665324.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.