Antibiotic checklist improves ICU prescribing quality but not overall appropriateness

A daily antibiotic checklist introduced in the adult medical intensive care unit of Rouen University Hospital in France improved several markers of prescription quality, including antibiotic dosing, treatment duration and therapeutic drug monitoring, but did not change the overall rate of appropriate antibiotic therapy, according to a prospective before-after study published in Antimicrobial Resistance & Infection Control.

The study enrolled adult patients with infectious episodes who received antibiotic therapy for more than 48 hours in the ICU. Two periods were compared: a baseline period from June 2020 to February 2021 and an intervention period from June 2021 to February 2022, during which a daily paper antibiotic checklist was used. In the intervention period, only patients for whom the checklist had been initiated were included, and the completion rate of the checklist was 51 percent.

The primary outcome was the rate of appropriate antibiotic therapy, defined as a composite of four criteria: guideline-concordant choice of empirical molecules, appropriate antibiotic dose, appropriate antibiotic re-evaluation and guideline-concordant antibiotic duration. Across the study, 385 infectious episodes in 347 patients were analyzed, and the most common reason for ICU hospitalization was respiratory failure.

The composite primary outcome showed no difference between the baseline and intervention periods, with appropriate therapy recorded in 23 percent of episodes before the checklist and 22 percent after, a difference that was not statistically significant. This null result on the composite measure contrasts with the improvements seen in several of its individual components.

Appropriate antibiotic dose rose from 81 percent to 91 percent, guideline-concordant antibiotic duration increased from 59 percent to 69 percent, and therapeutic drug monitoring increased from 31 percent to 49 percent, all statistically significant differences. The authors suggest that the checklist could be a useful tool within antimicrobial stewardship programs in intensive care.

Clinical outcomes did not change significantly. ICU mortality was 19 percent in the baseline period versus 27 percent in the intervention period, and ICU length of stay was a median of 8 days versus 11 days, differences that did not reach statistical significance. Antibiotic consumption decreased from 1,350 to 1,271 Daily Defined Doses per 1,000 patient-days, and antibiotic costs fell from 22 euros to 18 euros per patient-day.

The findings come against the backdrop of rising antimicrobial resistance, which the authors describe as a major public health concern and a key motivation for antimicrobial stewardship programs.

The study’s before-after design means the observed changes cannot be definitively attributed to the checklist, since other changes in practice between the two periods may have contributed. The moderate checklist completion rate of 51 percent also suggests that adherence to the intervention was incomplete, and the inclusion during the intervention period of only patients whose checklist had been initiated may have affected the comparison. As an open-access article published on 29 September 2026, the study is currently shared as an accepted manuscript that is subject to further edits before the final version of record.

Overall, the results indicate that a simple daily paper checklist was associated with improvements in prescription quality markers and reduced antibiotic costs in this single adult medical ICU, supporting its potential role in stewardship efforts, while the composite appropriateness rate itself remained unchanged and clinical outcomes showed no significant difference.

Subject of Research: Effect of a daily antibiotic checklist on antibiotic prescribing in an adult medical intensive care unit

Article Title: Impact of an antibiotic checklist on antibiotic prescription in an adult medical intensive care unit: a before-after study

Article References: Giry, M., Herrmann, K., Alexandre, K., Boyer, D., Carpentier, D., Demailly, Z., Jolly, G., Girault, C., Grall, M., Nicolas, J., Sarfati, S., Tamion, F., & Béduneau, G. (2026). Impact of an antibiotic checklist on antibiotic prescription in an adult medical intensive care unit: a before-after study. Antimicrobial Resistance & Infection Control. https://doi.org/10.1186/s13756-026-01825-5

Image Credits: AI Generated

DOI: 10.1186/s13756-026-01825-5

Keywords: antibiotic checklist, antimicrobial stewardship, intensive care unit, antimicrobial resistance, before-after study, therapeutic drug monitoring, antibiotic consumption, Rouen University Hospital, prescription quality, ICU mortality, Impact, antibiotic