Infections are the main reason for admission to intensive care units (ICU)s. [1] In addition, clinical deterioration during ICU stay often raises the suspicion of a new or inappropriately treated infection, [2] which results in approximately 70% of critically ill patients receiving any antibiotic (ATB) during hospitalization. [1] Otherwise, in general care, up to 60% of ATBs used are potentially not necessary. [3,4] Among the main concerns of excessive use of ATBs, especially carbapenems, are the increased colonization and consequently infections rates by multidrug-resistant organisms (MDRO), [5] which has been a global concern, especially in middle income countries. [6] Moreover, Clostridioides difficile infections are also proportionally associated with antibiotics use, and is a growing problem in Brazil. [7]

Most ICU acquired infections are avoidable with adequate patient care. [8] Furthermore, the mindset that disease severity and/or clinical deterioration alone define a liberal antibiotic introduction or escalation strategy can be changed. [9,10] Patients' care can be improved in many dimensions as with communication skills training, [11] families involvement in care, [12] adequate hands hygiene, [13] adequate devices care, [8,14] adequate pressure sores prophylaxis, [15] and appropriate antibiotics use. [9] This improvement task can only be reached with multi-professional educational efforts, [8] potentially ending up in more rational use of ATBs per se and reduced ATBs use for healthcare related infections.

In this study, we described a stepwise multifaceted educational program focusing on critically ill patients care improvement, and its impact on healthcare related infections, ATBs consumption, mortality, MDRO incidence, and costs over eleven years in a tertiary ICU in Brazil.