Impact of Two Different Antimicrobial Stewardship Methods on Frequency of Streamlining Antimicrobial Agents in Patients with Bacteremia.

OBJECTIVE To assess the likelihood of antimicrobial streamlining between 2 antimicrobial stewardship methods. DESIGN Retrospective cohort study. SETTING Large academic medical center. METHODS Frequency and time to antimicrobial streamlining were compared during a prior authorization and a prospective audit period. Streamlining was defined as an antimicrobial change to a narrower agent if available or to a broader agent if the isolate was resistant to empiric therapy. Patients included were ≥18 years old with monomicrobial bacteremia with S. aureus, Enterococcus spp., or any aerobic Gram-negative organism. RESULTS A total of 665 cases of bacteremia met inclusion criteria. Frequency of streamlining was similar between periods for all cases of bacteremia (audit vs restriction: 60.7% vs 53.2%; P=.12), S. aureus bacteremia (73.2% vs 76.9%; P=.671), and Enterococcus bacteremia (81.6% vs 71.9%; P=.335). Compared to restriction, the audit period was associated with an increased frequency of streamlining for cases of Gram-negative bacteremia (51.4% vs 35.6%; odds ratio [OR], 1.85; 95% confidence interval [CI], 1.06-3.25), those on the medical service (67.9% vs 53.1%; OR, 1.86; 95% CI, 1.09-3.16), and those admitted through the emergency department (71.6% vs 51.4%; OR, 2.32; 95% CI, 1.24-4.34). Characteristics associated with increased streamlining included: absence of ß-lactam allergy (P<.001), Gram-negative bacteremia (P<.001), admission through the emergency department (P=.001), and admission to a medical service (P=.011). CONCLUSIONS Compared with prior authorization, prospective audit increased antimicrobial streamlining for cases of Gram-negative bacteremia, those admitted through the emergency department, and those admitted to a medical but not surgical service. Infect Control Hosp Epidemiol 2016:1-7.

Point-of-prescription interventions to improve antimicrobial stewardship.

Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. Antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such "top-down" methods as formulary restriction and prospective audit with feedback; however, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship.

Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship.

OBJECTIVE: Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center. DESIGN: Quasi-experimental study. METHODS: We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS). RESULTS: In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (-9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (-4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively). CONCLUSIONS: Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.

Antiretroviral medication errors remain high but are quickly corrected among hospitalized HIV-infected adults.

BACKGROUND: Antiretroviral therapy (ART) medication errors can lead to drug resistance, treatment failure, and death. Prior research suggests that ART medication errors are on the rise in US hospitals. This analysis provides a current estimate of inpatient antiretroviral prescribing errors. METHODS: Retrospective review of medication orders during the first 48 hours of hospitalization for patients with human immunodeficiency virus (HIV) infection admitted to the Johns Hopkins Hospital between 1 January and 31 December 2009. Errors were classified as (1) incomplete regimen, (2) incorrect dosage, (3) incorrect schedule, and (4) nonrecommended drug-drug combinations. Multivariable regression was used to identify factors associated with errors. RESULTS: A total of 702 admissions occurred in 2009. Of these, 380 had ART medications prescribed on the first day and 308 on the second day of hospitalization. A total of 145 ART medication errors in 110 admissions were identified on the first day (29%), and 22 errors were identified in 21 admissions on the second day (7%). The most common errors were incomplete regimen and incorrect dosage or schedule. Protease inhibitors accounted for the majority of dosing and scheduling errors (71%-73%). Compared with patients admitted to the HIV/AIDS service, those admitted to surgical services were at increased risk of errors (adjusted odds ratio, 3.10; 95% confidence interval, 1.18-8.18). CONCLUSIONS: ART medication errors are common among hospitalized HIV-infected patients on the first day of admission, but most are corrected within 48 hours. Interventions are needed to safeguard patients and prevent serious complications of ART medication errors especially during the first 24 hours of hospitalization.