Impact of an Antimicrobial Utilization Program on Antimicrobial Use at a Large Teaching Hospital A Randomized Controlled Trial

Background. Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited. Objective. To determine the impact of an AUT on antimicrobial use at a teaching hospital. Design. Randomized controlled intervention trial. Setting. A 953-bed, public, university-affiliated, urban teaching hospital. Patients. Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams. Intervention. Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period. Measurements. Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage. Results. A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantiy more likely to prescribe end antimicrobial usage appropriately, compared with control teams. Conclusions. A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use. Trial Registration. ClinicalTrials.gov identifier: NCT00552838.

[1]  G. Dranitsaris,et al.  A RANDOMIZED TRIAL TO MEASURE THE OPTIMAL ROLE OF THE PHARMACIST IN PROMOTING EVIDENCE-BASED ANTIBIOTIC USE IN ACUTE CARE HOSPITALS , 2001, International Journal of Technology Assessment in Health Care.

[2]  R. Gaynes,et al.  Temporal Changes in Prevalence of Antimicrobial Resistance in 23 U.S. Hospitals , 2002, Emerging infectious diseases.

[3]  O. Cars,et al.  A European study on the relationship between antimicrobial use and antimicrobial resistance. , 2002, Emerging infectious diseases.

[4]  I. Gould,et al.  Antimicrobial Drug Use and Methicillin-resistant Staphylococcus aureus, Aberdeen, 1996–2000 , 2004, Emerging infectious diseases.

[5]  N. Fishman,et al.  Programmatic role of the infectious diseases physician in controlling antimicrobial costs in the hospital. , 1997, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[6]  D. Wennberg,et al.  Antibiotic optimization. An evaluation of patient safety and economic outcomes. , 1997, Archives of internal medicine.

[7]  S. Fletcher,et al.  Antibiotic resistance in the intensive care unit , 2009 .

[8]  T. Clemmer,et al.  A computer-assisted management program for antibiotics and other antiinfective agents. , 1998, The New England journal of medicine.

[9]  T. Cate,et al.  Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. , 1997, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[10]  Forum on Emerging Infections.  Antimicrobial Resistance: Issues and Options , 1998 .

[11]  J. Quinn,et al.  Antibiotic resistance among gram-negative bacilli in US intensive care units: implications for fluoroquinolone use. , 2003, JAMA.

[12]  D. Snydman,et al.  Influence of blood culture results on antibiotic choice in the treatment of bacteremia. , 1994, Archives of internal medicine.

[13]  R A Weinstein,et al.  Strategies to Prevent and Control the Emergence and Spread of Antimicrobial-Resistant Microorganisms in Hospitals. A challenge to hospital leadership. , 1996, JAMA.

[14]  J. L. Gray,et al.  Antimicrobial misuse in patients with positive blood cultures. , 1989, The American journal of medicine.

[15]  Mitchell L. Cohen.  Epidemiology of Drug Resistance: Implications for a Post—Antimicrobial Era , 1992, Science.

[16]  J. Avorn,et al.  Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center. , 2001, Archives of internal medicine.

[17]  T. Perl,et al.  Antimicrobial management measures to limit resistance: A process-based conceptual framework. , 2001, Critical care medicine.

[18]  S. Unal,et al.  Antimicrobial-drug use and methicillin-resistant Staphylococcus aureus. , 2001, Emerging infectious diseases.

[19]  C. Bantar,et al.  A hospitalwide intervention program to optimize the quality of antibiotic use: impact on prescribing practice, antibiotic consumption, cost savings, and bacterial resistance. , 2003, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[20]  R. Gross,et al.  Impact of a hospital-based antimicrobial management program on clinical and economic outcomes. , 2001, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[21]  T. Klaukka,et al.  The relationship between erythromycin consumption and resistance in Finland. Finnish Study Group for Antimicrobial Resistance. , 2007, Ciba Foundation symposium.

[22]  A. Ranaweera,et al.  Antimicrobial resistance , 1999 .

[23]  A. Apisarnthanarak,et al.  Effectiveness of education and an antibiotic-control program in a tertiary care hospital in Thailand. , 2005, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[24]  R. Y. Nishimi,et al.  From the Office of Technology Assessment. , 1993, JAMA.

[25]  D. Gerding,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. , 1997, Infection control and hospital epidemiology.

[26]  M. Cetron,et al.  Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. , 2000, The New England journal of medicine.

[27]  R. Gaynes,et al.  Antimicrobial resistance prevalence rates in hospital antibiograms reflect prevalence rates among pathogens associated with hospital-acquired infections. , 2001, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[28]  P Huovinen,et al.  The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. , 1997, The New England journal of medicine.