Antibiotic Stewardship Programs Feasible in Smaller Hospitals

Aspects of antibiotic stewardship programs typical of larger hospitals were implemented successfully in community hospitals, researchers found.

An antibiotic post-prescription audit and review program, where pharmacists would discuss prescriptions’ appropriateness with the prescribers after 72 hours of therapy, was able to identify inappropriate use, facilitate more direct pharmacist-clinician interaction, and resulted in antimicrobial de-escalation, reported Deverick J. Anderson, MD, of Duke University in Durham, North Carolina, and colleagues.

Post-prescription audit and review compared favorably to another antibiotic stewardship strategy, “modified pre-authorization,” where the prescriber had to receive approval from the pharmacist to continue antibiotic use after the first dose, though both strategies were deemed feasible for community hospitals, the authors wrote in JAMA Network Open.

Moreover, compared to matched controls, post-prescription audit and review was associated with a decline in antibiotic use in these community hospitals, they noted.

Antimicrobial restriction/preauthorization and post-prescription audit and review are two strategies recommended by the Infectious Diseases Society of America as antibiotic stewardship strategies. But these recommendations emerged from studies in large tertiary care hospitals, Anderson and colleagues pointed out, whereas most healthcare is provided in community hospitals. These facilities show the highest rates of antibiotic use in the U.S.

“Community hospitals typically have limited or no resources and no trained staff dedicated to [antibiotic stewardship],” the authors noted. “Therefore, understanding which of the core strategies is most feasible in this practice setting would assist in appropriate allocation of limited resources.”

Anderson and colleagues examined data from October 2014 to 2015 at four community hospitals, with median size of around 300 beds. The goal was to determine the feasibility of two antimicrobial stewardship strategies specifically targeting use of vancomycin, piperacillin-tazobactam, and antipseudomonal carbapenems.

Two hospitals performed modified pre-authorization for 6 months, then post-prescription audit and review for 6 months after a 1-month washout; the other two hospitals performed the reverse. Notably, the authors said that “strict pre-authorization” (where the pharmacist had to give approval prior to the first dose) was not possible at study onset.

Getting the intervention approved took a median of 95 days, Anderson and colleagues noted, with three of the four hospitals requiring a presentation to the medical executive committee. Seven pharmacists in total underwent training for the study.

Overall, 2,692 patients were part of the study. Their median age was 65, a little over half were women and about half were white. There were 164 clinicians contacted for a stewardship intervention (median of 38 per hospital).

Differences between the two interventions included that pharmacists were more likely to call the clinician during the post-prescription audit and review than during the modified prior authorization (31.0% vs 10.9%, respectively). They also found that study antimicrobials were more often determined to be inappropriate during post-prescription audit and review (41.0% vs 20.4%) and de-escalation occurred more frequently (29.1% vs 13.0%).

In contrast, pharmacists were more likely to assess appropriateness via medical record review alone during the modified pre-authorization intervention than during the post-prescription audit and review (57.9% vs 32.3%, respectively). They also recommended a dose change more often during the modified pre-authorization intervention (15.9% vs 9.6%).

While antibiotic use decreased significantly versus historical controls during post-prescription audit and review, there was no significant difference during the modified pre-authorization intervention. In addition, length of hospitalization was virtually unchanged throughout the study, the authors said.

An accompanying editorial by Daniel Livorsi, MD, of Iowa City VA Health Care System, and two colleagues said the results “shed some much-needed light on the practical aspects of implementing core stewardship strategies in community hospitals.”

“[These] findings are likely generalizable because the four participating hospitals were similar to community hospitals across the United States: they lacked ID resources to support the [antibiotic stewardship programs] and were not trained in antibiotic stewardship,” the editorialists wrote. “Using innovative study designs and tracking implementation outcomes can help us learn important lessons about the spread of [antibiotic stewardship programs] in community settings.”

Study limitations include that participating hospitals received outside support as part of the study. Also, the study was largely underpowered to analyze use of individual agents and the survey data were limited by “moderate response rates from clinicians and potential recall bias.”

“Ultimately, for hospitals to be most efficient, stewardship teams in community hospitals will need to have dedicated time and resources to complete stewardship interventions that fit their local environment,” Anderson and colleagues concluded.