In the Journals Plus

‘Expected practice’ intervention reduces antibiotic prescriptions

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December 5, 2018

Brad Spellberg
Brad Spellberg

An “expected practice” intervention centered around prescribing shorter courses of antibiotics for standard infections substantially reduced antibiotic therapy duration at a downtown Los Angeles hospital with no change in mortality, study findings published in Open Forum Infectious Diseases showed.

According to Brad Spellberg, MD, chief medical officer at the Los Angeles County-University of Southern California Medical Center and professor of clinical medicine and associate dean for clinical affairs at USC’s Keck School of Medicine, and colleagues, while prior studies have found that shorter courses of antibiotics have a similar effect as traditional courses for many infections, many clinicians are unaware of short-course therapy as a stewardship tool and most ID clinicians do not recommend it.

Spellberg explained to Infectious Disease News that “expected practice” interventions — first described in a JAMA article in 2016 — involve institutions setting their own expectations for standards of care among providers that are stronger than guidelines and based on published medical evidence. Primary care and specialty care experts develop the expected practice, which must then be approved by medical staff committees, including the medical executive committee, and hospital leadership, Spellberg said.

“When specific clinical circumstances dictate differing from the expected practice, the clinician is expected to document why in the medical record,” he said. “Thus, the expected practice supports change in practice by helping to inform clinicians about care standards that are expected to be met at the institution.”

“Furthermore,” Spellberg said, “since the institution and its medical staff have set the expected standards, they help shift responsibility for clinical decision-making to the institution itself. Thus, the expected practice provides a measure of psychological reassurance to staff that if they follow [it] and an unfortunate event happens to a patient, the clinician has done the right thing and the institution will bear responsibility for the decision. This is particularly important for antibiotic usage since providers tend to incorrectly and massively overprescribe antibiotics out of fear that not doing so could harm patients.”

Spellberg and colleagues developed an expected practice for antibiotic durations that was implemented at the hospital in October 2016. For the study, they collected all inpatient visits of adults aged 18 years or older for 12 months prior to implementation to establish baseline outcomes. October was treated as a “burn-in period” for the new interventions, and Spellberg and colleagues then collected inpatient visits for 12 months following implementation, from Nov. 1, 2016, through Oct. 31, 2017.

They included any patient with an ICD-10 code for a urinary tract infection (UTI), skin and skin structure infection (SSTI), pneumonia or ventilator-associated pneumonia in the first 20 discharge diagnoses. The primary outcome was antibiotic days of therapy, defined as the “sum total of days of each antibiotic administered as an inpatient plus the outpatient days prescribed upon hospital discharge.” The secondary outcome was total antibiotic exposure, defined as the “sum total of milligrams of antibiotics administered as an inpatient plus the milligrams prescribed as an outpatient upon discharge from hospital.”

After the implementation of the expected practice, Spellberg and colleagues observed a decrease in average antibiotic days of therapy of 10% for UTIs, 11% for both SSTIs and pneumonia, and 27% for ventilator-associated pneumonia. According to the study, the decreases in antibiotic exposures were even larger: 17%, 13%, 29% and 35% for UTIs, SSTIs, pneumonia and ventilator-associated pneumonia, respectively. Moreover, no changes in mortality were observed. According to Spellberg and colleagues, the use of expected practice as a psychological tool may help to improve antimicrobial stewardship.

“We described a no-cost, easy-to-implement, simple intervention that helped our providers significantly improve their antibiotic usage, resulting in a marked decrease in antibiotics prescribed, with no resulting harm to patients,” Spellberg said. – by Marley Ghizzone

Disclosures: Spellberg reports no relevant financial disclosures.