Core stewardship intervention feasible at community hospitals

Deverick J. Anderson, MD, MPH
Deverick J. Anderson

Researchers tested two core Infectious Diseases Society of America-recommended antimicrobial stewardship interventions at four community hospitals in North Carolina and found that one — post-prescription audit and review by a pharmacist after 72 hours of therapy — was feasible in facilities with limited resources and little to no antimicrobial stewardship expertise.

However, among the hospitals included in the study, adherence to a strict preauthorization intervention, wherein a pharmacist must approve continued use of an antibiotic after a first dose is administered, was not feasible, the researchers reported in JAMA Network Open.

“The Infectious Diseases Society of America recommends the following [two] core strategies for [antimicrobial stewardship]: (1) antimicrobial restriction/preauthorization (PA) and (2) post-prescription audit and review (PPR) with intervention and feedback,” Deverick J. Anderson, MD, MPH, associate professor of medicine at Duke University School of Medicine, and colleagues wrote. “While the need for these core [antimicrobial stewardship] strategies is clear, it remains unclear whether they can be effectively used in all health care settings.”

Anderson and colleagues assessed the feasibility of the strategies in community hospitals, which not only have the “highest rate of antibiotic use in the United States,” but are also typically limited in resources with no trained staff dedicated to stewardship practices, they said.

“In environments with limited resources, hospitals looking to perform active stewardship interventions should focus on post-prescription review,” Anderson told Infectious Disease News. “Conversely, not all ‘core’ stewardship interventions are feasible in community hospitals — particularly those without ID expertise in the local environment.”

They conducted the three-stage, multicenter, prospective nonrandomized clinical trial in four community hospitals in North Carolina between October 2014 and October 2015, with interventions that targeted vancomycin hydrochloride, piperacillin-tazobactam and the antipseudomonal carbapenems on formulary.

The study included 2,692 patients whose median age was 65 years. According to Anderson and colleagues, strict PA was deemed not feasible, and only modified PA — wherein the prescriber was required to get pharmacist approval to continue the antibiotic after the first dose was administered — was used throughout the study period.

Two of the hospitals performed modified PA for 6 months, then PPR for another 6 months, following a 1-month washout. The other two hospitals reversed the order of the strategies.

According to the study, 1,456 modified PA interventions and 1,236 PPR interventions were performed. The researchers observed that during the PPR period, study antimicrobials were classified as inappropriate twice as often compared with the modified PA period. Specifically, 41% of antibiotics in the PPR period compared with 20.4% in the modified PA period were deemed inappropriate.

During the modified PA period, pharmacists recommended dose changes 15.9% of the time and de-escalation 13% of the time compared with 9.6% and 29.1%, respectively, during the PPR period.

Compared with historical controls, overall antibiotic use decreased during the PPR period but not during the modified PA period, the researchers said.

“I strongly believe hospitals should perform ‘active’ stewardship — stewardship interventions that lead to engagement and interaction between the stewardship team and clinicians. Restriction is difficult in community hospitals,” Anderson said.

“So, stewardship teams in community hospitals will be more effective if they implement post-antibiotic prescription review,” he said. “On the other hand, results from our paper suggested there was still more to be gained. For community hospitals to be most effective in their stewardship activities, these hospitals need to provide sufficient resources and protected time to complete these interventions.

In a related editorial, Daniel J. Livorsi, MD, MSc, assistant professor of infectious diseases at the University of Iowa Carver College of Medicine, and colleagues said the findings “shed some much-needed light” on the practicality of core stewardship strategy implementation in community hospitals, although they did note that findings from another study concluded that involvement from an ID specialist was critical, in combination with targeted PPR, in reducing antibiotic use.

“Both Anderson and colleagues and [the previous study] have demonstrated that PA and PPR can be modified based on community hospitals’ local resources and local personnel,” Livorsi and colleagues wrote. “The need to improve antibiotic use is universal, but the approach to stewardship need not be the same. Adaptation, not imitation, is the key to success.” – by Marley Ghizzone

Disclosures: Anderson reports receiving grants from the NIH/NIAID, CDC and the Agency for Healthcare Research and Quality, and receiving personal fees from UpToDate. Livorsi reports receiving grant funding from Merck and the U.S. Department of Veterans Affairs Health Services Research & Development Service. Please see the study and commentary for all other authors’ relevant financial disclosures.

Deverick J. Anderson, MD, MPH
Deverick J. Anderson

Researchers tested two core Infectious Diseases Society of America-recommended antimicrobial stewardship interventions at four community hospitals in North Carolina and found that one — post-prescription audit and review by a pharmacist after 72 hours of therapy — was feasible in facilities with limited resources and little to no antimicrobial stewardship expertise.

However, among the hospitals included in the study, adherence to a strict preauthorization intervention, wherein a pharmacist must approve continued use of an antibiotic after a first dose is administered, was not feasible, the researchers reported in JAMA Network Open.

“The Infectious Diseases Society of America recommends the following [two] core strategies for [antimicrobial stewardship]: (1) antimicrobial restriction/preauthorization (PA) and (2) post-prescription audit and review (PPR) with intervention and feedback,” Deverick J. Anderson, MD, MPH, associate professor of medicine at Duke University School of Medicine, and colleagues wrote. “While the need for these core [antimicrobial stewardship] strategies is clear, it remains unclear whether they can be effectively used in all health care settings.”

Anderson and colleagues assessed the feasibility of the strategies in community hospitals, which not only have the “highest rate of antibiotic use in the United States,” but are also typically limited in resources with no trained staff dedicated to stewardship practices, they said.

“In environments with limited resources, hospitals looking to perform active stewardship interventions should focus on post-prescription review,” Anderson told Infectious Disease News. “Conversely, not all ‘core’ stewardship interventions are feasible in community hospitals — particularly those without ID expertise in the local environment.”

They conducted the three-stage, multicenter, prospective nonrandomized clinical trial in four community hospitals in North Carolina between October 2014 and October 2015, with interventions that targeted vancomycin hydrochloride, piperacillin-tazobactam and the antipseudomonal carbapenems on formulary.

The study included 2,692 patients whose median age was 65 years. According to Anderson and colleagues, strict PA was deemed not feasible, and only modified PA — wherein the prescriber was required to get pharmacist approval to continue the antibiotic after the first dose was administered — was used throughout the study period.

Two of the hospitals performed modified PA for 6 months, then PPR for another 6 months, following a 1-month washout. The other two hospitals reversed the order of the strategies.

According to the study, 1,456 modified PA interventions and 1,236 PPR interventions were performed. The researchers observed that during the PPR period, study antimicrobials were classified as inappropriate twice as often compared with the modified PA period. Specifically, 41% of antibiotics in the PPR period compared with 20.4% in the modified PA period were deemed inappropriate.

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During the modified PA period, pharmacists recommended dose changes 15.9% of the time and de-escalation 13% of the time compared with 9.6% and 29.1%, respectively, during the PPR period.

Compared with historical controls, overall antibiotic use decreased during the PPR period but not during the modified PA period, the researchers said.

“I strongly believe hospitals should perform ‘active’ stewardship — stewardship interventions that lead to engagement and interaction between the stewardship team and clinicians. Restriction is difficult in community hospitals,” Anderson said.

“So, stewardship teams in community hospitals will be more effective if they implement post-antibiotic prescription review,” he said. “On the other hand, results from our paper suggested there was still more to be gained. For community hospitals to be most effective in their stewardship activities, these hospitals need to provide sufficient resources and protected time to complete these interventions.

In a related editorial, Daniel J. Livorsi, MD, MSc, assistant professor of infectious diseases at the University of Iowa Carver College of Medicine, and colleagues said the findings “shed some much-needed light” on the practicality of core stewardship strategy implementation in community hospitals, although they did note that findings from another study concluded that involvement from an ID specialist was critical, in combination with targeted PPR, in reducing antibiotic use.

“Both Anderson and colleagues and [the previous study] have demonstrated that PA and PPR can be modified based on community hospitals’ local resources and local personnel,” Livorsi and colleagues wrote. “The need to improve antibiotic use is universal, but the approach to stewardship need not be the same. Adaptation, not imitation, is the key to success.” – by Marley Ghizzone

Disclosures: Anderson reports receiving grants from the NIH/NIAID, CDC and the Agency for Healthcare Research and Quality, and receiving personal fees from UpToDate. Livorsi reports receiving grant funding from Merck and the U.S. Department of Veterans Affairs Health Services Research & Development Service. Please see the study and commentary for all other authors’ relevant financial disclosures.