November 08, 2019
2 min read

Q&A: High-intensity vs. low-intensity prospective audit and feedback

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Bradley J. Langford, PharmD
Bradley J. Langford

Prospective audit and feedback is a staple intervention used by antimicrobial stewardship programs, or ASPs, to reduce antimicrobial use and improve patient outcomes. The intensity of the approach can vary.

Bradley J. Langford, PharmD, an antimicrobial stewardship pharmacist for Public Health Ontario, and colleagues conducted a study at St. Joseph’s Health Centre in Toronto to determine the impact of high-intensity prospective audit and feedback compared with a low-intensity version of the strategy.

Infectious Disease News spoke with Langford about the differences between the strategies, the benefits of high-intensity audit and feedback and the feasibility of its implementation. – by Marley Ghizzone

Q: What is the difference between high - and low - intensity prospective audit and feedback?

A: High-intensity prospective audit and feedback involves a review of all patients receiving antibiotics in an interdisciplinary rounds format. The interdisciplinary team includes the ASP physician, ASP pharmacist, internist and the internal medicine pharmacist. This collegial approach is similar to "handshake stewardship," described by MacBrayne and colleagues, in which there is a shared responsibility with both ASP pharmacist and physician involvement, in-person face-to-face provision of feedback and a lack of prior authorization restrictions. Low-intensity audit and feedback, on the other hand, is perhaps the more common approach that involves targeted review of selected patients receiving antibiotics with a single individual, often a pharmacist, providing feedback to the prescriber.

Q: What are the benefits of high - intensity audit and feedback?

A: A high-intensity approach to prospective audit and feedback ensures that all providers are on the same page regarding the plan for patients receiving antibiotics. It also acts as an educational opportunity, when applied to individual patient cases, that the provider can apply to future patient scenarios. Reviewing all patients on antibiotics prevents "squeezing the balloon" where shifts occur away from targeted agents to nontargeted drugs without an overall decrease in antimicrobial use. The interdisciplinary rounds-based format is a team approach where the ASP/ID physician is the expert in infectious diseases diagnosis and management, the ASP pharmacist provides expertise in antimicrobial pharmacotherapy and the internist and internal medicine pharmacist provide insight on the patient's current medical issues and overall clinical picture. This team approach leads to well-informed decisions and, in general, good buy-in to the prospective audit and feedback process.


Q: What are the drawbacks?

A: Implementing high-intensity audit and feedback leads to additional workload for each team member. A thorough patient review is required for both low- and high-intensity approaches, but to facilitate interdisciplinary rounds, the team needs to dedicate about 20 to 30 minutes twice a week to discuss patients on each internal medicine unit. As a result, scheduling can be a challenge and some flexibility is needed to meet the needs of team members.

Q: What did the study show?

A: We observed a 19% reduction in overall antibiotic use in the adjusted time-series analysis (24 months before vs. 24 months after), which was more evident in the 13 to 24 months after the switch from low- to high-intensity prospective audit and feedback. Overall a 33% reduction in targeted antibiotic use was observed. There were no differences in clinical outcomes at the unit level, including C. difficile infection, length of stay, readmission rate and mortality when comparing both time periods.

Q: Is it feasible for most hospitals to implement this intervention?

A: This intervention may not be suited to all hospitals. The decision to embark on any ASP intervention should be based on a needs assessment and understanding of the most common antibiotic use challenges in the facility. In smaller facilities or those with relatively low antibiotic use, a high-intensity approach may be less feasible and of lower yield. However high-intensity audit and feedback should be a consideration for ASPs already performing prospective audit and feedback and looking to increase their impact.


Langford BJ, et al. Infect Control Hosp Epidemiol. 2019;doi:10.1017/ice.2019.189.

Disclosure: Langford reports no relevant financial disclosures.