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    1 Comment for this article
    Ensuring appropriate medication use
    Frederick Rivara, MD, MPH | University of Washington
    This study shows that while strict pre-authorization for antibiotic utilization was not feasible or acceptable, post prescription review was acceptable and effective. It seems like all hospitals, regardless of size, should be able to conduct such reviews to ensure more appropriate medication use.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    Infectious Diseases
    August 16, 2019

    Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals

    Author Affiliations
    • 1Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
    • 2Duke Clinical Research Institute, Durham, North Carolina
    • 3The Biostatistics Center, The George Washington University, Rockville, Maryland
    • 4Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    JAMA Netw Open. 2019;2(8):e199369. doi:10.1001/jamanetworkopen.2019.9369
    Key Points español 中文 (chinese)

    Question  Are 2 core Infectious Diseases Society of America–recommended antimicrobial stewardship strategies, preauthorization (PA) and postprescription audit and review (PPR), feasible in community hospitals?

    Findings  Among 2692 patients in this multicenter nonrandomized clinical trial with crossover design, PPR and a modified PA strategy were feasible; strict PA was not feasible. Postprescription audit and review decreased antimicrobial use and identified more inappropriate antimicrobial therapy, led to more direct interactions with clinicians, and resulted in more antimicrobial de-escalation than the modified PA strategy.

    Meaning  Postprescription audit and review is a feasible and effective strategy for antimicrobial stewardship in settings with limited resources and expertise.


    Importance  The feasibility of core Infectious Diseases Society of America–recommended antimicrobial stewardship interventions in community hospitals is unknown.

    Objective  To determine the feasibility and results of implementing 2 core stewardship intervention strategies in community hospitals.

    Design, Setting, and Participants  Three-stage, multicenter, prospective nonrandomized clinical trial with crossover design. The setting was 4 community hospitals in North Carolina (median bed size, 305; range, 102-425). Participants were all patients receiving targeted study antibacterial agents or alternative, nonstudy antibacterial agents. The study dates were October 2014 through October 2015. All statistical analyses were completed as of October 2016.

    Interventions  Two antimicrobial stewardship strategies targeted vancomycin hydrochloride, piperacillin-tazobactam, and the antipseudomonal carbapenems on formulary at the study hospitals: (1) modified preauthorization (PA), in which the prescriber had to receive pharmacist approval for continued use of the antibiotic after the first dose, and (2) postprescription audit and review (PPR), in which the pharmacist would engage the prescriber about antibiotic appropriateness after 72 hours of therapy. Two hospitals performed modified PA for 6 months, then PPR for 6 months after a 1-month washout. The other 2 hospitals performed the reverse.

    Main Outcomes and Measures  The primary outcome was the feasibility of implementing the interventions, determined by (1) approval by hospital administration and committees at each study hospital; (2) completion of pharmacist training; (3) initiation and implementation as determined by number, type, and outcomes of interventions performed; and (4) time required for interventions. Secondary outcomes included antimicrobial use (days of therapy) compared with matched historical periods and length of hospitalization.

    Results  A total of 2692 patients (median age, 65 years; interquartile range, 53-76 years) underwent a study intervention; 1413 (52.5%) were female, 1323 (49.1%) were white, and 1047 (38.9%) were African American. Intervention approvals took a median of 95 days (range, 56-119 days); during these discussions, strict PA was deemed not feasible. Instead, the modified PA intervention was used throughout the study. Pharmacists performed 1456 modified PA interventions (median per hospital, 350 [range, 129-628]) and 1236 PPR interventions (median per hospital, 298 [range, 273-366]). Study antimicrobials were determined to be inappropriate 2 times as often during the PPR period (41.0% [435 of 1060] vs 20.4% [253 of 1243]; P < .001). Pharmacists recommended dose change more often during the modified PA intervention (15.9% [232 of 1456] vs 9.6% [119 of 1236]; P < .001) and de-escalation during PPR (29.1% [360 of 1236] vs 13.0% [190 of 1456]; P < .001). The median time dedicated to the stewardship interventions varied by hospital (range of median hours per week, 5-19). Overall antibiotic use decreased during PPR compared with historical controls (mean [SD] days of therapy per 1000 patient-days, 925.2 [109.8] vs 965.3 [109.4]; mean difference, −40.1; 95% CI, −71.7 to −8.6), but not during modified PA (mean [SD] days of therapy per 1000 patient-days, 931.0 [102.0] vs 926.6 [89.7]; mean difference, 4.4; 95% CI, −55.8 to 64.7).

    Conclusions and Relevance  Strict PA was not feasible in the study hospitals. In contrast, PPR was a feasible and effective strategy for antimicrobial stewardship in settings with limited resources and expertise.

    Trial Registration  ClinicalTrials.gov identifier: NCT02212808