Assessment of the Appropriateness of Antimicrobial Use in US Hospitals | Infectious Diseases | JAMA Network Open | JAMA Network
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    Original Investigation
    Infectious Diseases
    March 18, 2021

    Assessment of the Appropriateness of Antimicrobial Use in US Hospitals

    Author Affiliations
    • 1Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 2Lantana Consulting Group, Thetford, Vermont
    • 3Department of Medicine, Emory University, Atlanta, Georgia
    • 4Georgia Emerging Infections Program, Decatur
    • 5Tennessee Department of Health, Nashville
    • 6Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
    • 7Department of Infectious Diseases, Western Health, Melbourne, Victoria, Australia
    • 8Colorado Department of Public Health and Environment, Denver
    • 9Medical Epidemiology Consulting, Denver, Colorado
    • 10Department of Healthcare Management, University of Denver, Colorado
    • 11Minnesota Department of Health, St Paul
    • 12Hennepin County Public Health, Minneapolis, Minnesota
    • 13California Emerging Infections Program, Oakland
    • 14New Mexico Department of Health, Santa Fe
    • 15Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
    • 16Infection Prevention and Control Department, University of New Mexico Hospital, Albuquerque
    • 17Oregon Health Authority, Portland
    • 18Connecticut Emerging Infections Program, Hartford and New Haven
    • 19Department of Medicine, Columbia–New York Presbyterian Hospital
    • 20Maryland Department of Health, Baltimore
    • 21University of Maryland Baltimore County, Baltimore
    • 22New York Emerging Infections Program, Rochester
    • 23University of Rochester Medical Center, Rochester, New York
    JAMA Netw Open. 2021;4(3):e212007. doi:10.1001/jamanetworkopen.2021.2007
    Key Points

    Question  What percentage of hospital antimicrobial use in the US deviates from recommended practices, such as treatment selection or duration, on the basis of medical record documentation?

    Findings  In this cross-sectional study of 1566 patients at 192 hospitals, antimicrobial use deviated from recommended practices for 55.9% of patients who received antimicrobials for community-acquired pneumonia or urinary tract infection present at admission or who received fluoroquinolone or intravenous vancomycin treatment.

    Meaning  The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals.


    Importance  Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited.

    Objective  To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment.

    Design, Setting, and Participants  This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020.

    Exposure  Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin.

    Main Outcomes and Measures  The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration.

    Results  Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.5%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]).

    Conclusions and Relevance  The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.