antimicrobial stewardship trial 859
reductions in antimicrobial use errors or rates compared with the control. The limited reliability of our computer-assisted case
vignette forerroradjudication4 is a potential explanation for this finding. In addition, nearly 80%of cases in which antimicrobial regimens were initiated in the emergency department (ED) where the interventions used in this study were not imple- mented. However, the proportions of antimicrobial courses begun in the ED were similar among the 3 firms (Table 2), and study outcomes were similar between courses begun in the ED and in the hospital (data not shown). Our clinician education intervention had been effective
control firm than in either of the intervention firms (4, 5 and 5 days, respectively; P<.001; Table 1), and the prevalence of lower respiratory tract infection was lower in control firm cases randomly selected for error adjudication than for cases selected from the intervention firms. Because shorter lengths of stay have been associated with improved quality of care, reduced medical complexity, and greater physician experience among cardiac6 and general medical inpatients,7 unmeasured differences in patient or physician characteristics could plau- sibly have confounded our findings. If true, a different ran- domization of the 3 firms could have led to a type 1 error. Both informational interventions intended to improve anti-
in a public, long-term, acute-care hospital staffed by a small cadre of dedicated attending physicians and no residents.2 In comparison, the current intervention presented a broader range of topics to much larger groups of attending and resident physicians who regularly rotated to other duties. Also, our ID pharmacists’ recommendations for improvement were accepted for only 129 of the 901 antimicrobial regimens administered during the study period (14.9%), with only 43 (4.8%) of these leading to discontinuation of 1 or all drugs. This factor limited that intervention’simpactonantimicrobial errors anduse. The median length of stay was significantly shorter in the
microbial prescribing generally (eg, clinician education and infection management guidelines), and interventions providing patient-level decision support such as audit and feedback and drug restrictions are essential to hospital antimicrobial steward- ship.1,8 However, our findings reinforce our hypothesis that the optimal scope10 and intensity of these interventions remain poorly defined and difficult to measure. Clarification of this dynamic through additional research is needed to guide better integrated and better resourced antimicrobial stewardship.8,9
acknowledgments
Financial support. This project was funded by the Centers for Disease Control and Prevention (cooperative agreement #U01-CI000303 to R.A.W. and P.I.). Potential conflicts of interest. All authors report no conflicts of interest rele-
vant to this article. Affiliations: 1. Division of Infectious Diseases, Stroger Hospital of Cook
County, Chicago, Illinois; 2. Rush Medical College, Chicago, Illinois; 3. Providence VA Medical Center, Providence, Rhode Island; 4. Stroger Hos- pital of Cook County, Chicago, Illinois; 5. St Francis Hospital and
Medical Center, Hartford, Connecticut; 6. Pharmacy Department, Stroger Hospital of Cook County, Chicago, Illinois; 7. College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois. Address correspondence to David N. Schwartz, MD, Chair, Division of
Infectious Diseases, John H. Stroger, Jr Hospital of Cook County, 1900 W. Polk St, Room 1236, Chicago, IL 60612 (
david.schwartz@
hektoen.org). PREVIOUS PRESENTATION. These data were presented in part at the 16th
Annual Meeting of the Society for Healthcare Epidemiology of America, Chicago, Illinois, March 16–21, 2006, (abstracts 27 and 317), and at the 17th Annual Meeting of the Society for Healthcare Epidemiology of America, Baltimore, MD, April 14–17, 2007 (abstracts 27 and 298).
Received December 16, 2016; accepted March 21, 2017; electronically published June 2, 2017 © 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3807-0013. DOI: 10.1017/ice.2017.74
supplementary material
To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2017.74
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2. Schwartz DN, Abiad H, DeMarais PL, Armeanu E, Trick WE, Wang Y, Weinstein RA. An educational intervention to improve antimicrobial use in a hospital-based long-term care facility. JAm Geriatr Soc 2007;55:1236–1242.
3. Schackow TE, Chavez M, Loya L, et al. Audience response system: effect on learning in family medicine residents. Fam Med 2004;36:496–504.
4. Schwartz DN,WuUS, Lyles RD, Xiang Y, Kieszkowski P, Hota B, Weinstein RA. Lost in translation? Reliability of assessing inpatient antimicrobial appropriateness using computerized case vignettes. Infect Control Hosp Epidemiol 2009;30:163–171.
5. Wisniewski MF, Kieszkowski P, Zagorski BM, Trick WE, Sommers M, Weinstein RA. Development of a clinical data warehouse for hospital infection control. J Am Med Inform Assoc 2003;10:454–462.
6. Tickoo S, Bhardwaj A, Gonarow GC, Liang L, Bhatt DL, Cannon CP. Relation between hospital length of stay and quality of care in patients with acute coronary syndromes (from the American Heart Association’s Get with the Guidelines—coronary artery disease data set). Am J Cardiol 2016;117:201–205.
7. Parekh V, Saint S, Furney S, Kaufman S, McMahon L. What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service? J Gen Intern Med 2004;19:395–401.
8. Pollack LA, van Santen KL, Weiner LM, Dudeck MA, Edwards JR, Srinivasan A. Antibiotic stewardship programs in US acute-care hospitals: findings from the 2014 National Healthcare Safety Net- work annual hospital survey. Clin Infect Dis 2016;63:443–449.
9. Schwartz DN. Antimicrobial stewardship in US hospitals: Is the cup half-full yet? Clin Infect Dis 2016;63:450–453.
10. Popovski Z, Mercuri M, Main C, et al. Multifaceted intervention to optimize antibiotic use for intra-abdominal infections. J Antimicrob Chemother 2015;70:1226–1229.
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