infection control & hospital epidemiology july 2017, vol. 38, no. 7 concise communication


Computer-Assisted Antimicrobial Recommendations for Optimal Therapy: Analysis of Prescribing Errors in an Antimicrobial Stewardship Trial


David N. Schwartz, MD;1,2 Kevin W. McConeghy, PharmD, MS;3 Rosie D. Lyles, MD;4 Ulysses Wu, MD;5 Robert C. Glowacki, PharmD;6,7 Gail S. Itokazu, PharmD;6,7 Piotr Kieszkowski, MBA;3 Yingxu Xiang, MS;3 Bala Hota, MD;7 Robert A. Weinstein, MD1,2


Clinician education and prospective audit and feedback inter- ventions, deployed separately and concurrently, did not reduce antimicrobial use errors or rates compared to a control group of general medicine inpatients at our public hospital. Additional research is needed to define the optimal scope and intensity of hospital antimicrobial stewardship interventions.


Infect Control Hosp Epidemiol 2017;38:857–859


common infection syndromes, reinforcing recommendations from our hospital-wide infection management guidelines (see below) and emphasizing changing susceptibility patterns and syndromes associated with antimicrobial overuse. Asecond firm was assigned to prospective audit and


feedback by an ID pharmacist. Infectious disease pharmacists (R.C.G., G.S.I.) reviewed the charts of each inpatient antimicrobial recipient (excluding discharged patients or those whose antimicrobials had been discontinued) on each nonholiday weekday, using a computer program that reported patient demographic characteristics, test results, and antimicrobial therapy. Institutional guidelines provided a reference standard. Clinical pharmacist case review was not otherwise routinely available at our hospital. The control firm was not subjected to active interventions


The relative impact of different antimicrobial stewardship interventions on acute-care hospital rates of antimicrobial use and errors is largely unknown.1 After improving antimicrobial use at a long-term and acute-care hospital through clinician education and institutional infection management guideline implementation,2 we sought to determine the effectiveness of this approach by deploying a clinician education intervention concurrently with computer-assisted prospective audit and feedback by infectious disease (ID) pharmacists and with no intervention on the 3 inpatient internal medicine firms of our urban teaching hospital.


methods


to physicians in the clinician education firm twice during each 4-week rotation. Case vignettes using the Audience Response System3 were used to explore the diagnosis and treatment of


All adult patients admitted over a 24-week period beginning in February 2005 to inpatient medicine services in our publicly funded Chicago teaching hospital were assigned sequentially to 3 inpatient medicine firms, each staffed for 4-week rotations by 4 physician teams. These patients were cared for across 9 general medical-surgical wards with shared facilities and services. Inter- ventions were assigned to firms by coin flips. Interventions were developed as quality improvement initiatives under the auspices of the hospital’s Anti-Infective Committee, and the study was approved by the hospital’s institutional review board. An investigator (D.N.S.) presented teaching sessions


but had access to hospital-wide antimicrobial stewardship programs, including institutional infection management guidelines implemented in 2004 to support the diagnosis and treatment of common infection syndromes, and restrictions for 7 antimicrobials necessitating ID pharmacist or physician approval before dispensing. The primary outcomes were the proportion of initial antimicrobial regimens with error, antimicrobial courses, and antimicrobial treatment days in which 1 or more antimicrobial use errors could be identified during retrospective review of a random sample of


antimicrobial recipients hospitalized on the inpatient medicine firms during the study period. Methods for conducting case reviews were published previously.4 Secondary outcomes included the mean number of days of therapy with any error and the overall antimicrobial utilization (expressed as days of therapy (DOT) per 1,000 patient days).2 Weekly aggregate antimicrobial use rates for each firm during the study period were programmed from hospital pharmacy and administrative data stored in a data warehouse.5 A χ2 analysis or ANOVA test was used for comparisons of proportions or means when appropriate. For the secondary outcome, error days were modeled as counted data with an overdispersion variable (negative binomial regression) offset for total days of antimicrobial therapy (exposure). Analyses were performed using STATA SE 12 software (StataCorp, College Station, TX).


results


During the intervention period, 2,682 antimicrobial courses were administered among 5,804 admissions. Patients admitted to the control firm had shorter median lengths of stay than those in the other firms (4, 5, and 5 days, respectively; P<.001; Table 1). Among antimicrobial recipients randomly selected for antimicrobial error review, nearly 80% of antimicrobial courses were initiated in the emergency department (ED) (Table 1).


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