infection control & hospital epidemiology july 2018, vol. 39, no. 7 original article
Predictors of Antimicrobial Stewardship Program Recommendation Disagreement
Laura L. Bio, PharmD, BCPS;1 Jenna F. Kruger, MPH;1 Betty P. Lee, PharmD;1 Matthew S. Wood, PhD;1 Hayden T. Schwenk, MD, MPH1,2
objective. To identify predictors of disagreement with antimicrobial stewardship prospective audit and feedback recommendations (PAFR) at a free-standing children’s hospital.
design. Retrospective cohort study of audits performed during the antimicrobial stewardship program (ASP) from March 30, 2015, to April 17, 2017.
methods. The ASP included audits of antimicrobial use and communicated PAFR to the care team, with follow-up on adherence to recommendations. The primary outcome was disagreement with PAFR. Potential predictors for disagreement, including patient-level, anti- microbial, programmatic, and provider-level factors, were assessed using bivariate and multivariate logistic regression models.
results. In total, 4,727 antimicrobial audits were performed during the study period; 1,323 PAFR (28%) and 187 recommendations (15%) were not followed due to disagreement. Providers were more likely to disagree with PAFR when the patient had a gastrointestinal infection (odds ratio [OR], 5.50; 95% confidence interval [CI], 1.99–15.21), febrile neutropenia (OR, 6.14; 95% CI, 2.08–18.12), skin or soft-tissue infections (OR, 6.16; 95% CI, 1.92–19.77), or had been admitted for 31–90 days at the time of the audit (OR, 2.08; 95% CI, 1.36–3.18). The longer the duration since the attending provider had been trained (ie, the more years of experience), the more likely they were to disagree with PAFR recommendations (OR, 1.02; 95% CI, 1.01–1.04).
conclusions. Evaluation of our program confirmed patient-level predictors of PAFR disagreement and identified additional programmatic and provider-level factors, including years of attending experience. Stewardship interventions focused on specific diagnoses and antimicrobials are unlikely to result in programmatic success unless these factors are also addressed.
Infect Control Hosp Epidemiol 2018;39:806–813
Prospective audit and feedback (PAF) is a core strategy used in antimicrobial stewardship programs (ASPs).1,2 In general, PAF is defined as postprescription review of antimicrobials by a member of an ASP team who provides feedback to the patient care providers regarding opportunities for antimicrobial optimization.3 The patient care team then decides whether to accept and implement the recommended changes. The PAF strategy has been successfully deployed in the pediatric setting and has been shown to reduce antimicrobial utilization and improve patient outcomes.4–8 Also, PAF programs have been recommended as a way to preserve prescribing autonomy because acceptance of PAF recommendations (PAFR) is voluntary. However, the roadmap to PAF success has not been clearly illustrated, and predictors of provider disagreement with ASP recommendations have not been fully elucidated.3
Stanford, California.
PREVIOUS PRESENTATION: A previous iteration of this data was presented at the Eighth Annual International Pediatric Antimicrobial Stewardship Conference on June 2, 2017, in St Louis Missouri. © 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0006. DOI: 10.1017/ice.2018.85
Received December 27, 2017; accepted March 10, 2018; electronically published April 30, 2018
Given the time-intensive nature of individual chart review
and provider communication, an understanding of when and why providers disagree with PAFR is critically important to the efficiency and success of PAF. Prior studies in pediatric populations have identified the spectrum of antimicrobial activity, infectious problem, primary service, recommendation type, and role of the person receiving the PAFR as predictors of disagreement.8,9 The generalizability of these findings are limited by the exclusion of specific antimicrobials in PAF, including antifungals and antivirals, unique programmatic factors (eg, methods of communication, parallel stewardship activities), and the inclusion of a limited number of prespecified variables in models used to predict PAFR disagreement. Therefore, we sought to advance the current knowledge base and to examine whether additional patient-level, antimicrobial, programmatic,
Affiliations: 1. Lucile Packard Children’s Hospital Stanford, Stanford, California; 2. Department of Pediatrics, Stanford University School of Medicine,
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