810 infection control & hospital epidemiology july 2018, vol. 39, no. 7
table 1. Patient, Antimicrobial, and Programmatic Character- istics at Time of Prospective Audit and Feedback Recommendations (PAFR)
PAFR followed Characteristic
Patient age, mean y ± SDa Female gender
Patient race White or Caucasian
American Indian or Alaska Native or Native Hawaiian or other Pacific Islander or other or unknown
Asian Black or African American
Infectious problem groupinga Sepsis
Respiratory infection Prophylaxis Bacteremia
Urinary tract infection Febrile neutropenia Gastrointestinal/IAI
Skin and soft tissue infection Other
ID consulting Elevated CRP Febrile
Elevated procalcitonin Invasive ventilation
Noninvasive ventilation Central linea
Transplant during admission
(N=1,046), No. (%)
5.6±6.7
PAFR not followed
(N=187), No. (%)
8.2±9.5
695 (66) 115 (61.5) 418 (40)
79 (42.2) 395 (37.8) 74 (37.7)
180 (17.2) 30 (16) 53 (5)
4 (2.1)
433 (42.2) 82 (43.9) 232 (22.2) 35 (18.7) 121 (11.5) 15 (8) 77 (7.3) 42 (4)
8 (4.3) 4 (2.1)
38 (3.6) 37 (3.5) 32 (3)
24(2.2)
100 (9.6) 47 (4.5) 87 (8.3) 21 (2)
49 (4.7) 31 (3)
Stem-cell transplant during admission 13 (1.2) Oncology diagnosis ECMO before audit VAD before audit
Days from admission to audita 0–30
31–90 91+
Total ICU LOS, mean d ± SDa Total LOS, mean d ± SDa
Antimicrobial typea Broad-spectrum gram-negative antibiotic
Broad-spectrum gram-positive antibiotic
Narrow-spectrum antibiotic Other
Recommendation typea Stop
Change agent
Optimize dose or frequency Clarify
IV to PO
Duration modification Other
17 (9.1) 15 (8)
2 (1.1) 9 (4.8)
21 (11.2) 10 (5.3) 19 (10.2) 5 (2.7)
11 (5.9) 7 (3.7)
646 (62) 130 (69.5) 74 (7.1)
17 (9.1) 4 (2.1)
202 (19.3) 45 (24.1) 32 (3)
6 (3.2) 5 (0.5) 0
841 (80.4) 128 (68.5) 134 (12.8) 44 (23.5) 71 (6.8)
15 (8)
40.1±69.4 52.4±75.4 56.1±76 71.4±80
438 (41.9) 81 (43.3) 241 (23)
63 (33.7)
318 (30.4) 33 (17.6) 49 (4.7)
10 (5.3)
464 (44.4) 105 (56.1) 134 (12.8) 36 (19.3) 149 (14.2) 104 (9.9) 69 (6.6) 61 (5.8) 65 (6.2)
7 (3.7) 4 (2.1) 7 (3.7)
14 (7.5) 14 (7.5)
table 1. Continued PAFR followed Characteristic
Provider who communicated recommendation Pharmacist
Primary service ID service
Duration from process start to audit, mean d ± SD
Medical servicea Intensive care Neonatology
Cardiovascular intensive care
Hematology-oncology/stem-cell transplant
Medical Surgical
Attending experience posttraining, mean y ± SD
(N=1,046), No. (%)
PAFR not followed
(N=187), No. (%)
880 (84.1) 166 (88.8) 138 (13.2) 16 (8.6) 28 (2.7)
5 (2.7) 258±210 274±201 482 (46) 95 (50.8)
258 (24.7) 30 (16) 155 (14.8) 39 (20.9) 70 (6.7)
13 (7)
68 (6.5) 13 (1.2)
9 (4.8) 1 (0.5)
10.8±9.5 11.6±9.4
NOTE. CRP, C-reactive protein; ECMO, extracorporeal membrane oxygenation; IAI, intra-abdominal infection; ICU, intensive care unit; ID, infectious diseases; IV, intravenous; LOS, length of stay; PAFR, prospective audit and feedback recommendation; PO, enteral; SD, standard deviation; UTI, urinary tract infection; VAD, ventricular
assist device. aUnivariate analysis identified a statistically significant difference between groups (P<.05).
other pediatric studies, presumed and proven sepsis should be areas of focus for future stewardship research. We found some interesting differences between our study results and prior studies. In our study, nearly 30% of our audits resulted in a recommendation, which is significantly higher than previous reports of a 16%–19% recommendation rate.5,9,10 Potential explanations for this finding could include our review of all, rather than select, antimicrobials or clinical scenarios (eg, pathogen–drug mismatch, redundant therapy), worse overall antimicrobial prescribing practices at our institution, or a more aggressive approach to PAF by our ASP team. Our rate of disagreement of 15% was also slightly lower than previous reports of 18%–23%; however, the factors accounting for various rates of disagreement across institutions are likely multifactorial.5,7,9,10 Our study adds to the literature on the types of patient
conditions that are associated with provider disagreement with PAFR. One prior study showed that disagreement with PAFR was more common for specific patient conditions, including community-acquired pneumonia, suspected sepsis, febrile neutropenia, gastrointestinal disease, surgical infections, and diseases of the ear, nose, and throat.9 Similarly, our study identified the presence of febrile neutropenia, gastrointestinal,
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