Infection Control & Hospital Epidemiology
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Fig. 2. Impact of antibiotic stewardship program (ASP) strategic elements on antibiotic use. Forest plot of the rate ratio (RR) of unadjusted and adjusted antibiotic use measured in defined daily doses (DDD) per 1000 patient days (PD) for hospitals with specified ASP characteristics. The reference is the absence of the characteristic, and for the number of strategic characteristics it is 0–7 elements.
association between the overall number of strategies and anti- microbial use, both studies found that prospective audit and feedback was a predictor of reduced antibiotic use. In contrast, a study of 977 acute-care hospitals in France found no association between their “action score,” a measure of strategies implemented, and antibiotic usage. However, they found an association between the hospital’s “resource score,” an indicator of personnel and technological support, and antibiotic consumption.10 Predictors of antibiotic use variability differ across studies, which may reflect differences in definitions of ASP components, scoring systems used, risk-adjustment, and geography. Nevertheless, the literature to date supports the recommendations by the IDSA/SHEA and CDC that both structural and strategic characteristics must be considered when building an ASP. Presence of ASP funding and/or resources was associated with
modestly lower antibiotic use. The independent impact of this structural element is difficult to assess given that ASP resources allow for more robust implementation of strategies, the latter of which are expected to drive changes in antibiotic prescribing. However, evidence shows that ASPs without funding and/or resources may be less able to impact antibiotic prescribing through strategies such as prospective audit and feedback.11 Although we detected a trend toward reduced antibiotic use in programs with pharmacist and physician champions, these elements were not associated with reduced antibiotic use in the adjusted analysis. Pharmacist and physician leadership of ASPs is certainly important, but they are most likely to be effective when having protected time to perform ASP duties, further under- scoring the need for dedicated ASP personnel. A recent Cochrane review examining interventions to improve antibiotic prescribing in hospital settings found that both
restrictive and enabling (advice or feedback to guide prescribing) were effective at improving antibiotic use and reducing length of stay without increasing mortality.12 Furthermore, enabling approaches tended to amplify the impact of other interventions, including antimicrobial restrictions. We did not find an associa- tion between restrictions and antibiotic use, but we did find that the enabling intervention of prospective audit and feedback was a predictor of lower antibiotic use. Importantly, 2 interventions strongly recommended by
the IDSA/SHEA were associated with low antibiotic utilization: prospective audit and feedback and intravenous-to-oral conver- sion. Although prospective audit and feedback has a proven impact on antimicrobial utilization,13,14 the mechanism by which intravenous-to-oral conversion can reduce antibiotic consump- tion is less certain. One reason for this finding could be reduced length of stay15 for patients receiving antimicrobial agents, allowing for earlier discharge and shifting use to the outpatient setting. Alternatively, intravenous-to-oral strategies may be indirect markers of more robust ASPs. Our study does have some limitations. There may be selection
bias given that only 57% of eligible hospitals participated. Our model risk-adjusted antibiotic use at the facility level, but given the observational nature of the study, unmeasured confounding may have occurred. Factors that may influence antibiotic use patterns, such as percentage of cystic fibrosis, oncology, and organ transplantation patients, were not considered. On the other hand, in this study, antibiotic use tended to be higher in community hospitals where these populations are less likely to be found. Due to the self-reported nature of the survey, the fidelity and degree of implementation of each ASP element was not assessed, which although challenging to quantify, could be an
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