Prospective audit and feedback in antimicrobial stewardship: Is there value in early reviewing within 48 h of antibiotic prescription?☆
Introduction
Antimicrobial stewardship programmes (ASPs) have been implemented worldwide in an attempt to control the phenomenon of increasing antimicrobial resistance, especially in developed countries [1], [2]. Studies have shown that ASPs can effectively reduce antibiotic utilisation, the cost of care and even antimicrobial resistance rates [3], [4], [5]. There are many strategies and interventions aimed at improving appropriate prescription of antibiotics in healthcare settings and all are considered as part of ‘antimicrobial stewardship’. Prospective audit and feedback intervention is one of the two core ASP strategies recommended by the Infectious Diseases Society of America (IDSA) that has been shown to be effective. In a two-step review method adopted by Singapore General Hospital (SGH), clinical infectious diseases pharmacists will review the case individually first [6]. Thereafter, they will present cases with a diagnostic conundrum that fulfils pre-set criteria for intervention to the physician for vetting, with recommendations for change or discontinuation of antibiotics conveyed to the primary physicians via written forms or direct verbal communication. Whilst there are recommendations for reviewing antibiotic prescription within 48 h of antibiotic prescription [2], most ASP teams prefer a lapse of ≥72 h of antibiotic prescription before reviewing [7], [8], [9]. The latter approach allows more clinical information, including bacterial culture results, radiology results and response to initial therapy, to be made available before interventions are considered. Moreover, in some institutions, microbiological reports are only released or confirmed as finalised after >96 h from the time of culture. In SGH, we adopted the earlier review strategy on the premise that early reviewing and intervening of cases is beneficial to patients and does not adversely impact patient safety. Hence, this paper aimed to evaluate the impact of early ASP interventions (within 48 h of antibiotic prescription) on patient outcomes and safety.
Section snippets
Study and setting
SGH is a 1579-bed, acute tertiary-care hospital in Singapore. A prospective review of the ASP database was conducted focusing on outcomes of all patients in whom the ASP team had intervened in their antibiotic therapy within 48 h of antibiotic prescription between January 2012 and December 2012. Two types of interventions were performed within 48 h of antibiotic prescription: (i) interventions based on empirical therapy; and (ii) interventions based on culture-directed therapy. Each type of
Interventions
The ASP team had recommended 1946 interventions in a total of 5797 admissions audited between January 2012 and December 2012. Overall, 1440 (74.0%) of these interventions were accepted whilst the remaining 506 interventions (26.0%) were rejected by the primary healthcare team. The most commonly audited antibiotics were TZP (49.5%), followed by carbapenems (36.4%), i.v. ciprofloxacin (11.1%) and cefepime (2%).
A total of 1206 interventions were made to narrow or discontinue empirical antibiotic
Discussion
It is definitely worthwhile for the ASP team to review and intervene early within 48 h of broad-spectrum antibiotic prescription, without waiting for more clinical information such as culture results to be known. We found that 48.8% of all interventions were done within 48 h of antibiotic prescription. In addition, the rejection rates of early ASP intervention within 48 h of post antibiotic prescription were not statistically higher compared with those interventions made later, after cultures were
Acknowledgments
The authors would like to thank the whole of the ASP team for their contributions towards the programme.
Funding: No funding sources.
Competing interests: None declared.
Ethical approval: The SingHealth Centralised Institutional Review Board approved this study [CIRB Ref 2010/114/E].
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This paper has been previously presented as an oral presentation at the 24th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), 10–13 May 2014, Barcelona, Spain.