Prospective audit and feedback in antimicrobial stewardship: Is there value in early reviewing within 48 h of antibiotic prescription?

https://doi.org/10.1016/j.ijantimicag.2014.10.018Get rights and content

Highlights

  • Most antimicrobial stewardship programmes (ASPs) wait ≥72 h post antibiotic prescription before reviewing patients.

  • We evaluated the impact of reviewing patients within 48 h of antibiotic prescription on patient outcomes and safety.

  • ASP interventions were associated with decreased duration of therapy without increasing length of hospital stay, re-admissions and Clostridium difficile infection rate.

  • This was evident even during empirical therapy when not all clinical information was available.

Abstract

Antimicrobial stewardship programme (ASP) methodologies are not well defined, with most preferring to wait ≥72–96 h following antibiotic prescription before reviewing patients. However, we hypothesise that early ASP reviews and interventions are beneficial and do not adversely impact patient safety. This study aimed to evaluate the impact of early ASP interventions within 48 h of antibiotic prescription on patient outcomes and safety. A prospective review of ASP interventions made within 48 h of antibiotic prescription in Singapore General Hospital (SGH) from January to December 2012 was conducted. Patient demographics and outcomes were extracted from the database maintained by the ASP team. For culture-directed treatment, there was a shorter mean duration of therapy (DOT) in the accepted group compared with the rejected group (2.26 days vs. 5.56 days; P < 0.001). ASP interventions did not alter the length of hospital stay (LOS), 30-day mortality, 14-day Clostridium difficile infection (CDI), 30-day re-admissions and 14-day re-infection (all P > 0.05). For empirical treatment, a shorter DOT (3.61 days vs. 6.25 days; P < 0.001) and decreased 30-day all-cause mortality (P = 0.003) and infection-related mortality (P = 0.002) were observed among patients in the accepted group compared with the rejected group. There was no significant difference in LOS, 14-day CDI and 30-day re-admission (all P > 0.05). In conclusion, acceptance of early interventions recommended by ASP in SGH was associated with a reduction in DOT without compromising patient safety. This is evident even during empirical therapy when not all clinical information was available.

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.

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