Hospitals across the world continue to observe increasing rates of multidrug resistant pathogens and Clostrioides difficile infection; leading to significant morbidity, mortality, and hospital costs. In fact, these trends have become so alarming that the World Health Organization has labeled multidrug-resistant pathogens as one of the top 3 threats to modern health care.
An association between antibiotic exposure and acquire drug resistance is well establish. Because 30% to 50% of antibiotic use is inappropriate; hospital level quality improvement programs design to improve antimicrobial use, namely, antimicrobial stewardship (AS) teams, are an essential intervention to curb these concerning trends.
The Infectious Diseases Society of America (IDSA) recommends the following 2 core strategies for AS: antimicrobial restriction/preauthorization (PA) and postprescription audit and review (PPR) with intervention and feedback. While the need for these core AS strategies is clear; it remains unclear whether they can be effectively use in all health care settings.
Tertiary care hospitals
Stewardship recommendations have largely generate base on studies perform in large tertiary care hospitals. In contrast, most health care provide in the United States is provide in community hospitals. These hospitals represent a setting of increase need for stewardship because small; nonteaching community hospitals have the highest rate of antibiotic use in the United States.
Postprescription audit and review (PPR) is a feasible and effective strategy for antimicrobial stewardship in community hospitals; so according to a study publish online Aug. 16 in JAMA Network Open. Deverick J. Anderson, M.D., from Duke University in Durham, North Carolina, and colleagues asses the feasibility of implementing two core Infectious Diseases Society of America-recommend antimicrobial stewardship interventions: modified preauthorization and postprescription audit and review.
These two interventions were implement at four community hospitals in North Carolina (bed size range, 102 to 425). A total of 2,692 patients receiving either target study antibacterial agents or alternative; nonstudy antibacterial agents were include in the intervention. The researchers found that pharmacists perform 1,456 modify PA interventions (median per hospital, 350); also 1,236 PPR interventions (median per hospital, 298).
The stewardship interventions
Study personnel worked with study hospital personnel to ensure that protocols for the stewardship interventions were approve at each study hospital. Approval processes vary by study hospital but typically include discussions with and approval by pharmacy leadership, pharmacy and therapeutics, and medical executive committees. Study interventions were not start until approvals were receive from all study hospitals.
“Even modest decreases in antimicrobial utilization are valuable; so particularly when potentially achievable in the more than 3,000 community hospitals in the United States,” Anderson said in a statement. “This study suggests there are approaches that can work; so even in hospitals where resources might be limited.” Data from our 3-stage, multicenter, historically control prospective nonrandomize clinical trial with crossover design add to the growing literature that stewardship can be successfully perform in community hospital settings.
Active, core stewardship interventions were feasible in our community hospitals; although true PA or “restriction” of antibiotics was not. These interventions led to more interactions between pharmacists and prescribers; providing additional opportunities to optimize antimicrobial therapy. More specifically, PPR in our study led to more interventions, particularly de-escalation; which likely influence overall antimicrobial use. Ultimately, for hospitals to be most efficient; stewardship teams in community hospitals will need to have dedicate time and resources to complete stewardship interventions that fit their local environment.