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Pharmacist-led stewardship shows promise at limited-resource hospitals
Filed Under:
Antimicrobial Stewardship
Chris Dall | News Reporter | CIDRAP News
| Aug 19, 2019
A study conducted in four community hospitals in North Carolina indicates that pharmacist-led audit and review of antibiotic therapy is a feasible and effective strategy for antimicrobial stewardship in settings with limited resources and expertise, researchers reported in JAMA Network Open.
In the multicenter nonrandomized clinical trial with crossover design, researchers from the Duke Center for Antimicrobial Stewardship and Infection Prevention and elsewhere investigated the feasibility and effectiveness of two core antimicrobial stewardship strategies recommended by the Infectious Diseases Society of America: preauthorization approval (PA), in which the prescriber has to receive pharmacist approval to use an antibiotic, and postprescription audit and review (PPR), in which the prescriber and pharmacist review antibiotic appropriateness after 72 hours of therapy.
The two strategies are recommended based on studies that have been performed mainly in large hospitals that have infectious disease (ID) experts and other trained staff dedicated to antibiotic stewardship. But small community hospitals, which have the highest rate of antibiotic use in the United States, frequently lack these resources.
PPR results in decreased antibiotic use
To determine if these two strategies can work in such settings, the researchers enrolled four community hospitals from the Duke Antimicrobial Stewardship Outreach Network in the study. Two hospitals performed PA for 6 months, then PPR for 6 months after a 1-month washout. The other 2 hospitals performed the reverse. At each hospital, one or more pharmacists received stewardship training to address common questions and anticipated arguments, along with training in conflict management.
Because strict PA was deemed not feasible at the hospitals, a modified PA strategy, in which the prescriber has to receive pharmacist approval for continued use of an antibiotic after the first dose, was implemented.
A total of 2,692 patients underwent a study intervention, with pharmacists performing 1,456 modified PA interventions and 1,236 PPR interventions at the four hospitals. The targeted antibiotics were vancomycin hydrochloride, piperacillin-tazobactam, and antipseudomonal carbapenems.
The results showed that the targeted antimicrobials were determined to be inappropriate twice as often during the PPR intervention (41% vs 20.4%, P < .001), while dose changes were recommended more often during the modified PA intervention (15.9% vs 9.6%, P < .001).
Overall antibiotic use decreased during PPR compared with historic controls (mean days of therapy per 1,000 patient-days, 925.2 vs 965.3; mean difference, −40.1; 95% confidence interval [CI], −71.7 to −8.6), but not during modified PA (mean days of therapy per 1,000 patient-days, 931.0 vs 926.6; mean difference, 4.4; 95% CI, −55.8 to 64.7). The median time dedicated to the stewardship interventions varied by hospital (range of median hours per week, 5 to 19).
Clinicians often chose non-study antibiotics
In a survey of clinicians at the study hospitals, 88.1% said they agreed that antimicrobial stewardship was important for patients, and 48.8% said they changed therapy based on pharmacist recommendations. But 31.3% chose non-study antibiotics during the intervention periods to avoid interacting with the stewardship pharmacist.
The authors of the study say that, while both PPR and modified PA were feasible at the hospitals and identified several opportunities to improve antibiotic use, recommendations made during PPR were more likely to lead to de-escalation of therapy, resulting in lower antibiotic use compared with historic controls.
"Our findings suggest that PPR is a better choice than PA for stewardship teams in community hospitals with limited resources, particularly when stewardship interventions must be completed by a pharmacist," they write.
But they also note that PPR in community hospitals can be made more efficient if more resources are dedicated to stewardship. During the study, pharmacists intervened in only 31% of eligible patients, and the authors suggest that's because they had multiple non-stewardship responsibilities.
"Ultimately, for hospitals to be most efficient, stewardship teams in community hospitals will need to have dedicated time and resources to complete stewardship interventions that fit their local environment," they conclude.
In a related commentary, US experts not involved in the study applaud the approach and write, "The need to improve antibiotic use is universal, but the approach to stewardship need not be the same. Adaptation, not imitation, is the key to success."
See also:
Aug 16 JAMA Netw Open study
Aug 16 JAMA Netw Open commentary
Pharmacist-led stewardship shows promise at limited-resource hospitals
Filed Under:
Antimicrobial Stewardship
Chris Dall | News Reporter | CIDRAP News
| Aug 19, 2019
A study conducted in four community hospitals in North Carolina indicates that pharmacist-led audit and review of antibiotic therapy is a feasible and effective strategy for antimicrobial stewardship in settings with limited resources and expertise, researchers reported in JAMA Network Open.
In the multicenter nonrandomized clinical trial with crossover design, researchers from the Duke Center for Antimicrobial Stewardship and Infection Prevention and elsewhere investigated the feasibility and effectiveness of two core antimicrobial stewardship strategies recommended by the Infectious Diseases Society of America: preauthorization approval (PA), in which the prescriber has to receive pharmacist approval to use an antibiotic, and postprescription audit and review (PPR), in which the prescriber and pharmacist review antibiotic appropriateness after 72 hours of therapy.
The two strategies are recommended based on studies that have been performed mainly in large hospitals that have infectious disease (ID) experts and other trained staff dedicated to antibiotic stewardship. But small community hospitals, which have the highest rate of antibiotic use in the United States, frequently lack these resources.
PPR results in decreased antibiotic use
To determine if these two strategies can work in such settings, the researchers enrolled four community hospitals from the Duke Antimicrobial Stewardship Outreach Network in the study. Two hospitals performed PA for 6 months, then PPR for 6 months after a 1-month washout. The other 2 hospitals performed the reverse. At each hospital, one or more pharmacists received stewardship training to address common questions and anticipated arguments, along with training in conflict management.
Because strict PA was deemed not feasible at the hospitals, a modified PA strategy, in which the prescriber has to receive pharmacist approval for continued use of an antibiotic after the first dose, was implemented.
A total of 2,692 patients underwent a study intervention, with pharmacists performing 1,456 modified PA interventions and 1,236 PPR interventions at the four hospitals. The targeted antibiotics were vancomycin hydrochloride, piperacillin-tazobactam, and antipseudomonal carbapenems.
The results showed that the targeted antimicrobials were determined to be inappropriate twice as often during the PPR intervention (41% vs 20.4%, P < .001), while dose changes were recommended more often during the modified PA intervention (15.9% vs 9.6%, P < .001).
Overall antibiotic use decreased during PPR compared with historic controls (mean days of therapy per 1,000 patient-days, 925.2 vs 965.3; mean difference, −40.1; 95% confidence interval [CI], −71.7 to −8.6), but not during modified PA (mean days of therapy per 1,000 patient-days, 931.0 vs 926.6; mean difference, 4.4; 95% CI, −55.8 to 64.7). The median time dedicated to the stewardship interventions varied by hospital (range of median hours per week, 5 to 19).
Clinicians often chose non-study antibiotics
In a survey of clinicians at the study hospitals, 88.1% said they agreed that antimicrobial stewardship was important for patients, and 48.8% said they changed therapy based on pharmacist recommendations. But 31.3% chose non-study antibiotics during the intervention periods to avoid interacting with the stewardship pharmacist.
The authors of the study say that, while both PPR and modified PA were feasible at the hospitals and identified several opportunities to improve antibiotic use, recommendations made during PPR were more likely to lead to de-escalation of therapy, resulting in lower antibiotic use compared with historic controls.
"Our findings suggest that PPR is a better choice than PA for stewardship teams in community hospitals with limited resources, particularly when stewardship interventions must be completed by a pharmacist," they write.
But they also note that PPR in community hospitals can be made more efficient if more resources are dedicated to stewardship. During the study, pharmacists intervened in only 31% of eligible patients, and the authors suggest that's because they had multiple non-stewardship responsibilities.
"Ultimately, for hospitals to be most efficient, stewardship teams in community hospitals will need to have dedicated time and resources to complete stewardship interventions that fit their local environment," they conclude.
In a related commentary, US experts not involved in the study applaud the approach and write, "The need to improve antibiotic use is universal, but the approach to stewardship need not be the same. Adaptation, not imitation, is the key to success."
See also:
Aug 16 JAMA Netw Open study
Aug 16 JAMA Netw Open commentary