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Impact of Antimicrobial Stewardship Program Interventions on Antimicrobial Resistance

Reference Setting Key staff Intervention Impact Tools
Buising KL, Thursky KA, Robertson MB, Black JF, Street AC, Richards MJ, and Brown GV. Electronic antibiotic stewardship-reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting.  Journal of Antimicrobial Chemotherapy. 2008; 62:608-616 365-bed tertiary care teaching hospital, Melbourne, Australia Drug and Therapeutics Committee Electronic Monitoring-implementation of a computerized antimicrobial approval system for ordering restricted antibioics, limiting duration of dispensement and facilitating communication with pharmacy, ID and prescribers Gradients in DDD for use in 3rd and 4th generation cephalosporins (+.52, -0.05, -0.39 p<.01), glycopeptides (+0.27, -0.52 p=0.09), carbapenems (0.12, -0.24 p=0.21), aminoglycosides (0.15, -0.27 p<0.01) and quinolones (0.76, 0.11 p=0.08) decreased over 5 years while extended-spectrum penicillin use increased (0.16, 1.16 p<0.01).  Trends in improved susceptibility of S. aureus to methicillin and improved susceptibility of pseudomonas to many antibiotics observed
Raymond DP, Pelletier SJ, Crabtree TD, Gleason TD, Hamm LL,  Pruett TL,  Sawyer RG.  Impact of a rotating empiric antibiotic schedule on infectious mortality in an intensive care unit.  Critical Care Medicine 2001; 29: 1101-1108 Tertiary care teaching hospital in the surgical and trauma ICU, Charlottsville, VA, USA ICU physicians cycling-2 year study during which the first year had nonprotocal-driven antibiotic use compared with the second year during which a quarterly rotating empiric antibiotic schedule was used significant reductions in the incidence of antibiotic-resistant Gram-positive coccal infections (7.8 infections/100 admissions vs. 14.6 infections/100 admissions, p < .0001), antibiotic-resistant Gram-negative bacillary infections (2.5 infections/100 admissions vs. 7.7 infections/100 admissions, p < .0001), and mortality associated with infection (2.9 deaths/100 admissions vs. 9.6 deaths/100 admissions, p < .0001) during rotation.Antibiotic rotation was an independent predictor of survival (OR 6.27, 95% CI 2.78–14.16).
Cook PP, Catrou P, Gooch M, Holbert D. Effect of reduction in ciprofloxacin use on prevalence of methicillin-resistant Staphylococcus aureus rates within individual units of a tertiary care hospital. Journal of Hospital Infection. 2006; 64: 348-351 731-bed tertiary care teaching hospital, Greenville, NC, USA Antimicrobial management program, pharmacists Reduction-Active monitoring of oral and IV ciprofloxacin use.  Pharmacists would contact prescribers with recommendations for changing to alternative abx or d/c'ing abx based on micro data from individual patient Examined units with >10 isolates of S. aureus comparing 2004 and 2005 data. In 17 unites, ciprofloxacin use decreased by 31.2% (p<0.0001). MRSA rates decreased from 59.6% to 54.2% (p=0.112).  Correlation between cipro use and MRSA rates (r=0.70; 95% CI -0.01-0.94 p=0.053)
Rahal JJ, Urban C, Horn D, Freeman K, Segal-Maurer S, Maurer J, Mariano N, Marks S, Burns JM, Dominick D, Lim M. Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella.  JAMA, 1998;280(14): 1233-1237 500-bed university affiliated community hospital, Queens, NY, USA infectious disease physicians Restriction-Hospital adopted antibiotic guidelines restricting routine cephalosporin use and requiring primary team to seek ID approval for use 80.1% reduction in hospital-wide cephalosporin use in 1996 compared to 1995.  44% reduction in incidence of ceftazidime-resistant Klebsiella infection and colonization throughout medical center (p<0.01) and 70.9% reduction in all intensive care units (p<0.001) and 87.5% reduction in SICU).  68.7% increase in incidence of imipenem-resistant pseudomonas throughtout the hospital (p<0.01).
Bantar C, Sartori B, Vesco E, Heft C, Saúl M, Salamone F, Oliva ME. A hospitalwide intervention program to optimize the quality of antibiotic use: impact on prescribing practice, antibiotic consumption, cost savings, and bacterial resistance. CID 2003; 37(2): 180-186 250-bed public teaching hospital, Parana, Argentina Antimicrobial Treatment Committee (infectious disease physician, clinical and laboratory microbiologist, pharmacist, general internist, and computer systems analyst Multidisciplinary-Over the course of 6 months, 4 step-wise interventions occurred.  These were introduction of an optional antibiotic order form, feedback activities for prescribers and transforming the optional order form into a required one, creation of formal abx prescription policies and finally allowing the  ATC to inteverne and actively revise inappropriate prescriptions Sustained reduction of drug consumption was shown during the study (R2=0.6885; P=.01). Total cost savings was 913,236 US dollars. 3rd gen cephalosporin resistance: E. coli NS 18/months, Klebsiella NS/18months, proteus 32.5% reduction/18months, Enterobacter cloacae 80% reduction/18 months; amp/sulbactam resistance: e. coli NS/18 months; imipenem/clilastatin resistance: pseudomonas 100% reduction/18 months; cefepime resistance: pseudomonas NS/18months; MRSA: 36.3% reduction/18 months antibiotic order form
 
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