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Impact of Antibiotic Stewardship Program Interventions on Costs

Reference Setting Key staff Resources required Intervention Impact Tools
Seligman SJ. Reduction in Antibiotic Costs by Restricting Use of Oral Cephalosporin. American Journal of Medicine. 1981, 71: 941-944 1472-bed municipal hospital, Brooklyn, New York, USA infectious disease physicians, pharmacy Restriction-All physicians wanting to prescribe cephalexin had to seek approval from ID physician. Cost of cephalexin dispensed went from $314,105 to $4,166 over one year.  Total reduction in antibiotic costs was 29% when adjusted for inflation.
Britton HL, Schwinghamer TL, Romano MJ. Cost Containment through restrictions of cephalosporins. American Journal of Hospital Pharm. 1981; 38: 1897-900. 500-bed teaching hospital, Pittsburgh, PA, USA infectious disease service, pharmacists $1500 annually for monitoring program Guidelines - Establishment of guidelines that cefazolin is cephalosporin of choice. Physicians contacted if orders deemed to be noncompliant. Total purchases of cephalosporins decreased by $55,715 or 46.2% in first 12 months of program. Purchase costs for cephalosporins decreased from $0.921 per patient day to $0.519 (43.6%) per patient after the study period. Number of milligrams of cephalosporins used per patient day decreased from 398.16 to 178.77 (55.1%) while number of patient days decreased by 4.45%. guidelines for cephalosporin use
Hayman JN, Sbravati. Controlling cephalosporin and aminoglycoside costs through pharmacy and therapeutics committee restrictions. American Journal of Hospital Pharm. 1985; 42:1343-1347 545-bed, state-supported, tertiary-care teaching hospital, Jackson, MS, USA Pharmacy, Pharmacy and Therapeutics Committee Guidelines - Established restrictions on use of 2nd generation cephalosporins and aminoglycosides requiring obtaining pharmacy approval before drug disbursement Second generation cephalosporin use decreased 52.2%, tobramycin decreased by 75.9% while unrestricted gentamicin increased 229% during study period.  Reduced expenditures on injectable antibiotics by $193,172.06 during 12 months following restrictions.
Woodward RS, Medoff G, Smith MD, Gray JL. Antibiotic Cost Savings from Formulary Restrictions and Physician Monitoring in a Medical-School-Affiliated Hospital. American Journal of Medicine, 1987 (83):817-823 1,208-bed, tertiary-care teaching hospital, St. Louis, MO, USA infectious disease physician 76 hours per month for pharmacist, 24 hours per month for ID fellows, 10 hours per month for 4 faculty Restriction-creation of formulary restrictions for vancomycin and select aminoglycocides and cephalosporins, which would require obtaining ID approval for use. ID told not to reject requests but to use persuasion. Combined savings from restricted antibiotics $2.61 per antibiotic day and $34,597 after formulary restrictions. 7.2% and 12.4% savings respectively from the pharmacy’s 1985 $18.45 average cost per antibiotic day and $199,003 average monthly expenditure. No significant changes in LOS or mortality for patients after restrictions.
Maswoswe JJ, Okpara AU. Enforcing a policy for restrcting antimicrobial drug use. American Journal of Healthy Systems Pharm. 1995 (52): 1433-1435. 580-bed, county teaching hospital, Houston, TX, USA infectious disease physicians, pharmacists Restriction - Eight IV antibiotics (amikacin, aztreonam, ceftazidime, ciprofloxacin, fluconazole, imipenem-cilastatin, ofloxacin, and ticarcillin-clavulanate, (aztreonam was added to list two months into intervention) previously needed approval, but enforcement of restrictions lax. All staff informed that ID approval needed for dispensement and that pharmacists needed to be informed in writing or by telephone. Enhanced enforcement included issuing warnings to pharmacists if restricted antibiotics dispensed without ID approval. $82,544 reduction in restricted antimicrobials after 2 months, but $79,008 increase in cost of unrestricted.  After aztreonam restricted, acquisition costs decreased from $53,496 per month to $10,115 per month after two months.  Hospital reduced costs by $300,235 over nine-month period.
Briceland LL, Nightingale CH, Quintiliani R, Cooper BW, Smith KS. Antibiotic Streamlining from Combination Therapy to Monotherapy Utilizing an Interdisciplinary Approach.  Archives of Internal Medicine. 1988 (148): 2019-2022 600-bed, community teaching hospital, Hartford, CT, USA infectious disease physicians, nursing-unit pharmacists Streamlining - Patients on two or more empiric parenteral antibiotics identified by nursing unit pharmacist, results shared with ID physician, who then called prescribing physician to suggest alternative monotherapy. Cases necessitating streamling decreased from 98.6% during first month to 54.4% during seventh month. Total cost savings of $38,920.95 during intervention period.  Annual cost savings estimated to be $107,637 after adjusting for changes in improved prescribing practices.
Glowacki RC, Schwartz DN, Itokazu GS, Wisniewski MF, Kieszkowski P, Weinstein RA. Antibiotic Combinations with Redundant Antimicrobial Spectra: Clinical Epidemiology and Pilot Intervention of Computer-Assisted Surveillance. CID. 2003 (37): 59-64 600-bed, public teaching hospital, Chicago, IL, USA infectious disease pharmacist $2880 for pharmacist's time Streamlining - Patients on two or more antibiotics identified by computer. After records review for redundant combinations, pharmacist would contact clinician to determine clinical indication and make recommendations for streamlining when appropriate. 71% of combinations investigated found to be inappropriate. Intervention projected to have $10,800 in cost savings and 584-day reduction in antibiotic combination days. inpatient pharmacy computer system for identifying patients on >=2 antibiotics
Avorn J, Soumerai SB, Taylor W, Wessels MR, Janousek J, and Weiner M.  Reduction of incorrect antibiotic dosing through a structured educational order form. Archives of Internal Medicine. 1988; 148:1720-1724 621-bed, tertiary-care teaching hospital, Boston, MA, USA infectious disease physicians Order form - Creation of an order form with preset dosing orders for clindamycin, cefazolin and metronidazole. Physicians still had option to choose own dosing schedule on the form. Before intervention, incorrect dosing orders for clindamycin, cefazolin, and metronidazole were 90%, 60% and 75% patient days of therapy respectively.  After implementation, nonrecommended dosing fell to under 6% of patient days. Savings amounted to $76,000 annually in drug costs. antibiotic order form
Agwu AL, Lee CK, Jain SK, Murray KL, Topolski J, Miller RE, Townsend T and Lehmann CU. A World Wide Web-based antimicrobial stewardship program improves efficiency, communication, and user satisfaction and reduces cost in a tertiary care pediatric medical center. CID 2008; 47: 747-753 175-bed, tertiary-care children's hospital, Baltimore, MD, USA pediatric infectious disease physicians, pediatric pharmacists, and informatician Electronic Monitoring - Implementation of a web-based program to provide automated clinical decision support, faciliate approval and real-time communication with prescribers related to antibiotics. Reduction in $370,069 in projected, annual cost associated with restricted antimicrobial use and an 11.6% reduction in doses of restricted antibiotics over one year. User satisfaction improved from 22% to 68% and from 13% to 69% among prescribers and pharmacists respectively. World Wide Web-based antimicrobial restriction program
McGregor JC, Weekes E, Forrest GN, Staniford HC, Perencevich EN, Furuno JP, and Harris AD. Impact of a Computerized Clinical Decision Support System on Reducing Inappropriate Antimicrobial Use: A Randomized Controlled Trial. J Am Med Inform Assoc. 2006; 13: 378-384 648-bed, tertiary-care teaching hospital, Baltimore, MD, USA infectious disease physician and clinical pharmacist Electronic Monitoring – randomized controlled trial  of active monitoring by antimicrobial management team of all restricted antibiotic orders with a computer system compared to a group without the computer system to alert for inadequate antimicrobial therapy. Team intervened in 16% of patient cases in intervention arm vs 8% in control arm and spent one hour less per day with the intervention arm. Hospital expenditures were $285,812 vs. $370,000 in control arm over 3 months. No significant difference in mortality. Clostridium difficile super infection NS/3 months. computerized monitoring software
Fraser GL, Stogsdill P, Dickens JD, Wennberg DE, Smith RP, and Prato BS. An evaluation of patient safety and economic outcomes. Archives of Internal Medicine. 1997; 157: 1689-1694 600-bed, tertiary-care teaching hospital, Portland, ME, USA infectious disease physician and clinical pharmacist Multidisciplinary - Three month randomized controlled trial of patients receiving parenteral antibiotics for three or more consecutive days. Intervention group received suggestion for antibiotics from ID and pharmacist. The control did not. 49% of intervention group received suggestions. Per patient antibiotics cost was $400 lower in intervention vs. control (p=0.05). Clinical outcomes similar for patients in both groups.
Coleman RW, Rodondi LC, Kaubisch S, Granzella NB, and O'Hanley PD. Cost-effectiveness of prospective and continuous parenteral antibiotic control: experience at the Palo Alto Veterans Affairs Medical Center from 1987-1989. American Journal of Medicine. 1991;90:439-444. Palo Alto VA, Palo Alto, CA, USA infectious disease service Multidisciplinary - Implementation of new restrictions in antibiotic formulary for broad-spectrum antibiotics and restrictions for antibiotics maximum daily dosage. Average monthly antibiotics cost during 26-month, post-intervention period was $7,600 less than in 16-month pre-policy period (p<0.001). Therapies altered by ID 34.5% of cases during 26 month period. Antibiotic use per patient in similar DRG decreased by 24% (p=0.005) and cost decreased by 32% (p=0.004).  In repiratory infections  DRG average number of doses decreased by 33% and cost by 45% (p=0.05 and 0.04 respectively). Pt outcomes similar pre and post intervention.
Przybylski KG, Rybak MJ, Martin PR, Weingarten CM, Zaran FK, Stevenson JG, and Levine DP. A pharmacist-initiated program of intravenous to oral antibiotic conversion. Pharmacotherapy. 1997;17 (2):271-276. Detroit Receiving Hospital and University Health Center, Detroit, MI, USA Detroit Receiving Hospital and University Health Center, Detroit, MI, USA Pharmacists Conversion - Pharmacists contacted physicians to recommend oral antibiotics conversions from selected broad-spectrum and high-cost parenteral antibiotics for patients with predetermined mild to moderate clinical conditions. Over 12 months, 52% of patients converted to oral equivalent of intravenous antibiotics initially prescribed.  Average number of days of therapy for patients converted was 1.53 days shorter (3.3 +/-2.8 vs. 4.83+/-2.1) than those not converted (p<0.003). Cost savings for drug acquisition and LOS were $15,149.24 and $161,071.88 respectively. Over 12 months, 52% of patients converted to oral equivalent of intravenous antibiotics initially prescribed. Average number of days of therapy for patients converted was 1.53 days shorter (3.3 +/-2.8 vs. 4.83+/-2.1) than those not converted (p<0.003). Cost savings for drug acquisition and LOS were $15,149.24 and $161,071.88 respectively.
Omidvari K, De Boisblanc BP, Karam G, Nelson S, Haponik E and Summer W.  Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis. Respiratory Medicine 1998 (92):1032-1039 Omidvari K, De Boisblanc BP, Karam G, Nelson S, Haponik E and Summer W. Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis. Respiratory Medicine 1998 (92):1032-1039 Multicenter-Medical Center of Louisiana, New Orleans USA as main site and other hospitals in USA Multicenter-Medical Center of Louisiana, New Orleans USA as main site and other hospitals in USA Conversion - CAP pts randomized to conventional course of IV antibiotics vs. abbreviated course of IV antibiotics followed by conversion to oral antibiotics conversion-CAP pts randomized to conventional course of IV antibiotics vs. abbreviated course of IV antibiotics followed by conversion to oral antibiotics. No difference in clinical courses, cure rates, survival, or resolution of CXR abnormality.  Mean duration of therapy was 6.88 days in control vs. 7.3 days in intervention and frequencies of symptom improvement were 97% vs. 95% respectively. Patients in intervention had shorter hospital stays (7.3 vs. 9.71 days p=0.01) and lower total costs of care ($2,953 vs. $5,002) p<0.05). There was no difference in clinical courses, cure rates, survival, or resolution of CXR abnormality. Mean duration of therapy was 6.88 days in control vs. 7.3 days in intervention and frequencies of symptom improvement were 97% vs. 95% respectively. Patents in intervention had shorter hospital satys (7.3 vs. 9.71 days p=0.01) and lower total costs of care ($2,953 vs. $5,002) p<0.05).
Gums JG, Tancey Jr RW, Hamilton CA, Kubilis PS. A randomized, prospective study measuring outcomes after antibiotic therapy intervention by a multidisciplinary consult team.  Pharmacotherapy 1999; (19):1369-1377 275-bed, community teaching hospital, Gainesville, FL, USA ID physician, clinical pharmacy fellow and micro lab personnel part-time work for all members of multidisciplinary team Patients with known resistant infections randomized to a intervention consult vs. usual care.  Interventional consult done by multidisciplinary team and made recommendations for appropriate therapies while also weighing economic factors of medication. Median length of stay after randomization for control and intervention groups was 9.0 days and 5.7 days, respectively (3.3-day difference, p=0.0001). Physician acceptance of suggestions was 89%. Median patient charges for radiology, laboratory, pharmacy, and room were reduced by $4,404/intervention, and median hospital costs were reduced by $2,642/intervention.
 
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