Impact of ASP Interventions on Use

Reference Setting Key staff Intervention Impact
Cosgrove SE, Patel A, Song XY, Miller RE, Speck K, Banowetz A, Hadler R, Sinkowitz-Cochran RL, Cardo DM, Srinivasan A. Impact of Different Methods of Feedback to Clinicians After Postprescription Antimicrobial Review Based on the Centers for Disease Control and Prevention’s 12 Steps to Prevent Antimicrobial Resistance among Hospitalized Adults. Infection Control and Hospital Epidemiology. 2007,28,6:641-646 1,000-bed tertiary care teaching hospital, Baltimore, MD, USA Infectious disease physician, infectious disease pharmacist Infectious disease physician, infectious disease pharmacist Creation of computer-based, clinical-event detection system that identifies inpatients on broad spectrum abx for 48-72 hours.  Data undergoes review and, when indicated, feedback provided to clinicians on modifying or discontinuing therapy.  Acceptance of feedback was recorded and recommendations categorized by 12 steps recommended by CDC. Interventions recommended in 30% of reviewed cases, rate of compliance with interventions was 78%, no differences in compliance based on feedback methodology.
Lipsky BA, Baker, CA, McDonald LL, Suzuki NT. Improving the appropriateness of vancomycin use by sequential interventions. American Journal of Infection Control. 1999,27,2:84-89 446-bed university-affiliated tertiary care VA, Seattle, WA, USA Infection Control committee, clinical pharmacist
  1. Administrative intervention involving sharing vancomycin use data with chiefs of clinical programs with high levels of inappropriate use and revising of preprinted orders for perioperative abx prophylaxis (11/21/95-1/22/96).
  2. Educational intervention aimed at prescribing clinicians discussing appropriate use of vanco and hospital data on vre (5/7/96-6/18/96).
Following administrative intervention, inappropriate vancomycin use decreased by 30%.  Following educational intervention, inappropriate prescribing rate increased from 40 to 50%; however, comparing those who received education vs. not revealed 32% inappropriate orders compared to 68% inappropriate orders respectively (baseline 70%). Overall, vancomycin usage decreased from 6200g per year to 5000g per year during the study period.
Ibrahim EH, Ward S, Sherman G, Schaiff R, Fraser VJ, Kollef MH.  Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.  Critical Care Medicine, 2001,29(6):1109-1115 1000-bed tertiary care teaching hospital, St. Louis, MO, USA MICU staff Guidelines-implementation of VAP treatment guideline in MICU for initial abx administration to prevent inadequate treatment and to reduce unnecessary abx use. Over 2 years, initial abx treatment was adequate 94.2% compared to 48% preintervention.  Duration of abx treatment was shorted to 8.6 +/-5.1 days vs. 14.9+/-8.1days.  Second episode of VAP occurred less frequently 7.7% vs. 24%.
Girotti MJ, Fodoruk S, Irvine-Meek J, Rotstein OD. Antibiotic handbook and pre-printed perioperative order forms for the surgical antibiotic prophylaxis: do they work? CJS. 1990;33(5):385-388 1,000-bed tertiary care teaching hospital, Toronto, Ontario, Canada Antibiotic Committee Education and Guidelines-distributed handbook on perioperative use of antimicrobial agents to surgeons, additionally select surgical teams were given pre-printed perioperative order sets Compliance with recommended abx increased from 11% to 18% (p=0.06) in the handbook only group.  Compliance for recommended abx increased from 17% to 78% (p<0.001) in the pre-printed order set over the course of a year.
Mol PG, Wieringa JE, NannanPanday PV, Gans R, Degener JE, Laseur M, Haaijer-Ruskamp FM. Improving compliance with hospital antibiotic guidelines: a time-series intervention analysis. Journal of Antimicrobial Chemotherapy. 2005(55):550-557 190-bed tertiary care university hospital, Groningen, Netherlands hospital antimicrobial committee
  1. Guidelines-revised previous antimicrobial guidelines with new recommendations provided in paper and electronic format.
  2. Academic Detailing-5 months after initial intervention, physicians approached to prescribe in line with guidelines through individual and group sessions, special targeting of individual sessions with residents not prescribing ciprofloxacin and co-amoxiclav according to guidelines.
Baseline compliance with guidelines was 67%, after first intervention compliance increased 15.5% (8%, 23%), 2nd intervention did not lead to statistically significant change in compliance +12.5% (-3%, 28%). Post-intervention compliance remained at 86%.
Dellit TH, Chan JD, Skerrett SJ, Nathens AB. Development of a Guideline for the Management of Ventilator-Associated Pneumonia based on local microbiologic findings and impact of the guideline on antimicrobial use practices. Infection Control and Hospital Epidemiology. 2008;29(6):525-533 390-bed tertiary care urban teaching hospital, Seattle, WA, USA (performed in 75-bed ICU) Antimicrobial management program, general surgeons, ICU physicians, critical care advisory committee Guidelines-development of VAP guideline that used quantitative bronchoscopy or mini-BAL for diagnosis.  Empirical treatment for VAP was based on epidemiology of local organisms and timing of the infection, tailoring of therapy encouraged after culture results became available. Following intervention, increase in use of appropriate definitive therapy to 89.4% from 80.4% (p=0.001), decrease in mean duration of therapy to 10.7 days from 12 days (p=0.0014).  Therapy more frequently tailored on basis of quantitative culture results (68.9% vs. 61.3% before (p=0.034).
Echols RM, Kowalsky SF. The use of an antibiotic order form for antibiotic utilization review: influence on physicians’ prescribing patterns. Journal of Infectious Diseases. 1984,150(6):803-807 800-bed tertiary care teaching hospital, Albany, NY, USA Infection control committee Order Form-creation of a preprinted Antibiotic Order Sheet to all inpatient charts, additionally antibiotic use audited on a monthly basis to allow for review of potential misuse of antibiotics Significant reduction in number of antibiotic treatment course (30% decrease p=0.025) and the percentage of patients receiving sentinel antibiotics (30% from 47% p=0.007) over 18 months.
Hermsen ED, Shull SS, Puumala SE, Rupp ME. Improvement in prescribing habits and economic outcomes associated with the introduction of a standardized approach for surgical antimicrobial prophylaxis.  Infection Control and Hospital Epidemiology. 2008;29 (5):457-461 689-bed tertiary care teaching hospital, Omaha, NE, USA Antimicrobial Stewardship Program Order form-creation of an order form for surgical antimicrobial prophylaxis to assist clinicians with optimized abx choices.  Form use was mandatory but had an “opt out” space on it Increase in patients receiving appropriate abx following intervention (84.9% from 62.3%), significant improvement in appropriate dosing of abx for weight (89.9% from 62.1%), significant increase in appropriate duration of prophylaxis (89.1% from 77.8%).  Mean cost of antimicrobial prophylaxis decreased to $40 per patient from $46 per patient (p=0.02).
Bolon MK, Arnold AD, Feldman HA, Goldmann DA, Wright SB.  An antibiotic order form intervention does not improve or reduce vancomycin use.  Pediatrics Infectious Disease Journal. 2005;24(12):1053-1058 325-bed pediatric tertiary care teaching hospital, Chicago, IL, USA Pharmacy and Therapeutics Committee Order form-creation of an order form for all antibiotics prescriptions to guide clinicians to appropriate “preapproved” medications. Compliance with the order form was poor during planned study period (<50%) but an additional 2 months saw increase in compliance to (70-80%).  Rates of inappropriate vancomycin use increased to 39% from 35% after introduction of order form, inappropriate vancomycin use increased to 51% during the additional 2 months.
Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, and Feagan BG.  A Controlled Trial of a Critical Pathway for Treatment of Community-Acquired Pneumonia. JAMA 2000;283(6):749-755 Multicenter at 19 teaching and community hospitals in Canada Nursing, ED physicians Critical Pathway-controlled trial examining implementation of a critical pathway to provide a clinical prediction rule to guide hospital admission, type of levofloxacin therapy and practice guidelines for inpatient management of patients presenting to n ED with CAP Use of the critical pathway compared to the control group saw a 1.7 bed day per patient managed reduction (4.4 vs., 6.1 day p=0.01).  Although inpatients at intervention hospital had more severe disease, they require 1.7 fewer days of IV abx (4.6 vs. 6.3 days p=0.01) and were more likely to receive treatment with a single class of abx (64% vs. 27% p<0.001).
Durbin WA, Lapidas B, and Goldman DA.  Improved Antibiotic usage following introduction of a novel prescription system.  JAMA 1981;246:1796-1800 396-bed tertiary care children’s teaching hospital in 70 beds of 4 surgical wards, 10 bed cardiac surgery ward, and 31 bed general pediatric ward, Boston, MA, USA pediatric infectious disease physicians Order form-medical prescription form requiring categorization of antibiotic use (i.e., prophylactic, empirical, and therapeutic) that would have automatic discontinuation times depending on category of use Over 2 months, mean duration of prophylaxis was reduced from 4.9+/-2.4 to 2.9+/-1.6 (p<0.001). In the intervention, 11% of patients received first dose of prophylaxis postoperatively compared with 30% at baseline (p<0.001). Percentage of urology patients receiving appropriate therapy for UTI increased from 38% to 89% (p=0.02).  No significant changes were seen in abx use in the general pediatric ward.
Solomon DH, Van Houten L, Glynn RJ, Baden L, Curtis K, Schrager H, Avorn J.  Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center.  Archives of Internal Medicine.  2001;161:1897-1902 697-bed tertiary care teaching hospital, Boston, MA, USA clinician educators, infectious disease physicians, clinical pharmacist Detailing-computerized flagging of levofloxacin and ceftazidime orders to determine appropriateness, then provided education about appropriate use of these antibiotics to the ordering interns and residents 37% reduction in days of unnecessary levofloxacin and ceftazidime use per 2 week interval.  41% reduction in use of these antibiotics compared to controls over 18-week period.  No differences in patient outcomes between groups.
Kisuule F, Wright S, Barreto J, Zenilman J. Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach.  Journal of Hospital Medicine. 2008;3(1):64-70 560-bed tertiary care teaching hospital, Baltimore, MD, USA physician and pharmacist Detailing-reviewed appropriateness of abx prescriptions of select hospitalists and then held individualized meetings with practitioners to appraise practitioner’s prescribing habits based on abx selection (zosyn, vanco, extended spectrum quinolones) and cost. Following 4 month intervention, appropriate prescriptions ordered 74% of the time compared to 43% at baseline.
Avorn J and Soumerai SB. Improving drug-therapy decisions through educational outreach: A randomized controlled trial of academically based detailing. NEJM. 1983;308(24):1457-1463 Four-state setting examining 435 prescribers identified through Medicaid records pharmacists Detailing-Prescribers randomly assigned to control group, one that received mailed advertisements on appropriate prescribing and one that received mailed advertisements and educational sessions with clinical pharmacists Physicians in the advertisement and educational group prescribed an average of 382 units fewer of cephalexin than controls (p=0.0006) during 5-month intervention.  Physicians in mailed advertisements only did not have a significant change in prescribing habits compared to controls following intervention.
Richards MJ, Robertson MB, Dartnell JG, Duarte MM, Jones NR, Kerr DA, Lim L, Ritchie PD, Stanton GJ, Taylor SE.  Impact of a web-based antimicrobial approval system on broad -spectrum cephalosporin use at a teaching hospital.  MJA 2003;178:386-390 Royal Melbourne Hospital, tertiary care hospital, Melbourne Australia Drug and Therapeutics Committee Electronic Monitoring-web-based antimicrobial approval system to monitor use of cephalosporin use and allow feedback on prescribing patterns to be provided to staff Cephalosporin use decreased from mean of 38.3DDDs/1000 bed days at intervention to 15.9, 18.7 and 21.2DDDs/bed days at 1, 4, and 15 months postintervention.  Concordance with national antibiotic guidelines rose to 51% from 25% within 5 months of intervention (p<0.002).  Gentamycin use increased from 30 to 48DDD/1000 bed days (p=0.0001) during intervention.
Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF, Lloyd JF, and Bure JP. A computer-assisted management program for antibiotics and other anti-infective agents. NEJM. 1998;338(4):232-238 12-bed ICU in tertiary care teaching hospital, Salt Lake City, Utah, USA ICU physicians Electronic Monitoring-computerized decision support program linked to patient records to recommend antimicrobial regimens and courses to prescribers for particular patients and provides immediate feedback. Significant reductions in orders for drugs to which patients had allergies (35 vs. 146), excess drug dosages (87 vs. 405), and antibiotic susceptibility mismatches (12 vs. 206) over 1 year intervention. Significant reduction in mean number of days of excessive drug dosage (2.7vs. 5.9).   Significant reduction in anti-infective agent cost $102 vs. $427 and reduction in mean LOS.
Gross R, Morgan AS, Kinky DE, Weiner M, Gibson GA, and Fishman NO.  Impact of a hospital-based antimicrobial management program on clinical and economic outcomes. CID 2001;33:289-295 772-bed tertiary care teaching hospital, Philadelphia, PA, USA Antimicrobial Management Team (clinical pharmacist with ID physician for back up) and ID fellows Multidisciplinary-following creation of redesigned restricted abx formulary, conducted quasi-experimental study to compare effectiveness of AMT with that of ID fellows with respect to abx recommendations and clinical and economic outcomes. AMT outperformed ID fellows consistently.  Comparing AMT vs. ID fellow, appropriate regimen was 87% vs. 47% (p<0.001), cure rate was 64% vs. 42% (p=0.007), and treatment failures were 15% vs. 28% (p=0.007).  Economic differences favored AMT but were not statistically significant.
Ruttimann S, Keck B, Hartmeier C, Maetzel A, Bucher HC.  Long-term antibiotic cost savings from a comprehensive intervention program in a medical department of a university-affiliated teaching hospital. CID 2004;38:348-356 80-bed tertiary care teaching hospital, Schaffhausen, Switzerland Internal Medicine department head, clinical pharmacist, ID physician Multidisciplinary-restriction of formulary requiring abx approval, creation of a comprehensive educational program with lectures and handbooks for prescribers as well as biannual feedback on prescribing practices, creation of guidelines for abx selection, and a checklist to use before selecting abx choices. In short term-analysis, defined daily doses (DDD) decreased by 36% (p<0.001) and IV DDDs decreased by 46% (p<0.01).  Abx withheld for URI more frequently after intervention (47% vs. 27% p=0.04), Decrease in delivery of broad-spectrum abx (10% from 23% of treatment comparing post-and pre-intervention).  Overall reduction in abx use by 35% (p<0.001).
Cook PP, Catrou PG, Christie JD, Young PD, Polk RE. Reduction in broad-spectrum antimicrobial use associated with no improvement in hospital antibiogram.  Journal of Antimicrobial Chemotherapy. 2004 (53):853-859 731-bed tertiary care teaching hospital, Greenville, NC, USA clinical pharmacist, infectious disease physician physician reviews reports of patients on controlled abx and make recommendations to change or stop those medications as appropriate, primary team had option to accept or reject the recommendations Compared to 6 quarters before intervention, broad-spectrum abx use decreased by 28% (693 DDD/1000 patient days to 502DDD/1000PD  p=0.003). Total antifungal use decreased similarly (144DDD/1000PD to 103DDD/1000PD p=0.02).  Total antimicrobial use decreased by 27% (1461DDD/1000PD to 1069DDD/1000PD p=0.0007).  Susceptibilities of nosocomial Gram-negative organisms did not change significantly over 3 years.  Rates of MRSA increased significantly in the non-intensive care areas of the hospital (0.02) and decreased significantly in the intensive care areas of the hospital (p=0.009) over 4 years.  Vancomycin use initially decreased by 23.9% but returned to preintervention levels by the end of the study.
Lautenbach E, LaRossa LA, Marr AM, Nachamkin I, Bilker WB, Fishman NO. Changes in the prevalence of vancomycin-resistant enterococci in response to antimicrobial formulary interventions: impact of progressive restrictions on use of vancomycin and third-generation cephalosporins. CID 2003;36(4):440-446 725-bed tertiary care teaching hospital Infectious disease physician, infectious disease pharmacist Restriction-Increasing restriction on vancomycin and third-generation cephalosporin use over 10-year period requiring ID approval for dispensing abx Third‐generation cephalosporin use decreased by 85.8%. However, VRE prevalence increased steadily from 17.4% to 29.6% during the 10‐year period (p<0.001). Clindamycin use was associated with VRE prevalence (r=0.75, p=0.01)