Background Multidisciplinary antimicrobial utilization teams (AUT) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited. Objective To determine the impact of an AUT on antimicrobial use at a teaching hospital. Design Randomized controlled intervention trial. Setting A 953-bed public university-affiliated urban teaching hospital. Patients Patients who were prescribed selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams. Intervention Twelve internal medicine teams were randomized monthly: 6 teams to intervention group (academic detailing by the AUT), and 6 teams to a control group given indication-based guidelines for prescription of broad spectrum antimicrobials (standard of care) during a 10-month study period. Measurements Proportion of appropriate empiric, definitive (therapeutic), and end antimicrobial (overall) usage. Results A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of appropriate antimicrobial prescriptions written by the intervention teams was significantly higher than prescribed by the control teams: 82% vs. 73% for empiric (RR=1.14, 95% CI 1.04–1.24), 82% vs. 43% for definitive (RR=1.89, 95% CI 1.53–2.33), and 94% vs. 70% for end antimicrobial usage (RR=1.34, 95% CI 1.25–1.43). In a multivariate analysis, teams that received feedback from the AUT alone (aRR=1.37, 95% CI 1.27–1.48) or from both the AUT and the ID consult service (aRR=2.28, 95% CI 1.64–3.19) were significantly more likely to prescribe end antimicrobial usage appropriately compared to control teams. Conclusions A multidisciplinary AUT which provides feedback to prescribing physicians was an effective method in improving antimicrobial use.
Background: Multidrug-resistant Acinetobacter baumannii (MDR-Ab) has emerged as an increasingly problematic cause of hospital-acquired infections in the intensive care unit (ICU). MDR-Ab is resistant to most standard antimicrobials but often retains susceptibility to polymyxin B and doxycycline. Objective: To evaluate the efficacy and toxicity of polymyxin B and doxycycline in the treatment of MDR-Ab infections. Methods: A retrospective chart review was conducted between March 2002 and May 2005 in patients who received doxycycline or polymyxin B for treatment of MDR-Ab infections in ICUs within Grady Memorial Hospital, Atlanta, GA. Results: Thirty-seven patients with MDR-Ab infections were treated with polymyxin B or doxycycline. Median age was 41 years and median ICU length of stay was 18 days prior to acquisition of MDR-Ab. Clinical cure was observed in 22 of 29 (76%) evaluable patients treated with polymyxin B and 2 of 4 (50%) patients treated with doxycycline. In patients with follow-up cultures, microbiological cure was observed in 17 of 21 (81%) patients treated with polymyxin B and 2 of 3 (67%) patients treated with doxycycline. Nephrotoxicity developed in 21% (7 of 33) of patients who received polymyxin B. Neurotoxicity was observed in 2 (6%) patients who received polymyxin B. No adverse reactions were observed with doxycycline. Overall, crude mortality was 27% (9 of 33) and 75% (3 of 4) among those who received polymyxin B and doxycycline, respectively. Three (9%) deaths were attributed to polymyxin B treatment failure, and no deaths were attributed to doxycycline treatment failure. Conclusions: Polymyxin B was effectively used to treat a substantial proportion of critically ill patients with MDR-Ab infection and was associated with a similar rate of nephrotoxicity as previously reported. Doxycycline monotherapy was used in a limited number of patients for the treatment of MDR-Ab; further evaluation of its efficacy in larger numbers of patients is warranted.
We investigated knowledge, attitudes, and behaviors of prescribers concerning piperacillin-tazobactam use at 4 Emory University-affiliated hospitals. Discussions during focus groups indicated that the participants' perceived knowledge of clinical criteria for appropriate piperacillin-tazobactam use was inadequate. Retrospective review of medical records identified inappropriate practices. These findings have influenced ongoing interventions aimed at optimizing piperacillin-tazobactam use.
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