Using an index-based approach to assess the population-level appropriateness of empirical antibiotic therapy

Abstract

The index-based framework can be an alternative approach to the estimation of point values and counterfactual trends in population-level empirical treatment appropriateness. In resource-constrained settings, where empirical prescribing is most prevalent and comprehensive studies to directly measure appropriateness may not be a practical proposition, an index-based approach could provide useful information to aid in the development and monitoring of antibiotic prescription guidelines.

How to measure the impacts of antibiotic resistance and antibiotic development on empiric therapy: new composite indices

“…Despite simplifying assumptions, index-based approaches can yield useful information about the burden of resistance; Ciccolini et al 11 successfully predicted the appropriateness of empiric therapy of complicated urinary tract infections using a drug resistance index (DRI) 10. Poor treatment decisions and consideration of allergies, side effects and ecological impacts all reduce empiric coverage, so we expect the actual percentage of appropriate empiric therapy to be lower than our ECI 14…”

“…Our approach differs in this respect from the drug resistance index (DRI) proposed by Laxminarayan and Klugman 10. The DRI can be interpreted as the probability of inadequate treatment given observed drug use 11. In contrast, we estimate potential empiric coverage by assuming that the empiric therapy that is most likely to succeed is selected, informed by cumulative antibiograms, Gram stains, and knowledge of the likely causative organism(s) for each clinical syndrome 16–18.…”

Research needs in antibiotic stewardship

“…9 Early attempts at assessing appropriateness have used concordance with guidelines to help adjudicate prescribing behavior. 10,11 Yet this approach is flawed: national guidelines do not always prioritize treatment approaches, frequently exclude clinically relevant populations (eg, immunocompromised patients, older adults, etc), and generally fail to address other aspects of infection management, such as the role of source control. 12,13 The need for up-to-date, evidence-informed guidance based on the principles of antibiotic stewardship that provides management recommendations informed by relevant patient characteristics and priorities is clear.…”

Measuring Appropriate Antimicrobial Use: Attempts at Opening the Black Box

“…Initial assessments of antimicrobial use focused on drug selection and dose, with some evaluation of the accuracy of the diagnosis ascribed to the patient; however, details of methods to determine diagnostic appropriateness are not described [5–7]. Most published assessments of antimicrobial appropriateness (Table 1) come from inpatient settings and simply evaluate empiric and/or definitive drug selection [8–16], with a few evaluations of dosing [17,18] and duration of therapy [19–28].…”