Impact of a multicenter stewardship‐targeted carbapenem justification requirement on the use of carbapenems in 23 hospitals

Abstract

Introduction Increasing resistance to broad‐spectrum antibiotics is a growing concern. Antimicrobial stewardship programs (ASPs) are needed to ensure appropriate antibiotic use, but the most effective method remains unknown. Objective To measure the change in carbapenem days of therapy (DOT) across 23 hospitals after a stewardship intervention and determine changes in morbidity, mortality, and resistance rates. Methods A retrospective, multicenter, sequential period analysis was initiated to evaluate carbapenem prescribing rates in 23 medical centers. We compared carbapenem utilization from December 1, 2016 to March 31, 2017 when a stewardship‐targeted justification was active with utilization from December 1, 2015 to March 31, 2016 without the justification requirement. Stewardship‐targeted justifications are appropriate indications for the prescribing of carbapenems selected by ASP leaders in our health care system. The primary outcome was carbapenem DOT per 1000 patient days (PDs). Results Carbapenem utilization decreased from 35.8 DOT per 1000 PDs in the preintervention period to 23.7 DOT per 1000 PDs in the postintervention period (33.8% reduction, P < .01). Morbidity and mortality end points were not adversely affected, with resistance rates remaining unchanged. Conclusions This study suggests that a stewardship‐targeted justification requirement in computerized physician order entry is an effective approach to reducing carbapenem utilization.

Antimicrobial stewardship using electronic prescribing systems in hospital settings: a scoping review of interventions and outcome measures

“…The outcomes of mandated documentation of indication and/or duration were reported in three studies. 18 , 28 , 29 Whilst mandating documentation reduced the incidence of incomplete fields in the eP system, it did not increase the rate of accurate documentation. Two studies investigated the impact of embedding the infection management or antimicrobial prescribing guidelines into eP.…”

“…Mortality was found to be measured from a fixed time period from the intervention ( n = 3/9)—one at 14 days ( n = 1/9) 1 and two at 30 days ( n = 2/9), 21 , 22 whilst five studies adopted the more flexible ‘in-hospital mortality’ determined as patient death within that episode of inpatient care. 11 , 12 , 24 , 28 , 30 One additional paper did not provide information regarding how mortality rate was determined. 3 Readmission rates were used in seven studies.…”

“…The length of time to readmission varied between studies, ranging from 14 to 90 days of the intervention. Six papers reported readmission rates due to all causes 9 , 20 , 22 , 25 , 28 , 31 whilst one reported those only related directly to the infection. 14 …”

“…Appropriateness for IV-to-oral switch (IVOS) was reported in three studies ( n = 3/28) (Table 3 ), with consideration of IVOS in the de-escalation process of antimicrobials reported in all three. Two out of 28 studies investigated the impact of their intervention on resistance rates (Table 3 ), with one reporting ESBL and carbapenem-resistant Enterobacterales rates 28 and one monitoring the resistance rates 33 of ‘major pathogens’.…”

“…There was some consistency in the methodology used to measure LOS with 10/12 papers reporting total duration of inpatient hospital stay and the remaining 2 determining ‘infection-related length of stay’. 11 , 25 Divergence was observed in the reporting of DOT, with three studies reporting total DOT and seven reporting this outcome as a rate using one of four denominators: 100 patient days, 21 1000 patient days, 13 , 25 , 28 , 31 1000 at-risk patient days 12 and 1000 occupied bed days. 11 Three studies investigated the antibiotic consumption reported in all cases as antibiotic expenditure.…”