Journal of Antimicrobial Chemotherapy Advance Access published January 21, 2015
J Antimicrob Chemother doi:10.1093/jac/dku555
An evaluation of the association between an antimicrobial stewardship score and antimicrobial usage Amy L. Pakyz1*, Leticia R. Moczygemba1, Hui Wang2, Michael P. Stevens3 and Michael B. Edmond4 1
Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA; Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA; 3Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA; 4Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
2
*Corresponding author. Tel: +1-804-828-6027; Fax: +1-804-828-8359; E-mail: [email protected]
Received 7 September 2014; returned 10 October 2014; revised 10 December 2014; accepted 13 December 2014 Objectives: To determine whether an antimicrobial stewardship ‘intensity’ score predicts hospital antimicrobial usage. Methods: An antimicrobial stewardship score for 44 academic medical centres was developed that comprised two main categories: resources (antimicrobial stewardship programme personnel and automated surveillance software) and strategies (preauthorization, audit with intervention and feedback, education, guidelines and clinical pathways, parenteral to oral therapy programmes, de-escalation of therapy, antimicrobial order forms and dose optimization). Multiple regression analyses were used to assess whether the composite score and also the categories were associated with either total or antimicrobial stewardship programme-target antimicrobial use as measured in days of therapy. Results: The mean antimicrobial stewardship programme score was 55 (SD 21); the total composite score was not significantly associated with total or target antimicrobial use [estimate – 0.49 (95% CI – 2.30 to 0.89)], while the category strategies was significantly and negatively associated with target antimicrobial use [– 5.91 (95% CI –9.51 to –2.31)]. Conclusions: The strategy component of a score developed to measure the intensity of antimicrobial stewardship was associated with the amount of antimicrobials used. Thus, the number and types of strategies employed by antimicrobial stewardship programmes may be of particular importance in programme effectiveness. Keywords: preauthorization, audit with intervention and feedback, automated surveillance software
Introduction
Methods
A joint policy statement by the Society for Healthcare Epidemiology of America, the IDSA and the Pediatric Infectious Diseases Society advocates mandatory implementation of antimicrobial stewardship programmes (ASPs) to improve outcomes in infection treatment and to minimize resistance development.1 While there are recommended core strategies and structural elements for ASPs,2 few studies have documented the effectiveness of different ASP elements in decreasing antimicrobial use. Identification of specific ASP aspects that are effective in lowering use would enable ASPs to allocate limited resources to strategies that have greater success. Thus, an ASP score comprising programme elements, such as the number and types of strategies and personnel utilized, was developed to designate the ‘intensity’ of an ASP. It was then ascertained whether the score was associated with antimicrobial usage in a sample of academic medical centres (AMCs).
Data source and study population An ASP intensity score was developed based on a survey administered to infectious diseases physician and pharmacist ASP members employed at AMCs that are part of the University HealthSystem Consortium (UHC) in March 2013 (the survey is available as Supplementary data at JAC Online). Specifically, members from a subset of UHC hospitals that subscribe to the Clinical Research Manager (CRM) Pharmacy Program were invited to participate (n¼79); a total of 44 (56%) completed the survey. Survey components included questions regarding ASP structure and strategies. To develop the score, content experts in the area of ASPs (the authors), met in person and participated in a consensus-building process to agree on score composition and category weighting. Variability in survey responses was also considered. The score was based on a 100-point scale with two categories: resources (60 points) and strategies (40 points). More weight was placed on the resources category because certain ASP resources are needed in order to carry out programme strategies.
# The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
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Pakyz et al.
Table 1. Antimicrobial stewardship intensity score point composition (total points possible¼100) Category Resources (60 points total) personnel (30 points)
Question
To what extent are clinical pharmacists allotted to ASP?
To what extent are physicians allotted to ASP?
automated surveillance software (30 points) Strategies (40 points total) preauthorization (18 points)
Does your ASP utilize automated surveillance software? Which antimicrobials are restricted?
When is preauthorization conducted?
audit with intervention and feedback (14 points)
Are automated stop orders used in the preauthorization process? Which antimicrobials are reviewed post-prescription?
Who conducts the post-prescription review? What is the mechanism to contact the prescriber? other strategies (8 points)
Which other strategies are also performed? How often does the antimicrobial committee meet?
Answers
† † † † † † † † † †
.1.0 FTE 0.5– 1.0 FTE ,0.5 FTE 0 FTE .1.0 FTE 0.5– 1.0 FTE ,0.5 FTE 0 FTE yes no
15 10 5 0 15 10 5 0 30 0
† quinolone; piperacillin/tazobactam; carbapenem; cephalosporin; echinocandin; extended-spectrum azole; lipid amphotericin product; daptomycin; linezolid; tigecycline; quinupristin/dalfopristin; amikacin; ceftaroline; colistin; ticarcillin/clavulanate † before the first dose, either 24/7 or during work day only † after the second dose or later † yes † no
1 point for each restricted agent/class (up to 15 points total)
† quinolone; piperacillin/tazobactam; carbapenem; cephalosporin; echinocandin; extended-spectrum azole; lipid amphotericin product; daptomycin; linezolid; tigecycline; quinupristin/dalfopristin; amikacin; ceftaroline; colistin; ticarcillin/clavulanate † physician only or physician and pharmacist † pharmacist only † face-to-face or page/phone † text/e-mail or note in paper or electronic medical record † education; guidelines and clinical pathways; antimicrobial order forms; parenteral to oral conversion therapy; dose optimization; streamline/de-escalation of therapy † once per month † once per quarter or as needed † no committee
0.6 points for each restricted agent/class (up to 9 points total)
The resources category comprised two subcategories, personnel and presence of automated surveillance software. Though many types of healthcare professionals are involved in ASPs, such as clinical microbiologists, only physician and pharmacist ASP members contributed to the personnel score, as they are considered ASP core personnel.2 Though the IDSA guideline2 does not specify a requirement for automated surveillance software, it does mention that this option could facilitate strategies such as audit with intervention and feedback, and the authors agreed that this aspect was a key ASP component. The strategies category included three subcategories: preauthorization, audit with intervention and feedback, and other. The subcategories preauthorization and audit with intervention and feedback contributed the largest number of points to the strategies category,
2 of 4
Points
2 0 1 0
2 0 3 0 1 point for each selected (up to 6 points total) 2 1 0
as they are core ASP strategies.2 Table 1 summarizes how the score was calculated.
Outcome variables Aggregated antimicrobial data were obtained from the CRM for adult patients discharged in 2012. Details concerning antimicrobial data obtained from the CRM have been described elsewhere.3 Two antimicrobial use measures [days of therapy per 1000 patient days (DOTs/1000 PDs)] were generated: (i) total use, the majority of antimicrobials except for infrequently used agents, such as antimycobacterials; and (ii) target use, which comprised the 15 individual agents/classes that ASPs targeted (Table 1).
JAC
Antimicrobial stewardship score and antimicrobial use
Statistical analysis For the 11 individual score components (Table 1), univariate analyses were conducted. In addition, several multiple regression models were constructed. Separate models were developed for the dependent variables of total and target antimicrobial use; the main independent variable was the total composite score. Furthermore, a model was constructed to include resources and strategy categories as separate explanatory variables. Additional factors associated with antimicrobial use in UHC hospitals were considered: geographical region; number of PDs per 35 UHC clinical service lines collapsed into four (surgery, medicine, transplant and other; expressed as less than or equal to or greater than the median); and cancer chemotherapy DOTs (H. Wang & A. L. Pakyz, unpublished data). Variables were considered in a forward stepwise manner using the Akaike information criterion; P,0.05 was considered significant. The study was approved by the Virginia Commonwealth University Institutional Review Board.
Table 2. Association between antimicrobial stewardship score and antimicrobial use Total antimicrobialsa estimate Total composite score Resources Strategies
95% CI
Target antimicrobialsb estimate
95% CI
–0.49
– 2.30
1.32
– 0.75
– 2.38
0.89
0.38 –3.53
– 1.73 – 7.87
2.49 0.81
0.55 – 5.91
– 1.22 – 9.51
2.23 –2.31
a Adjusted for cancer chemotherapy DOTs and surgery, transplant and other clinical service lines. b Adjusted for cancer chemotherapy DOTs and surgery and other clinical service lines.
Results ASP characteristics
Discussion
Among 44 ASPs, a total of 39 (89%) had physician members, with 24 (54%) having less than one-half of a full-time equivalent (FTE), 17 (38%) having 0.5 – 1.0 FTEs and 4 (9.0%) having .1.0 FTE. A total of 42 (95%) had pharmacists, with 3 (7.0%) having less than one-half of an FTE, 31 (71%) having 0.5 – 1.0 FTEs and 9 (21%) having .1.0 FTE. A total of 30 (68%) had a preauthorization policy (formulary restriction) and 8 (27%) used automatic stop orders in the process. A total of 39 (89%) had an audit with intervention and feedback policy, and 14 (36%) had a physician and pharmacist conduct reviews, while 23 (59%) were conducted by pharmacists only and 2 (5%) had physician-only review. Over onehalf of ASPs contacted the prescriber in a face-to-face manner [25 (57%)] or by page/phone [37 (84%)] for at least one of their prescriber-contacting mechanisms. A total of 40 (91%) had an antimicrobial subcommittee, with 17 (42%) meeting at least monthly and 16 (40%) meeting quarterly. A total of 23 (52%) used automated surveillance software. Commonly restricted agents by preauthorization and audit with intervention and feedback policies were daptomycin, tigecycline, micafungin and linezolid, among others.
The findings indicate that the ASP score strategies category was associated with target antimicrobial use; higher scores were associated with lower use. Thus, the data suggest that the numbers and types of strategies employed, especially the two core strategies of preauthorization and audit with intervention and feedback, as well as the number of antimicrobials targeted in ASP policies, may be of importance in an ASP’s effectiveness in decreasing use. While it was not possible to evaluate individual associations between the two core strategies and antimicrobial use because of limited hospital sample size, the univariate analyses indicated that the preauthorization strategy may be of importance. Given limited resources, ASPs may want to focus their efforts on modifying their strategies first rather than altering the numbers and types of ASP personnel. Previously, in French hospitals, a composite score was developed for ASP policies publicly reported.4 Among the sub-policy scores of action, resources and organization, resources (information technology) were associated with lower antibiotic use and organization (antibiotic committee) was associated with higher use of penicillins. In the current study, the category strategies was associated with lower target antimicrobial use. The strategies component captured the number and types of strategies employed and antimicrobials targeted. The largest portion of strategy points comprised preauthorization and audit with intervention and feedback, which have been previously documented as effective strategies in decreasing antimicrobial usage.5 – 8 The category resources, which accounted for a larger proportion of the total score (60%), was not associated with antimicrobial use, either total or target. This may be in part due to the greater importance of the strategy component of ASPs or the inability to account for the effectiveness of ASP personnel. It is possible, too, that ASP activities could also have been conducted by non-dedicated ASP personnel, which may have diluted the effect of the resources score component.9,10 Furthermore, while the use of automated surveillance software has been associated with successful implementation of ASP strategies,11 – 13 its availability may not be crucial to ASP operations, or the extent of software implementation could be limited by a lack of ASP personnel in some hospitals. There are some limitations to this study. The relatively small sample size limits the individual evaluation of specific strategy components, such as preauthorization and audit with intervention
ASP intensity score and antimicrobial use Antimicrobial data were available for 42 hospitals; among these hospitals, the mean ASP score was 55 (SD 21). For the category resources, out of 60 points the mean score was 34 (SD 18), and for strategies, out of 40 points the mean score was 22 (SD 8). The average total antimicrobial use was 817 DOTs/1000 PDs (range 560 – 1150); average target use was 457 DOTs/1000 PDs (range 209–735).
Univariate and multiple regression analyses Regarding the univariate analyses of the 11 individual score components with total and target antimicrobial use, only the preauthorization strategy with target use was statistically significant (estimate – 7.59, P ¼ 0.02). For the multiple regression analyses, neither the total score nor the category of resources or strategies was associated with total use. The category strategies was significant and negatively associated with target antimicrobial use (Table 2).
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Pakyz et al.
and feedback polices. Though the strategies category was associated with antimicrobial use, we were unable to assess the appropriateness of use or resulting outcomes from ASP efforts; reductions in antimicrobial use may not necessarily confer improvements in patient outcomes.14 Furthermore, the results of the current study need to be validated in other hospital types. For an ASP intensity score comprising resource and strategy elements, the strategy component was associated with the amount of antimicrobials used, especially those that are commonly targeted by ASP policies. The number and types of strategies utilized and antimicrobials restricted may be of particular importance compared with the number and types of ASP personnel or the availability of automated surveillance software.
Acknowledgements We thank all of the ASP members who completed the survey.
Funding This project was supported by grant number K08HS018578 (to A. L. P.) from the Agency for Healthcare Research and Quality.
Transparency declarations None to declare.
Supplementary data The survey is available as Supplementary data at JAC Online (http://jac. oxfordjournals.org/).
References 1 Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012; 33: 322–7. 2 Dellit TH, Owens RC, McGowan JE Jr et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guide-
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lines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159– 77. 3 Pakyz AL, MacDougall C, Oinonen M et al. Trends in antibacterial use in US academic health centers: 2002 to 2006. Arch Intern Med 2008; 168: 2254– 60. 4 Amadeo B, Dumartin C, Parneix P et al. Relationship between antibiotic consumption and antibiotic policy: an adjusted analysis in the French healthcare system. J Antimicrob Chemother 2011; 66: 434–42. 5 White AC Jr, Atmar RL, Wilson J et al. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997; 25: 230–9. 6 Reed EE, Stevenson KB, West JE et al. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence 2013; 4: 158–62. 7 Carling P, Fung T, Killion A et al. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol 2003; 24: 699– 706. 8 Elligsen M, Walker SA, Pinto R et al. Audit and feedback to reduce broadspectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol 2012; 33: 354–61. 9 Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther 2013; 35: 751–7. 10 Laible BR, Nazir J, Assimacopoulos AP et al. Implementation of a pharmacist-led antimicrobial management team in a community teaching hospital: use of pharmacy residents and pharmacy students in a prospective audit and feedback approach. J Pharm Pract 2010; 23: 531–5. 11 Hermsen ED, VanSchooneveld TC, Sayles H et al. Implementation of a clinical decision support system for antimicrobial stewardship. Infect Control Hosp Epidemiol 2012; 33: 412–5. 12 Pogue JM, Mynatt RP, Marchaim D et al. Automated alerts coupled with antimicrobial stewardship intervention lead to decreases in length of stay in patients with gram-negative bacteremia. Infect Control Hosp Epidemiol 2014; 35: 132–8. 13 Schulz L, Osterby K, Fox B. The use of best practice alerts with the development of an antimicrobial stewardship navigator to promote antibiotic de-escalation in the electronic medical record. Infect Control Hosp Epidemiol 2013; 34: 1259 –65. 14 McGowan JE. Antimicrobial stewardship—the state of the art in 2011: focus on outcome and methods. Infect Control Hosp Epidemiol 2012; 33: 331–7.
J Antimicrob Chemother doi:10.1093/jac/dku555
An evaluation of the association between an antimicrobial stewardship score and antimicrobial usage Amy L. Pakyz1*, Leticia R. Moczygemba1, Hui Wang2, Michael P. Stevens3 and Michael B. Edmond4 1
Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA; Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA; 3Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA; 4Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
2
*Corresponding author. Tel: +1-804-828-6027; Fax: +1-804-828-8359; E-mail: [email protected]
Received 7 September 2014; returned 10 October 2014; revised 10 December 2014; accepted 13 December 2014 Objectives: To determine whether an antimicrobial stewardship ‘intensity’ score predicts hospital antimicrobial usage. Methods: An antimicrobial stewardship score for 44 academic medical centres was developed that comprised two main categories: resources (antimicrobial stewardship programme personnel and automated surveillance software) and strategies (preauthorization, audit with intervention and feedback, education, guidelines and clinical pathways, parenteral to oral therapy programmes, de-escalation of therapy, antimicrobial order forms and dose optimization). Multiple regression analyses were used to assess whether the composite score and also the categories were associated with either total or antimicrobial stewardship programme-target antimicrobial use as measured in days of therapy. Results: The mean antimicrobial stewardship programme score was 55 (SD 21); the total composite score was not significantly associated with total or target antimicrobial use [estimate – 0.49 (95% CI – 2.30 to 0.89)], while the category strategies was significantly and negatively associated with target antimicrobial use [– 5.91 (95% CI –9.51 to –2.31)]. Conclusions: The strategy component of a score developed to measure the intensity of antimicrobial stewardship was associated with the amount of antimicrobials used. Thus, the number and types of strategies employed by antimicrobial stewardship programmes may be of particular importance in programme effectiveness. Keywords: preauthorization, audit with intervention and feedback, automated surveillance software
Introduction
Methods
A joint policy statement by the Society for Healthcare Epidemiology of America, the IDSA and the Pediatric Infectious Diseases Society advocates mandatory implementation of antimicrobial stewardship programmes (ASPs) to improve outcomes in infection treatment and to minimize resistance development.1 While there are recommended core strategies and structural elements for ASPs,2 few studies have documented the effectiveness of different ASP elements in decreasing antimicrobial use. Identification of specific ASP aspects that are effective in lowering use would enable ASPs to allocate limited resources to strategies that have greater success. Thus, an ASP score comprising programme elements, such as the number and types of strategies and personnel utilized, was developed to designate the ‘intensity’ of an ASP. It was then ascertained whether the score was associated with antimicrobial usage in a sample of academic medical centres (AMCs).
Data source and study population An ASP intensity score was developed based on a survey administered to infectious diseases physician and pharmacist ASP members employed at AMCs that are part of the University HealthSystem Consortium (UHC) in March 2013 (the survey is available as Supplementary data at JAC Online). Specifically, members from a subset of UHC hospitals that subscribe to the Clinical Research Manager (CRM) Pharmacy Program were invited to participate (n¼79); a total of 44 (56%) completed the survey. Survey components included questions regarding ASP structure and strategies. To develop the score, content experts in the area of ASPs (the authors), met in person and participated in a consensus-building process to agree on score composition and category weighting. Variability in survey responses was also considered. The score was based on a 100-point scale with two categories: resources (60 points) and strategies (40 points). More weight was placed on the resources category because certain ASP resources are needed in order to carry out programme strategies.
# The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
1 of 4
Pakyz et al.
Table 1. Antimicrobial stewardship intensity score point composition (total points possible¼100) Category Resources (60 points total) personnel (30 points)
Question
To what extent are clinical pharmacists allotted to ASP?
To what extent are physicians allotted to ASP?
automated surveillance software (30 points) Strategies (40 points total) preauthorization (18 points)
Does your ASP utilize automated surveillance software? Which antimicrobials are restricted?
When is preauthorization conducted?
audit with intervention and feedback (14 points)
Are automated stop orders used in the preauthorization process? Which antimicrobials are reviewed post-prescription?
Who conducts the post-prescription review? What is the mechanism to contact the prescriber? other strategies (8 points)
Which other strategies are also performed? How often does the antimicrobial committee meet?
Answers
† † † † † † † † † †
.1.0 FTE 0.5– 1.0 FTE ,0.5 FTE 0 FTE .1.0 FTE 0.5– 1.0 FTE ,0.5 FTE 0 FTE yes no
15 10 5 0 15 10 5 0 30 0
† quinolone; piperacillin/tazobactam; carbapenem; cephalosporin; echinocandin; extended-spectrum azole; lipid amphotericin product; daptomycin; linezolid; tigecycline; quinupristin/dalfopristin; amikacin; ceftaroline; colistin; ticarcillin/clavulanate † before the first dose, either 24/7 or during work day only † after the second dose or later † yes † no
1 point for each restricted agent/class (up to 15 points total)
† quinolone; piperacillin/tazobactam; carbapenem; cephalosporin; echinocandin; extended-spectrum azole; lipid amphotericin product; daptomycin; linezolid; tigecycline; quinupristin/dalfopristin; amikacin; ceftaroline; colistin; ticarcillin/clavulanate † physician only or physician and pharmacist † pharmacist only † face-to-face or page/phone † text/e-mail or note in paper or electronic medical record † education; guidelines and clinical pathways; antimicrobial order forms; parenteral to oral conversion therapy; dose optimization; streamline/de-escalation of therapy † once per month † once per quarter or as needed † no committee
0.6 points for each restricted agent/class (up to 9 points total)
The resources category comprised two subcategories, personnel and presence of automated surveillance software. Though many types of healthcare professionals are involved in ASPs, such as clinical microbiologists, only physician and pharmacist ASP members contributed to the personnel score, as they are considered ASP core personnel.2 Though the IDSA guideline2 does not specify a requirement for automated surveillance software, it does mention that this option could facilitate strategies such as audit with intervention and feedback, and the authors agreed that this aspect was a key ASP component. The strategies category included three subcategories: preauthorization, audit with intervention and feedback, and other. The subcategories preauthorization and audit with intervention and feedback contributed the largest number of points to the strategies category,
2 of 4
Points
2 0 1 0
2 0 3 0 1 point for each selected (up to 6 points total) 2 1 0
as they are core ASP strategies.2 Table 1 summarizes how the score was calculated.
Outcome variables Aggregated antimicrobial data were obtained from the CRM for adult patients discharged in 2012. Details concerning antimicrobial data obtained from the CRM have been described elsewhere.3 Two antimicrobial use measures [days of therapy per 1000 patient days (DOTs/1000 PDs)] were generated: (i) total use, the majority of antimicrobials except for infrequently used agents, such as antimycobacterials; and (ii) target use, which comprised the 15 individual agents/classes that ASPs targeted (Table 1).
JAC
Antimicrobial stewardship score and antimicrobial use
Statistical analysis For the 11 individual score components (Table 1), univariate analyses were conducted. In addition, several multiple regression models were constructed. Separate models were developed for the dependent variables of total and target antimicrobial use; the main independent variable was the total composite score. Furthermore, a model was constructed to include resources and strategy categories as separate explanatory variables. Additional factors associated with antimicrobial use in UHC hospitals were considered: geographical region; number of PDs per 35 UHC clinical service lines collapsed into four (surgery, medicine, transplant and other; expressed as less than or equal to or greater than the median); and cancer chemotherapy DOTs (H. Wang & A. L. Pakyz, unpublished data). Variables were considered in a forward stepwise manner using the Akaike information criterion; P,0.05 was considered significant. The study was approved by the Virginia Commonwealth University Institutional Review Board.
Table 2. Association between antimicrobial stewardship score and antimicrobial use Total antimicrobialsa estimate Total composite score Resources Strategies
95% CI
Target antimicrobialsb estimate
95% CI
–0.49
– 2.30
1.32
– 0.75
– 2.38
0.89
0.38 –3.53
– 1.73 – 7.87
2.49 0.81
0.55 – 5.91
– 1.22 – 9.51
2.23 –2.31
a Adjusted for cancer chemotherapy DOTs and surgery, transplant and other clinical service lines. b Adjusted for cancer chemotherapy DOTs and surgery and other clinical service lines.
Results ASP characteristics
Discussion
Among 44 ASPs, a total of 39 (89%) had physician members, with 24 (54%) having less than one-half of a full-time equivalent (FTE), 17 (38%) having 0.5 – 1.0 FTEs and 4 (9.0%) having .1.0 FTE. A total of 42 (95%) had pharmacists, with 3 (7.0%) having less than one-half of an FTE, 31 (71%) having 0.5 – 1.0 FTEs and 9 (21%) having .1.0 FTE. A total of 30 (68%) had a preauthorization policy (formulary restriction) and 8 (27%) used automatic stop orders in the process. A total of 39 (89%) had an audit with intervention and feedback policy, and 14 (36%) had a physician and pharmacist conduct reviews, while 23 (59%) were conducted by pharmacists only and 2 (5%) had physician-only review. Over onehalf of ASPs contacted the prescriber in a face-to-face manner [25 (57%)] or by page/phone [37 (84%)] for at least one of their prescriber-contacting mechanisms. A total of 40 (91%) had an antimicrobial subcommittee, with 17 (42%) meeting at least monthly and 16 (40%) meeting quarterly. A total of 23 (52%) used automated surveillance software. Commonly restricted agents by preauthorization and audit with intervention and feedback policies were daptomycin, tigecycline, micafungin and linezolid, among others.
The findings indicate that the ASP score strategies category was associated with target antimicrobial use; higher scores were associated with lower use. Thus, the data suggest that the numbers and types of strategies employed, especially the two core strategies of preauthorization and audit with intervention and feedback, as well as the number of antimicrobials targeted in ASP policies, may be of importance in an ASP’s effectiveness in decreasing use. While it was not possible to evaluate individual associations between the two core strategies and antimicrobial use because of limited hospital sample size, the univariate analyses indicated that the preauthorization strategy may be of importance. Given limited resources, ASPs may want to focus their efforts on modifying their strategies first rather than altering the numbers and types of ASP personnel. Previously, in French hospitals, a composite score was developed for ASP policies publicly reported.4 Among the sub-policy scores of action, resources and organization, resources (information technology) were associated with lower antibiotic use and organization (antibiotic committee) was associated with higher use of penicillins. In the current study, the category strategies was associated with lower target antimicrobial use. The strategies component captured the number and types of strategies employed and antimicrobials targeted. The largest portion of strategy points comprised preauthorization and audit with intervention and feedback, which have been previously documented as effective strategies in decreasing antimicrobial usage.5 – 8 The category resources, which accounted for a larger proportion of the total score (60%), was not associated with antimicrobial use, either total or target. This may be in part due to the greater importance of the strategy component of ASPs or the inability to account for the effectiveness of ASP personnel. It is possible, too, that ASP activities could also have been conducted by non-dedicated ASP personnel, which may have diluted the effect of the resources score component.9,10 Furthermore, while the use of automated surveillance software has been associated with successful implementation of ASP strategies,11 – 13 its availability may not be crucial to ASP operations, or the extent of software implementation could be limited by a lack of ASP personnel in some hospitals. There are some limitations to this study. The relatively small sample size limits the individual evaluation of specific strategy components, such as preauthorization and audit with intervention
ASP intensity score and antimicrobial use Antimicrobial data were available for 42 hospitals; among these hospitals, the mean ASP score was 55 (SD 21). For the category resources, out of 60 points the mean score was 34 (SD 18), and for strategies, out of 40 points the mean score was 22 (SD 8). The average total antimicrobial use was 817 DOTs/1000 PDs (range 560 – 1150); average target use was 457 DOTs/1000 PDs (range 209–735).
Univariate and multiple regression analyses Regarding the univariate analyses of the 11 individual score components with total and target antimicrobial use, only the preauthorization strategy with target use was statistically significant (estimate – 7.59, P ¼ 0.02). For the multiple regression analyses, neither the total score nor the category of resources or strategies was associated with total use. The category strategies was significant and negatively associated with target antimicrobial use (Table 2).
3 of 4
Pakyz et al.
and feedback polices. Though the strategies category was associated with antimicrobial use, we were unable to assess the appropriateness of use or resulting outcomes from ASP efforts; reductions in antimicrobial use may not necessarily confer improvements in patient outcomes.14 Furthermore, the results of the current study need to be validated in other hospital types. For an ASP intensity score comprising resource and strategy elements, the strategy component was associated with the amount of antimicrobials used, especially those that are commonly targeted by ASP policies. The number and types of strategies utilized and antimicrobials restricted may be of particular importance compared with the number and types of ASP personnel or the availability of automated surveillance software.
Acknowledgements We thank all of the ASP members who completed the survey.
Funding This project was supported by grant number K08HS018578 (to A. L. P.) from the Agency for Healthcare Research and Quality.
Transparency declarations None to declare.
Supplementary data The survey is available as Supplementary data at JAC Online (http://jac. oxfordjournals.org/).
References 1 Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012; 33: 322–7. 2 Dellit TH, Owens RC, McGowan JE Jr et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guide-
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