Problem Statement and introduction
Scope of Problem
Published reports suggest that antibiotic susceptibility mismatch (ASM) is a significant problem. Buising and colleagues noted that in a population of adult ICU patients, 14.3% of sterile and 30.8% of non-sterile isolates were treated inadequately initially, 4.0% of sterile and 21.3% of non-sterile isolates were treated inadequately after identification, and narrower-spectrum therapy was available for 30% of patients after microbe identification. In addition, Paterson et al reported that 52% of mismatches occurred in patients who previously received a drug that was shown to be inadequate against the infecting organism, 30% of patients had a prior history of a drug’s ineffectiveness against an organism, and 62.5% of mismatches occurred in patients staying 14 days or longer (i.e., intensive care unit patients, cancer patients). These reports indicate that there are clear patterns and risk factors that describe ASM. Therefore, the process of identification and intervention for ASM is a particularly well-suited target for ongoing quality improvement efforts, which could identify workflow causes or process failures that promote ASM.
Published research reviewed in developing the guideline reported various improvements in antimicrobial use and patient outcomes, among them: a) a 22% to 36% decrease in antimicrobial use through more efficient prescribing practice and use of less expensive alternatives; b) savings of $200,000 to $900,000 in direct drug costs (savings dependent on institution size); c) short-term susceptibilities among gram-negative pathogens (e.g., Klebsiella); d) reduced use of broad-spectrum antimicrobials by 34% to 84%; and e) modification of 25% of antimicrobial orders, with prescription of narrower-spectrum drugs in 47% of these cases.
A large metropolitan children's hospital
To reduce the use of ineffective antibiotics for documented infections
To reduce the incidence of antibiotic susceptibility mismatches (ASM) for documented infections in urine and bloodstream through active surveillance of culture results and antibiotic use
Process and Prioritization
The process of selection of antibiotics at various stages of microbiology reporting will be affected.
Measure(s): ASMs per week and average length of stay during the 26 weeks before and the 26 weeks after implementation of an antibiotic audit and feedback intervention
Antimicrobial stewardship programs and guidelines for the appropriate use of antibiotics are reviewed and compared with the hospital's current ASM rate.
The ASM rate is monitored for 26 weeks without action. The hospital begins flagging ASMs in lab results for a second 26-week so physicians can change antibiotic orders. Average length of stay (LOS) in the hospital for patients receiving antibiotics is monitored through both 26-week periods.
The investigators study the ASM and LOS data to identify underlying cause(s) of failure to recognize and/or act on ASMs.
The hospital implements additional intervention(s) such as electronic alerts and one-to-one physician counseling to further reduce the ASM rate and, potentially, the average LOS.
- Buising KL, Thursky KA, Bak N, Skull S, Street A, Presneill JJ, Cades JF, Brown GV. Antibiotic prescribing in response to bacterial isolates in the intensive care unit. Anaesth Intensive Care. 2005 Oct;33(5):571-7.
- Paterson DL, McKinnon J, Ndirangu M, Capitano B, Potoski B, Linden PK. Why do doctors give microbiologically inadequate empiric therapy to critically ill patients? Abstr Intersci Conf Antimicrob Agents Chemother. 2003 Sep 14-17; 43:abstract no. K-1419.
- Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM, Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007 Jan 15;44(2):159-77. Epub 2006 Dec 13.
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