PostRx Antimicrobial Stewardship Feasible in Community Hospitals

Postprescription audit and review (PPR) is a feasible and effective strategy for antimicrobial stewardship in community hospitals, according to a study published online in JAMA Network Open.

Deverick J. Anderson, M.D., from Duke University in Durham, North Carolina, and colleagues assessed the feasibility of implementing two core Infectious Diseases Society of America-recommended antimicrobial stewardship interventions: modified preauthorization (PA; prescriber receives pharmacist approval for continued use of the antibiotic after the first dose) and postprescription audit and review (PPR; pharmacist engages the prescriber about antibiotic appropriateness after 72 hours of therapy). These two interventions were implemented at four community hospitals in North Carolina (bed size range, 102 to 425). A total of 2,692 patients receiving either targeted study antibacterial agents or alternative, nonstudy antibacterial agents were included in the intervention.

The researchers found that pharmacists performed 1,456 modified PA interventions (median per hospital, 350) and 1,236 PPR interventions (median per hospital, 298). Study antimicrobials were assessed as inappropriate twice as often during the PPR period (41 versus 20.4 percent). During the modified PA intervention, pharmacists recommended dose changes more often (15.9 versus 9.6 percent), while de-escalation was recommended more often during PPR (29.1 versus 13 percent). The median time dedicated to the stewardship interventions ranged from five to 19 hours weekly. Compared with historical levels, overall antibiotic use decreased during PPR (mean difference, −40.1 days of therapy per 1,000 patient-days; 95 percent confidence interval, −71.7 to −8.6), but not during modified PA (mean difference, 4.4; 95 percent confidence interval, −55.8 to 64.7).

"Even modest decreases in antimicrobial utilization are valuable, particularly when potentially achievable in the more than 3,000 community hospitals in the United States," Anderson said in a statement. "This study suggests there are approaches that can work, even in hospitals where resources might be limited."

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