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Post-prescription review associated with fewer days of antibiotic therapy

Patients prescribed antibiotics who received a post-prescription review with feedback showed a decrease in antibiotic days of therapy compared with patients who received pre-prescription authorization, according to results published in Clinical Infectious Diseases.

“Antibiotic stewardship programs have been shown to reduce antibiotic use, improve patient outcomes, and decrease adverse drug events such as Clostridium difficile infections and antibiotic resistance,” Pranita D. Tamma, MD, MHS, of the Johns Hopkins University School of Medicine, and colleagues wrote. “However, the optimal approach to conducting antibiotic stewardship interventions has yet to be defined.”

“The 2016 Infectious Disease Society of America and Society for Healthcare Epidemiology of America guidelines ... consider both pre-prescription authorization (PPA) and post-prescription review with feedback (PPRF) approaches as ‘strong recommendations’ for reducing antibiotic use in the health care setting. However, they do not provide additional data on which approach is preferred for optimizing antibiotic use,” they added.

Between September 2013 and June 2014, Tamma and colleagues conducted a quasi-experimental, crossover trial to compare the effectiveness of PPA and PPRF for adult inpatients who were prescribed antibiotics. Two medicine teams were assigned to the PPA group, while another two teams were assigned to the PPRF group during the first 4 months of the study. Afterwards, the teams swapped groups for an additional 4 months. At least two infectious disease clinicians determined if the antibiotic use was appropriate.

The researchers enrolled 2,686 patients into the PPA group and 2,693 patients into the PPRF group. In the PPA group 778 patients (29%) were prescribed antibiotics, as were 730 patients (27%) in the PPRF group.

During the first 4 months, patients in the PPA group showed a relatively stable number of antibiotic days of therapy, but when these patients received PPRF treatment, antibiotic use decreased (–2.45 days of therapy per 1,000 patient-days). In the PPRF group days of antibiotic therapy initially decreased steadily (slope of –5.73 days of therapy per 1,000 patient-days); however, in the second 4 months of the study, when these patients received PPA treatment, the number of antibiotic days of therapy remained constant.

Overall, the median patient-days of antibiotic therapy were 8 per 1,000 patient-days in the PPA and 6 per 1,000 patient-days in the PPRF groups. In the PPA group, antibiotic therapy was guideline-noncompliant in 34% of patients on day 1 and 57% of patients on day 3. In the PPRF group, therapy was noncompliant in 41% of patients on day 1 and 36% of patients on day 3.

The median patient length of therapy were 7 per 1,000 patient-days in the PPA group and 5 per 1,000 patient-days in the PPRF group.

“Although both PPA and PPRF have an impact on overall antibiotic use, a favorable impact on antibiotic [days of therapy] and [lengths of therapy] may be more pronounced with PPRF,” Tamma and colleagues concluded. “Both of these approaches are useful and impactful antibiotic stewardship techniques, but they both also require significant personnel time. We favor incorporating a combination of PPA and PPRF into stewardship activities but in settings where resources are limited precluding this possibility, our findings suggest it may be more value to prioritize PPRF.” – by Alaina Tedesco

Disclosure: The researchers reported receiving a grant from Pfizer Independent Grants for Learning and Change and The Joint Commission.