Introduction The Infectious Diseases Society of America (IDSA) recommends a minimum of 5 days of antibiotic therapy in stable patients who have community-acquired pneumonia (CAP). However, excessive duration of therapy (DOT) is common. Define, measure, analyze, improve, and control (DMAIC) is a Lean Six Sigma methodology used in quality improvement efforts, including infection control; however, the utility of this approach for antimicrobial stewardship initiatives is unknown. To determine the impact of a prospective physician-driven stewardship intervention on excess antibiotic DOT and clinical outcomes of patients hospitalized with CAP. Our specific aim was to reduce excess DOT and to determine why some providers treat beyond the IDSA minimum DOT. Methods A single-center, quasi-experimental quality improvement study evaluating rates of excess antimicrobial DOT before and after implementing a DMAIC-based antimicrobial stewardship intervention that included education, prospective audit, and feedback from a physician peer, and daily tracking of excess DOT on a Kaizen board. The baseline period included retrospective CAP cases that occurred between October 2018 and February 2019 (control group). The intervention period included CAP cases between October 2019 and February 2020 (intervention group). Results A total of 123 CAP patients were included (57 control and 66 intervention). Median antibiotic DOT per patient decreased (8 versus 5 days; p < 0.001), and the proportion of patients treated for the IDSA minimum increased (5.3% versus 56%; p < 0.001) after the intervention. No differences in mortality, readmission, length of stay, or incidence of Clostridioides difficile infection were observed between groups. Almost half of the caregivers surveyed were aware that as few as 5 days of antibiotic treatment could be appropriate. Conclusions A physician-driven antimicrobial quality improvement initiative designed using DMAIC methodology led to reduced DOT and increased compliance with the IDSA treatment guidelines for hospitalized patients with CAP reduced without negatively affecting clinical outcomes.

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Background The IDSA and American Thoracic Society (IDSA/ATS) Community Acquired Pneumonia (CAP) guidelines recommend 5 days of therapy for clinically stable patients that defervesce, however, duration of therapy (DOT) is often longer. Pharmacists curb this via antimicrobial stewardship (AMS), but budgetary constraints are barriers to robust AMS programs in some hospitals. Physicians are increasingly encouraged to participate in quality improvement (QI) and are a potential resource to improve AMS. We sought to determine the impact of a prospective, physician-driven stewardship intervention on DOT and clinical outcomes in hospitalized veterans with CAP, with the goal to reduce the median DOT by at least 1 day within 5 months. Methods This single center, quasi-experimental QI study evaluated two concurrent physician-driven interventions over a 5-month period in an inner-city Veterans Affairs Hospital. Using DMAIC (Define, measure, analyze, improve, and control) methodology, the Chief Resident in Quality and Safety (CRQS) provided monthly education and daily audit and feedback with patient-specific DOT recommendations. Clinical outcomes were followed until 30 days post discharge. Results A total of 123 patients with CAP were included (57 in the historic control group and 66 in the AMS intervention group). The AMS intervention significantly increased the proportion of CAP patients treated with a 5-day treatment course (56% versus 5.3%, p< 0.0001), and reduced the proportion of patients treated beyond 7 days (12.1% versus 70.2%, p< 0.0001). Median DOT per patient was reduced significantly (5 versus 8 days, p< 0.0001). Median excess antibiotic days were significantly reduced (0 versus 3, p< 0.0001) and 118 days of unnecessary antibiotics were avoided (62 versus 180). 30-day all-cause mortality, all-cause readmission, and Clostridium difficile infection were similar between groups. Median LOS was similar between groups (p=0.246). DOT in the Historic Control Group Versus Stewardship Intervention Group Conclusion A physician driven QI stewardship intervention in hospitalized CAP patients significantly reduced the total antibiotic DOT and excess antibiotic days without adversely affecting patient outcomes. Providers can be educated through physician driven interventions resulting in substantial improvements in appropriate antibiotic use. Disclosures All Authors: No reported disclosures

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