Antimicrobial stewardship is an emerging field currently defined by a series of strategies and interventions aimed toward improving appropriate prescription of antibiotics in humans in all healthcare settings. The ultimate goal is the preservation of current and future antibiotics against the threat of antimicrobial resistance, although improving patient safety and reducing healthcare costs are important concurrent aims. Prospective audit and feedback interventions are probably the most widely practiced of all antimicrobial stewardship strategies. Although labor-intensive, they are more easily accepted by physicians compared with formulary restriction and preauthorization strategies and have a higher potential for educational opportunities. Objective evaluation of antimicrobial stewardship is critical for determining the success of such programs. Nonetheless, there is controversy over which outcomes to measure and there is a pressing need for novel study designs that can objectively assess antimicrobial stewardship interventions despite the limitations inherent in the structure of most such programs.

Our prospective-audit-and-feedback antimicrobial stewardship (AS) program for hematology and oncology inpatients was switched from one led by dedicated clinicians to a rotating team of infectious diseases trainees in order to provide learning opportunities and attempt a “de-escalation” of specialist input towards a more protocol-driven implementation. However, process indicators including the number of recommendations and recommendation acceptance rates fell significantly during the year, with accompanying increases in broad-spectrum antibiotic prescription. The trends were reversed only upon reverting to the original setup. Dedicated clinicians play a crucial role in AS programs involving immunocompromised patients. Structured training and adequate succession/contingency planning is critical for sustainability.

BackgroundThe optimal way for antimicrobial stewardship programs (ASPs) to interact with existing infectious disease physician (IDP) services within the same institution is unknown. In our institution, IDPs and our prospective audit and feedback ASP operate independently, with occasionally differing recommendations offered for the same inpatient. We performed a retrospective audit on inpatients that had been reviewed by both IDPs and ASP within a 7-day period, focusing on cases where different therapy-modifying recommendations had been offered. We analyzed the outcomes in inpatients where the ASP recommendations were accepted and compared these with the inpatients where the IDP recommendations were accepted instead. Outcomes assessed were 30-day mortality post-ASP review, unplanned re-admission within 30 days post-discharge from hospital, and clinical deterioration at 7 days post-ASP review.FindingsThere were 143 (18.9%) patients where differing recommendations had been offered, with primary physicians accepting 69.9% of ASP recommendations. No significant differences in terms of demographics, clinical characteristics, 30-day mortality, and re-admission rates were observed, although clinical deterioration rates were lower in patients where the ASP recommendation was accepted (8.0% vs. 27.9%; p = 0.002). On multivariate analysis, hematology-oncology inpatients were associated with unplanned readmission. Increasing age and hematology-oncology inpatients were associated with clinical deterioration 7 days post-recommendation, whereas acceptance of ASP recommendations was protective. No characteristic was independently associated with 30-day mortality.ConclusionIn conclusion, independent reviews by both IDPs and ASPs can be compatible within large tertiary hospitals, providing primary physicians even in situations of conflicting recommendations viable alternative antimicrobial prescribing advice.

Background: Infectious diseases (ID) specialists are a core element of an immediate concurrent feedback (ICF) antimicrobial stewardship team. Owing to manpower changes, an antimicrobial stewardship program (ASP) originally anchored by a dedicated ID specialist was switched to a team of rotational ID trainees. We reviewed the impact of this on the outcomes of an ASP in the hematology-oncology unit of a tertiary care hospital.Methods: Hematology-oncology inpatients who were prescribed broad-spectrum antibiotics were reviewed by a multidisciplinary team. Cases that required optimization of therapy were issued written recommendations by the ID physician. A dedicated ID specialist anchored the program in the first year, while rotating ID trainees covered in the second year. Outcomes analyzed included compliance to recommendations made and antibiotic consumption in terms of defined daily doses (DDD) per 100 inpatient-days.Results: 1415 and 1168 cases were reviewed during the first and second years respectively. 649 recommendations were made in the first year and 266 in the second year. Compliance was higher in the first year (87.8% versus 73.3%, p = 0.0002). Positive clinical outcomes post-recommendation acceptance was observed in 79.2% in the first year, but only in 68.9% during the second year. Average monthly consumption of antibiotics increased from 81.25 DDD/100 inpatient-days in the first year, to 97.49 DDD/100 inpatient-days in the second year (p = 0.0006). Carbapenem, piperacillin/tazobactam and quinolone use increased by 38%, 86% and 15% respectively. Of note, subsequent restoration of dedicated ID specialist reviews saw the average monthly consumption of antibiotics declining to 78.19 DDD/100 inpatient-days in four months and recommendation compliance rate improving to 81.0%.Conclusion: Committed and experienced ID physicians are integral to an effective ASP. Possible reasons for the enhanced effectiveness in this setting include increased clinical experience with immunocompromised patients leading to improved patient outcomes, stronger rapport with the primary team and a greater sense of accountability to both the patients and outcomes of the ASP.