Patterns of use and perceptions of an institution-specific antibiotic stewardship application among emergency department and urgent care clinicians

Changes in antibiotic consumption, AMR and Clostridioides difficile infections in a large tertiary-care center following the implementation of institution-specific guidelines for antimicrobial therapy: A nine-year interrupted time series study

BACKGROUND

Institution-specific guidelines (ISGs) within the framework of antimicrobial stewardship programs offer locally tailored decision support taking into account local pathogen and resistance epidemiology as well as national and international guidelines.

OBJECTIVES

To assess the impact of ISGs for antimicrobial therapy on antibiotic consumption and subsequent changes in resistance rates and Clostridioides difficile infections (CDIs).

METHODS

The study was conducted at the Leipzig University Hospital, a 1,451-bed tertiary-care medical center, and covered the years 2012 to 2020. Since 2014, ISGs were provided to optimize empirical therapies, appropriate diagnostics, and antimicrobial prophylaxis. We used interrupted time series analysis (ITSA) and simple linear regression to analyze changes in antimicrobial consumption, resistance and CDIs.

RESULTS

Over the study period, 1,672,200 defined daily doses (DDD) of antibiotics were dispensed, and 85,645 bacterial isolates as well as 2,576 positive C. difficile cultures were collected. Total antimicrobial consumption decreased by 14% from 2012 to 2020, without clear impact of the deployment of ISGs. However, implementation of ISGs was associated with significant decreases in the use of substances that were rarely recommended (e.g., fluoroquinolones). Over the whole study period, we observed declining resistance rates to most antibiotic classes of up to 25% in Enterobacterales, staphylococci, and Pseudomonas aeruginosa. Switching from ceftriaxone to cefotaxime was associated with reduced resistance to third-generation cephalosporins. The number of CDI cases fell by 65%, from 501 in 2012 to 174 in 2020.

CONCLUSIONS

Well-implemented ISGs can have a significant, immediate, and lasting impact on the prescription behavior. ISGs might thereby contribute to reduce resistance rates and CDI incidences in the hospital setting.

Factors Associated With Longer Than Recommended Durations of Antibiotic Therapy for Uncomplicated Ambulatory Infections in an Integrated Healthcare System

Across the ambulatory care network of an integrated health care system, durations of antibiotic therapy prescribed for uncomplicated infections were longer than recommended in 39% of cases. By logistic regression, site of care, prescriber characteristics, and type of infection were independently associated with longer than recommended durations of therapy.

Assessing the impact of institution-specific guidelines for antimicrobials on doctors' prescribing behavior at a German tertiary-care center and the additional benefits of providing a mobile application

Objective

To assess usage patterns, perceived usability, and effects of institution-specific guidelines (ISGs) for antimicrobials on clinicians’ prescribing behavior and the additional benefits of the mobile application (app), a single-center survey among medical doctors was performed.

Methods

The study was carried out in a 1451-bed tertiary-care academic medical center in Leipzig, Germany. To ensure optimal empirical antibiotic therapies, appropriate diagnostics, and targeted antimicrobial prophylaxis, ISGs were provided as printed pocket guides (since 2014), a PDF version on ward computers, and a mobile app (since 2017). For the survey, we used an electronically structured cross-sectional questionnaire with 31 items, ordinal Likert scales, and percent bars, allowing for quantitative comparisons.

Results

Of the 914 doctors contacted by email, 282 (31%) responded, and 254 (28%) surveys were eligible. ISGs were reported to be the most commonly used source of information for antimicrobial prescribing among the respondents. Ninety-four percent used ISGs at least once and 55% at least weekly. On average, participants reported using them in 38% of antibiotic prescriptions and to adhere to consulted recommendations in 87% of cases. Young clinicians (≤ 30 years) reported significantly higher use of the ISGs than their older colleagues (47% vs. 35% of antibiotic prescriptions, p = 0.004). Ninety-six percent of users found ISGs to be user-friendly, and nearly 100% recommended ISGs to other colleagues. Forty-five percent regarded the app as the most user-friendly way to access ISGs, and app users were significantly more likely to use ISGs regularly (p = 0.024). Eighty-four percent reported behavioral changes regarding at least one aspect of antimicrobial therapy (e.g. duration, application mode, prescription frequency), while 54% reported changes regarding the choice of specific substance groups.

Conclusions

ISGs are used regularly and appear to have a relevant impact on clinicians’ prescribing habits. A mobile app may be the most effective way to provide ISGs, although multiple platforms seem to add value. While the majority of participants reported perceived effects on their prescribing behavior, this study does not allow any conclusions to be drawn about the extent of the effects of ISGs on antibiotic use and patient outcomes.