Impact of an antimicrobial stewardship intervention on appropriateness of prescribing for community-acquired pneumonia in an Australian regional hospital

Utility of radiographic keyword abstraction for identification of misdiagnosed pneumonia

Misdiagnosis of bacterial pneumonia is a leading cause of inappropriate antimicrobial use in hospitalized patients. We report a novel strategy of keyword abstraction from chest radiography transcripts that reliably identified patients with pneumonia misdiagnosis and opportunities for antibiotic discontinuation and/or de-escalation.

The impact of a stewardship program on antibiotic administration in community-acquired pneumonia: Results from an observational before-after study

BACKGROUND

A majority of patients with community-acquired pneumonia (CAP) receive antibiotics. According to the evidence, 5-7 days of treatment should be sufficient for most patients. Many, however, are treated longer than recommended. We have previously conducted a quality improvement study to ensure guideline-conform treatment for CAP. However, the impact of the interventions on antibiotic use has not been investigated.

OBJECTIVE

To estimate the impact of an eight-month stewardship program on antibiotic use.

METHODS

We conducted a before-after study comparing a four-month baseline period with data from a corresponding follow-up period. We performed univariable and multivariable logistic regression to compare odds for ≤7 days of total antibiotic treatment, ≤3 days of intravenous treatment and the proportion of correct empiric antibiotics. As sensitivity analysis, we repeated the univariable logistic regression on a propensity score-matched cohort by using the same variables we used for adjustments in the multivariable analysis. We also performed subgroup analyses for patients stable ≤72 h of admission.

RESULTS

In total, 771 patients were included. Compared to preintervention, the unadjusted odds ratio (OR) for ≤7 days of total antibiotic treatment were 1.84 (95% CI 1.34-2.54) for the whole population and 2.08 (1.41-3.10) for the stable patients. The OR for ≤3 days of intravenous antibiotics were 1.16 (0.87-1.54) and 1.38 (0.87-2.22), respectively. The OR for correct empiric antibiotics were 1.96 (1.45-2.68) and 1.82 (1.23-2.69). Comparable results regarding all outcomes were derived from the other analyses.

CONCLUSION

The program resulted in a significantly lower overall antibiotic exposure and a higher proportion of patients treated with the recommended antibiotics without a the reduction of exposure to intravenous antibiotics significantly.

Impact of clinical decision support on empirical antibiotic prescribing for children with community-acquired pneumonia

AIM

To assess the impact of a computerised clinical decision support system (CDSS) on antibiotic use in hospitalised children with a presumptive diagnosis of uncomplicated community-acquired pneumonia (CAP).

METHODS

Codes associated with lower respiratory tract infection were used to identify cases of presumed uncomplicated CAP requiring admission to a tertiary paediatric hospital. Random sampling of the periods between 1 October 2010 and 30 September 2012 (pre-CDSS) and 1 October 2012 and 30 September 2014 (post-CDSS) determined the sequence of case assessment by two independent investigators. Initial antibiotic therapy, associated CDSS approvals and documented signs of clinical deterioration prior to antibiotic decision-making were recorded.

RESULTS

Statistically significant differences between cases pre- and post-CDSS implementation were minimal. High fever was observed in 57.5% (77/134) cases pre-CDSS and 45.8% (49/107) cases post-CDSS (P = 0.07). Supplemental oxygen was used in 30.6% pre-CDSS and 54.2% post-CDSS cases (P < 0.001). Narrow-spectrum penicillins were prescribed most often, with no statistically significant change post-CDSS implementation (81.3% pre-CDSS, 77.6% post-CDSS, P = 0.47). Macrolides were used consistently throughout the study period (53.7% pre-CDSS, 61.7% post-CDSS; P = 0.21).

CONCLUSION

CDSS implementation did not reduce already low rates of broad-spectrum antibiotic use for uncomplicated CAP.

Similarities and differences in antimicrobial prescribing between major city hospitals and regional and remote hospitals in Australia

Many regional and remote hospitals (RRHs) do not have the specialist services that usually support antimicrobial stewardship (AMS) programmes in major city hospitals. It is not known if this is associated with higher rates of inappropriate antimicrobial prescribing. The aim of this study was to identify similarities and differences in antimicrobial prescribing patterns between major city hospitals and RRHs in Australia. The Australian Hospital National Antimicrobial Prescribing Survey (H-NAPS) datasets from 2014, 2015 and 2016 (totalling 47,876 antimicrobial prescriptions) were analysed. The antimicrobial prescribed, indications for use, documentation of indication, recording of a review date and assessment of the appropriateness of prescribing were evaluated. Overall, inappropriate prescribing of antimicrobials was higher in RRHs than in major city hospitals (24.0% vs. 22.1%; P<0.001). Compared with major city hospitals, inappropriate prescribing of ceftriaxone was higher in RRHs (33.9% vs. 27.6%; P<0.001), as was inappropriate prescribing for cellulitis (25.7% vs. 19.0%; P≤0.001). A higher rate of inappropriate prescribing was noted for some high-risk infections in RRHs compared with major city hospitals, including Gram-positive bacteraemia with sepsis (12.6% vs. 6.5%; P=0.004), empiric therapy for sepsis (26.0% vs. 12.0%; P<0.001) and endocarditis (8.2% vs. 2.7%; P=0.02). To the authors' knowledge, this is the largest study to date comparing antimicrobial prescribing of RRHs with major city hospitals. A key finding was that antimicrobial prescribing was more frequently inappropriate for some high-risk infections treated in RRHs. Targeted strategies that support appropriate antimicrobial prescribing in RRHs are required.