1. In this prospective stepped-wedge participatory intervention study, implementation of a behavioral antimicrobial stewardship program which maintained prescriber autonomy resulted in improved appropriateness of antimicrobial prescribing in hospitals.
2. Despite the improvement in appropriate antibiotic prescribing practices, there was no decrease in total antimicrobial consumption.
Evidence Rating Level: 2 (Good)
Study Rundown: Minimizing antimicrobial resistance and potential iatrogenic nosocomial infections like C. difficile is predicated on minimizing inappropriate antibiotic use. Changing the prescribing behaviors of practitioners is complex and this prospective, stepped-wedge, participatory intervention study examined whether an antimicrobial stewardship approach grounded in behavioral theory and focus on preserving prescriber autonomy would be effective in improving appropriateness of antimicrobial prescribing in hospitals.
Implementation of the behavioral theory-based antimicrobial stewardship program resulted in an increase in appropriate antimicrobial prescribing by 13% at 12-month follow-up. However, there was no associated decrease in antimicrobial consumption noted. Strengths of this study included investigation of a low-cost, easily implementable intervention to improve appropriate antimicrobial use. However, there was no blinding of the intervention thus awareness of being monitored may have altered prescribers’ behaviors on its own.
In-Depth [prospective study]: This prospective, stepped-wedge, participatory intervention study was performed October 2011 to December 2015 in 7 clinical departments (2 medical, 3 surgical and 2 pediatric) in one tertiary medical hospital in the Netherlands. Any physician that prescribed any medication for any indication on these seven clinical wards during the study period was included in the study. There was a baseline period and intervention period. The intervention of interest was a stewardship program to help with antimicrobial prescribing that was offered to all physicians of the clinical departments. The stewardship programs were created individually based on root-cause analysis. Appropriateness of antimicrobials was determined using validated approach based on guideline adherence measured 6 times a year with surveys. Pharmacy records determined antimicrobial consumption. Linear and logistic mixed-model regression was used for statistical analysis.
There were a total of 1121 patient cases with 700 antimicrobial prescriptions during the baseline period, and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. Antimicrobial appropriateness increased from 64.1% during the baseline to 77.4% at the 12-month follow-up (relative risk 1.17; 95%CI 1.04-1.27). However, there was no decrease in antimicrobial consumption over the study period.
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