Hospital Size,
Primary Strategy |
ASP Team Members |
Patient Outcomes |
Bacterial Resistance and
Infection Outcomes |
Impact on Antibiotic Use |
Reduced Expenditures and Costs |
Comments |
| 575 beds, prior authorization (24 hrs/day-7 days/wk, dedicated pager)[22] |
ID physicians, pharmacists |
Outcomes (pre- and postprogram implementation) were assessed for patients with gram-negative bacteremia
No differences in patient demographics, SAPSII score (p>0.3 for all)
No differences in survival (p=0.49)
No differences in infection (bacteremia)-related length of stay (p>0.05)
No differences in time to receipt of appropriate antibiotic (p>0.05) |
Reduction in resistance rates after program implementation (p≤0.01) for the following drug-organism pairings:
Ticarcillin-clavulanate: P. aeruginosa, K. pneumoniae, E. cloacae, A. anitratus, E. coli
Imipenem: E. coli, P. aeruginosa, K. pneumoniae
Aztreonam: E. coli, P. aeruginosa, K. pneumoniae, E. cloacae
Ceftazidime: E. coli, P. aeruginosa, E. cloacae, A. anitratus
Amikacin: E. coli
Ciprofloxacin: E. coli, P.aeruginosa |
Significant reductions in use of the following restricted agents (p value not specified): aztreonam, ceftazidime, imipenem, ticarcillin-clavulanate |
First year reduction in total antimicrobial expenditures was $803,910
Antibiotic costs/patient-day reduced from $18.00 to $14.40 |
Prospective before-and-after study used to determine outcomes of a prior-authorization program on antimicrobial resistance, costs, and clinical outcomes
Simultaneous infection control efforts only included three hand-hygiene inservices for surgical ICU staff |
| 772 beds, prior authorization[23] |
ID physician, ID-trained Pharm.D. |
No differences in patient demographics, MedisGroup score (p>0.05 for all)
Appropriateness of therapy defined as use of antimicrobial agent that adheres to institution-specific guidelines for spectrum of activity and route of delivery for each indication; doses had to be correctly adjusted according to organ function; known allergies be avoided
Results: ASP vs ID fellows
Appropriateness: 87% vs 47% (p<0.001)
Cure: 56% vs 38% (p=0.007)
Failure: 15% vs 28% (p=0.03) |
Not determined |
Factors contributing to inappropriate treatment: ASP vs ID fellows (represented as no./total no.)
Cost: 6/87 vs 25/93 (p<0.001)
Spectrum too broad: 4/87 vs 21/93 (p<0.001)
Spectrum too narrow: 1/87 vs 5/93 (p=0.11)
Spectrum inappropriate (other than reasons above): 1/87 vs 14/93 (p<0.001)
Antimicrobial agents not indicated: 6/87 vs 9/93 (p=0.5)
Route inappropriate: 0/87 vs 2/93 (p=0.17)
Dose inappropriate: 0/87 vs 2/93 (p=0.17) |
Median costs were compared between groups (ASP vs ID fellow)
Hospital cost after approval call: $6468 vs $7864 (p=0.08)
Cost attributable to infection: $3510 vs $4205 (p=0.10)
Cost of antimicrobial agents: $79 vs $122 (p=0.09) |
Study prospectively compared outcomes of the ASP with that of the ID fellows covering the program (during off-hrs) in terms of antimicrobial recommendations and clinical and economic measures |
| 250 beds, concurrent review[24] |
ID physician, two pharmacists, clinical microbiologist, laboratory microbiologist, data analyst |
No differences in nosocomial infection rates, crude mortality rate, and ICU length of stay
Hospital length of stay decreased significantly (p=0.04) |
Consumption ratios of ≥ 2 antimicrobials and resistance over time were determined
The increase in cefepime use relative to decreased use of third-generation cephalosporins over time was associated with decreased resistance to E. cloacae (p=0.03) and P. mirabilis (p=0.05)
The increase in ampicillin-sulbactam use relative to decreased use of third-generation cephalosporins was associated with reduction in E. cloacae (p=0.03) resistance and MRSA (p=0.04)
Reduction in carbapenem use correlated with reduction in carbapenem-resistant P. aeruginosa
The increased use of cefepime was not associated with increase in cefepime-resistant P. aeruginosa |
Only i.v. antimicrobial use was measured and considered in theanalysis
Overall i.v. antimicrobial use reduced from 430.89 to 276.35 DDD/1000 patient-days (p<0.0001)
Significant reductions in use of cephalothin (p<0.0001), clindamycin (p<0.003), ceftriaxone (p<0.0001), and carbapenems (p=0.03)
Increase in microbiologically based prescribing intention occurred during study, from 27% to 62.8% (p<0.0001)
Interventions (n=349):
Less-expensive treatment initiated: 86.1%
Narrower spectrum of activity: 47%
Reduced dose or duration: 11.5% |
Only i.v. antimicrobial costs were considered: $913,236 savings during the 18-mo period |
|
| 600 beds, concurrent review[18] |
ID physician fellow and critical care Pharm.D. |
No differences in demographics or severity of illness (measured by the Charlson Prognostic Comorbidity Index) (p>0.1 for all) |
Not determined |
Intervention group had fewer antibiotic DDDs/patient, but not statistically significant: 10.16 DDDs vs 13.59 DDDs/patient (p=0.9)
50% of patients had targeted drugs streamlined at day 3 of therapy without negatively affecting outcome |
Antimicrobial charges/patient were significantly less in the intervention group: $1287.17 vs $1873.97(p<0.04) |
Prospective, randomized, controlled study of clinical, safety, and economic outcomes
Patients receiving ≥ 1 of 10 designated antibiotics for ≥ 3 days were randomized to intervention or no intervention (control)
Study showed that interventions to improve antimicrobial use could be performed safely without adversely affecting short-term and long-term clinical outcomes |
| 600 beds, concurrent review[25,26] |
ID physician, ID Pharm.D. |
Not determined |
5-yr longitudinal study[26] of changes in antibiotic use (influenced by computerized decision support and education) and its impact on resistance trends
Ceftazidime use diminished (36.6 to 10.4 antibiotic-days/1000 patient-days)
Cefepime use increased from 0 to 49 antibiotic-days/1000 patient-days over the same time period
In parallel, susceptibility of AmpC phenotypes (S. marcescens and E. cloacae) to third-generation cephalosporins from 1998-2002 increased from 40% to 90% (r2 = 0.98, p=0.0001) and from 72% to 83% (r2 = 0.79, p=0.04), respectively |
Interventions published from first 6 mo of program (no.)[25]:
Dose optimization: 239
Discontinuation of redundant therapy: 94
Change of route: 88
Streamlined therapy: 55
Interventions from first 2 yrs, unpublished (no.):
Dose optimization: 825
Discontinuation of redundant therapy: 245
Change of route: 220
Streamlined therapy: 210 |
Measured annual savings compared with pre-ASP expenditures:
In 2002: $67,358
In 2003: $227,028 |
Clinical program developed from prospective, randomized, controlled, study previously conducted at our institution[18]
After demonstrating that interventions could be performed safely in patients at our institution, a clinical program was developed.
This program was more efficient (able to see more patients/day due to significantly reduced amount of data collected compared with randomized trial)
With newly available data, evidence-based initiatives that optimize patient care and safety, while being cost-effective, were started
Impact on education and implementation of physician order entry enhancements on prescribing of cephalosporins and resultant organisms with AmpC phenotypes was evaluated over the 5-yr period |
| "Large-sized," concurrent review[19] |
Unspecified |
Not determined |
Not determined |
Appropriate use defined as indication met hospital guidelines, spectrum active against isolated or suspected pathogen, use was necessary, and no known allergy to prescribed antibiotic existed
Greater extent of appropriate antibiotic prescribing in the intervention vs control group: 80% vs 60% (p<0.005)
Therapy deemed inappropriate for the following reasons: unnecessary treatment (contaminant or asymptomatic bacteriuria), 43%; overly broad- or narrow-spectrum antibiotics, 30%; and use outside hospital guidelines, 27%
Intervention group was more likely to have therapy streamlined (79% vs 59%, p<0.01) and had reduced exposure to inappropriate therapy, measured by median DDD/patient (2 vs 3, p=0.006) and duration (3 vs 5 days, p<0.005) |
Not determined |
Randomized, controlled study of the impact of an ASP over the 5-mo period
12 internal medicine teams randomized to either intervention group (received input on antimicrobial use from ASP) or control group (used indication-based guidelines with no ASP input)
Daily audits of targeted drug use (levofloxacin, piperacillin-tazobactam, vancomycin) |
| 1000 beds, concurrent review added to prior-authorization program[20] |
ID physician, ID Pharm.D., data analyst |
Not determined |
Not determined |
Not reported |
Costs for antimicrobial agents for the covered areas decreased by 6.4% the first yr and 2.2% the second yr
Authors factored in inflation rate of 4.5% annually, reporting a savings of $224,753 and $413,998 for fiscal yrs 2002 and 2003, respectively |
Prior-approval program at Johns Hopkins Hospital was supplemented with more comprehensive strategy that was responsible for concurrent review of antimicrobialn therapy, publication of local guidelines, and educational sessions
Cost savings justified expenses of program (ID physician, ID Pharm.D., data analyst) |
| Medium-sized community hospital, concurrent review[28] |
ID physician, ID Pharm.D. |
Not determined |
Reductions in nosocomial infections caused by C. difficile (p=0.002) and resistant Enterobacteriaceae (p=0.02) |
A 22% reduction in parenteral broad-spectrum antibiotic use occurred during a 7-yr period (p<0.0001)
Sustained reduction in ceftazidime use occurred (from 24.7 to 6.2 DDD/1000 patient-days) |
Comparing costs from 1990 to subsequent yrs demonstrated reduction in annual antimicrobial expenditures between $200,000 and $250,000 each yr |
A long-term successful impact on both costs and the hospital's ecology in terms of infection rates with problematic and/or drug-resistant organisms was demonstrated
Parenteral antibiotic use and expenditures were reduced in spite of 15% increase in Medicare Case Mix Index and 56% increase in ICU patient-days throughout 7-yr period |
| 80 beds, concurrent review and prior authorization[27] |
Internal medicine department (5 attending physicians, 13 residents), and pharmacy department (role not clarified) |
No difference in patient demographics
Severity of illness scoring system not used
Results: intervention vs control group
Cured or improved: 81% vs 84% (p=0.52)
Length of stay (median): 12 vs 13 days (p value not given)
Relapse during hospital stay: 1.4% vs 1.7% (p=0.72)
Infection-related mortality: 2.4% vs 4% (p=0.15)
Readmission rates within 30 days due to infection: 1% vs 1.8% (p=0.28) |
Not determined |
Using DDD data:
Reduction in overall antimicrobial use: 36% (p=0.001)
Reduction in i.v. antimicrobial use: 46% (p<0.01) |
Reduction in overall antimicrobial expenditures: 53% (p=0.001) |
A quasi-experimental before-and-after study conducted in small Swiss hospital
Objectives were to evaluate impact of its ASP on costs and clinical outcomes and to monitor long-term impact on costs
Interventions: targeted antimicrobial restriction, education, feedback to staff on expenditures, provision of annual antibiogram
Study showed durability of program on antimicrobial expenditure reductions and, of importance, that its interventions did not adversely effect patients' outcomes |
| 120 beds, concurrent review[29] |
ID physician, clinical pharmacist (infection control and microbiologist also mentioned) |
Not determined |
Not determined |
Interventions (no.): Dose optimization: 20
Discontinuation of redundant therapy, excessive duration, inappropriate use: 127
Route change: 110
Addition of antimicrobial: 77 |
Antibiotic costs/patient-day: reduced from $18.21 to $14.77 (19% reduction)
Annualized expenditure reduction: $177,000 |
Methods adopted from previous study,[18] with customized approach to smaller hospital setting
Concurrent review occurred 3 days/wk |
| Veterans Affairs medical center, concurrent review of patients receiving restricted or nonformulary antimicrobials[30] |
ID Pharm.D. (antimicrobial advisory group consisted of ID physicians, microbiology laboratory director, and ID Pharm.D.) |
Patient demographics were similar between groups, although intervention group was slightly older (63.8 vs 63.1 yrs, p=0.049)
Severity of illness scoring not determined
Results: pre- vs postprogram implementation
Length of stay (mean): 13.2 vs 10.8 days (p<0.0001)
Infection-related mortality: 8.28% vs 6.61% (p=0.007)
Readmission rates within 30 days due to infection: 10.96% vs 10.42% (p=0.46) |
Not determined |
Interventions (no. during first yr/no. during second yr):
Dose optimization: 87/140
Approved use of agent and recommended additional agent: 35/35
Approved use of agent while discontinuing current antibiotic: 40/39
Initial order denied for an alternative regimen: 244/199 |
Average annual reduction in parenteral antimicrobial expenditures was 30.8% ($145,942/yr) |
Retrospective study of patient outcomes and costs for two consecutive 2-yr periods (2 yrs before and 2 yrs after program introduction)
Clinical protocols were developed for approval or denial of restricted or nonformulary antimicrobials (indications, dosages, alternative regimens)
Restricted antimicrobials were allowed to be prescribed; the ID Pharm.D. was notified of their use, followed the patients' courses, and approved or denied their continued use
For complex cases, the ID Pharm.D. facilitated ID consultation |
Comments