Kate Johnson

September 16, 2014

WASHINGTON — An antibiotic stewardship program that guided individual prescriptions during a 6-month period significantly reduced rates of readmission due to infection, report researchers presenting here at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).

It is well established that antibiotic stewardship programs can reduce the rate of antibiotic use, but very few have been able to demonstrate patient benefit, which is controversial, said lead investigator Fredrik Resman, MD, from Skåne University Hospital in Malmö, Sweden.

"This was a noninferiority study, so we were able to show that we achieved a reduction in antibiotics without compromising patient safety," said Dr. Resman. "It's hard to show benefit, but you at least need to show noninferiority, because you have to show that patients are not getting sicker or dying as a result of fewer antibiotics."

Dr. Resman told Medscape Medical News, "We were surprised to show a reduced readmission rate."

 
We were surprised to show a reduced readmission rate. Dr. Fredrik Resman
 

The study analyzed a 6-month period in 2013 during which an infectious disease specialist offered an antibiotic stewardship program in four geriatric wards (74 beds) at Skåne University Hospital in Malmö. Investigators compared this period to a temporally matched control period in the previous year, when antibiotic prescribing was guideline-based only.

In the stewardship program, an infectious disease expert visited the wards twice weekly to give treatment recommendations — a commitment of about 8 hours per week.

During this time, 781 elderly patients received antibiotics, compared with 886 in the control period.

There were no significant differences between the 2 groups for most measures of patient outcome, including mortality, readmission within 28 days, adverse events, or duration of hospital stay. However, rates of readmission specifically for infection were significantly lower in the stewardship group (4% vs 7.5%, P = .04).

In addition, there was a 27% reduction in overall antibiotic use (2387 fewer days) in the stewardship group (P = .001), with a particular reduction in use of broad-spectrum antibiotics, such as fluoroquinolones (P=.002), and third-generation cephalosporins (P=.09), in favor of narrow-spectrum antibiotics.

The findings are particularly striking because the study population was elderly, making clinical diagnostics challenging, said Dr. Resman.

"The Holy Grail"

"While geriatric patients are very vulnerable to severe infections, they often lack distinct clinical features of such infections, yet this study showed they were overusing antibiotics," he said.

But, Dr. Resman added, good antibiotic stewardship programs are not necessarily always about reducing antibiotics, "they're about improving antibiotic use for the patient. In some patients, we actually widened the treatment, but not in many."

 
In the US, readmission rates are one of the principal metrics that the Center for Medicare Services is evaluating. Dr. Michael Schmidt
 

Despite reducing antibiotic use, most antibiotic stewardship programs are unlikely to save money in the short term because of the cost of the program itself, said Dr. Resman. "The question in the long run is if we can afford not to use them."

Reduced readmissions are "the holy grail" in the United States, commented Michael Schmidt, MD, professor and vice chairman of microbiology and immunology at the Medical University of South Carolina in Charleston, who was not involved in the study.

"In the US, readmission rates are one of the principal metrics that the Center for Medicare Services is evaluating, so anything that can have an impact on that will have a phenomenal effect," he said.

This study was partly funded by STRAMA, a nonprofit Swedish network promoting rational antibiotic use. Dr. Resman and Dr. Schmidt report no relevant financial relationships.

54th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC): Abstract L-408. Presented September 6, 2014.

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