Antibiotic Use Falls in Hospitals With Antimicrobial Plans

Jenni Laidman

December 10, 2014

Pediatric hospitals that adopted antimicrobial stewardship programs (ASPs) showed a sharper drop in average antibiotic prescribing rates since 2007 than hospitals that adopted no plan, according to a study published online December 8 in Pediatrics.

Adam L. Hersh, MD, PhD, assistant professor, Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City, and colleagues compared antibiotic use in 31 freestanding children's hospitals from 2004 to 2012. Nine of the hospitals had antimicrobial stewardship plans (ASP+), and 22 did not (ASP−). Using data from the Pediatric Health Information Systems, the researchers compared the use of all antibacterials and the prescription rates for a subset of antibiotics (vancomycin, carbapenems, and linezolid) both before and after the Infectious Diseases Society of America adopted guidelines for the development of ASPs in 2007, by measuring days of therapy per 1000 patient days.

The researchers found a larger drop in the average use of all antibiotics among ASP+ hospitals (11%) compared with ASP− hospitals (8%) from 2007 to 2012 (P = .04). However, both ASP+ and ASP− hospitals changed practices significantly after the passage of guidelines (P < .001 for both).

Use of vancomycin, carbapenems, and linezolid was similar in both ASP+ and ASP− hospitals before 2007. After the guidelines were established, ASP+ hospitals saw use of this subset of antibiotics fall 4%, to an average of 110 days of therapy per 1000 patient days (P = .06). There was minimal change in use of these antimicrobials in ASP− hospitals.

The researchers also measured antibiotic use on a hospital-by-hospital basis, comparing facilities both before and after the adoption of an ASP. Eight of the nine ASP+ hospitals used fewer antibiotics after adopting an ASP, with an average monthly change in days of therapy per 1000 patient days of −5.7% (95% confidence interval [CI], −4.3% to −7.2%). For vancomycin, carbapenems, and linezolid, the average days of therapy fell by 8.2% (95% CI, −6.75% to −9.7%).

The study showed that hospitals that invest in ASP will have the best outcomes, the authors conclude. "Despite the fact that favorable changes occurred in ASP− hospitals, our findings suggest that the development of a formalized stewardship program, defined to include commitment of financial resources for personnel, translates into declines in antibiotic use that are above and beyond those achieved without similar investment," the authors write.

More than half of all hospitalized children receive antibiotics, previous studies have shown. Earlier single-center studies have shown promising results after the adoption of an ASP. However, those studies may not present the full picture, the authors report, lacking comparator hospitals, and perhaps representing publication bias, with only the most successful programs reporting results.

"Progress has been made in some areas but we continue to struggle in others," the authors of an accompanying editorial write. The editorial authors are Wilbert Mason, MD, MPH, head of the Division of Infectious Disease, Children's Hospital, Los Angeles, and professor of clinical pediatrics at the University of Southern California School of Medicine, Los Angeles, and Kanokporn Mongkolrattanothai, MD, associate professor of clinical pediatrics, Keck School of Medicine, University of Southern California, and Children's Hospital Los Angeles.

For example, they note that efforts are underway to develop novel antiinfective drugs, and enhanced efforts have been made to limit the spread of multidrug-resistant organisms.

"However, progress is urgently needed in the areas of global leadership and coordination of antimicrobial use, economic incentives for new drug development, continued use of antibiotics to enhance food production, and inappropriate use of antibiotics in the treatment of viral infections and other non-infectious conditions."

Although a hospital's financial support of full-time equivalents such as clinical pharmacists and/or pediatric infectious disease specialists is thought to improve the performance of ASPs, there are few data to support the claim, the editorial authors write. In addition, the way antibiotic use is measured in this study, via days of therapy, does not reveal whether a patient is switched to oral therapy or whether treatment has been de-escalated. Finally, not everyone agrees on what outcomes are the most important to measure in comparing the efficacy of ASPs.

"Outcomes favored by infectious disease physicians were appropriate use of antimicrobial agents and infection-related mortality rate, whereas antimicrobial use and cost were the most commonly reported metrics. There is growing consensus that the focus of ASPs should be on optimizing clinical outcomes and patient safety and minimizing unintended consequences of the use of antimicrobial agents, for example, adverse events, selection of resistant bacteria, and Clostridium difficile infections," the editorialists conclude.

The authors and editorialists have disclosed no relevant financial relationships.

Pediatrics. Published online December 8, 2014. Article full text, Editorial full text

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