Hostname: page-component-7c8c6479df-27gpq Total loading time: 0 Render date: 2024-03-27T04:23:04.346Z Has data issue: false hasContentIssue false

Favorable Impact of a Multidisciplinary Antibiotic Management Program Conducted During 7 Years

Published online by Cambridge University Press:  02 January 2015

Philip Carling*
Affiliation:
Infectious Diseases Section, Carney Hospital, Boston, Massachusetts Boston University School of Medicine, Boston, Massachusetts Tufts University School of Medicine, Boston, Massachusetts
Teresa Fung
Affiliation:
Infectious Diseases Section, Carney Hospital, Boston, Massachusetts
Ann Killion
Affiliation:
Infectious Diseases Section, Carney Hospital, Boston, Massachusetts
Norma Terrin
Affiliation:
Tufts University School of Medicine, Boston, Massachusetts
Michael Barza
Affiliation:
Infectious Diseases Section, Carney Hospital, Boston, Massachusetts Tufts University School of Medicine, Boston, Massachusetts
*
Infectious Diseases Section, Carney Hospital, 2100 Dorchester Avenue, Boston, MA 02124

Abstract

Objective:

To evaluate the impact of an interventional multidisciplinary antibiotic management program on expenditures for antibiotics and on the incidence of nosocomial infections caused by Clostridium difficile and antibiotic-resistant pathogens during 7 years.

Design:

Prospective study with comparison with preintervention trends.

Setting:

University-affiliated teaching hospital.

Patients:

All adult inpatients.

Intervention:

A multidisciplinary antibiotic management program to minimize the inappropriate use of third-generation cephalosporins was implemented in 1991. Its impact was evaluated prospectively. The incidence of nosocomial C. difficile and resistant Enterobacteriaceae infections as well as the rate of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) were compared with those of National Nosocomial Infections Surveillance System hospitals of similar size.

Results:

Following implementation of the program, there was a 22% decrease in the use of parenteral broad-spectrum antibiotics (P < .0001) despite a 15% increase in acuity of patient care during the following 7 years. Concomitantly, there was a significant (P= .002) decrease in nosocomial infections caused by C. difficile and a significant (P = .02) decrease in nosocomial infections caused by resistant Enterobacteriaceae. The program also appeared to have a favorable impact on VRE rates without a sustained impact on MRSA rates.

Conclusion:

These results suggest that an ongoing multidisciplinary antibiotic management program may have a sustained beneficial impact on both expenditures for antibiotics and the incidence of nosocomial infection by C. difficile and resistant bacterial pathogens.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2003

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Kunin, CM, Tupasi, T, Craig, WA. Use of antibiotics: a brief exposition of the problem and some tentative solutions. Ann Intern Med 1973:79:555560.CrossRefGoogle ScholarPubMed
2.Kunin, CM. Evaluation of antibiotic usage: a comprehensive look at alternative approaches. Rev Infect Dis 1981;34:745753.CrossRefGoogle Scholar
3.Kunin, CM. The responsibility of the infectious disease community for the optimal use of antimicrobial agents. J Infect Dis 1985;151:388398.CrossRefGoogle ScholarPubMed
4.McGowan, JE Jr, Tenover, FC. Control of antimicrobial resistance in the health care system. Infect Dis Clin North Am 1997;11:297311.CrossRefGoogle ScholarPubMed
5.Gerberding, JL, McGowan, JE, Tenover, FC. Emerging nosocomial infections and antimicrobial resistance. In: Remington, JS, Schwartz, MN, eds. Current Clinical Topics in Infectious Diseases. Boston: Blackwell Science; 1999.Google Scholar
6.Marr, JJ, Moffet, HL, Kunin, CM. Guidelines for improving the use of antimicrobial agents in hospitals: a statement by the Infectious Diseases Society of America. J Infect Dis 1988;157:869876.CrossRefGoogle ScholarPubMed
7.Carling, PC, Fung, TK, Coppola, PG, O'Donnell, FP. The use of a standardized antibiotic monitoring program to document cost savings. Presented at the 31st Annual Meeting of the Infectious Diseases Society of America; October 15-17, 1993; New Orleans, LA. Abstract 102.Google Scholar
8.Carling, PC, Fung, T, Killion, A, Barza, M. The favorable impact of the multi-disciplinary antibiotic management program analyzed over seven years. Presented at the 40th Interscience Conference on Antimicrobial Agents in Chemotherapy; September 16-20, 2000; Toronto, Ontario, Canada. Abstract 2131.Google Scholar
9.Shlaes, DO, Gerding, DN, John, JF, et al.Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis 1997;25:584599.CrossRefGoogle Scholar
10.Fishman, NO. Antimicrobial management and cost containment. In: Mandeli, JL, Bennet, JE, Dolin, R, eds. Principles and Practice of Infectious Diseases, 5th ed. New York: Plenum; 2000:539546.Google Scholar
11.Briceland, LL, Nightingale, CH, Quintiliani, R, Cooper, BW, Smith, KS. Antibiotic streamlining from combination therapy to monotherapy utilizing an interdisciplinary approach. Arch Intern Med 1988;148:20192022.CrossRefGoogle ScholarPubMed
12.Schaffner, W, Ray, WA, Federspiel, F, Miller, WO. Improving antibiotic prescribing in office practice: a controlled trial of three educational methods. JAMA 1983;250:17281732.CrossRefGoogle Scholar
13.Avorn, J, Soumerai, SB. Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically based “detailing.” N Engl J Med 1983;308:14571463.CrossRefGoogle ScholarPubMed
14.Fridkin, SK, Steward, CD, Edwards, JR, et al.Surveillance of antimicrobial use and antimicrobial resistance in United States hospitals: Project I CARE phase 2. Clin Infect Dis 1999;29:245252.CrossRefGoogle ScholarPubMed
15.Hearst Corporation. First Databank Blue Book of Pharmaceuticals. New York: Hearst Corp.; 1994.Google Scholar
16.Carling, PC, Fung, T, Coldiron, JS. Parenteral antibiotic use in acute-care hospitals: a standardized analysis of fourteen institutions. Clin Infect Dis 1999;29:11891196.Google ScholarPubMed
17.Shanholtzer, CJ, Willard, KE, Holter, JJ, et al.Comparison of the VIDAS Clostridium difficile toxin A immuno assay with C-difficile culture and cytotoxin and latex tests. J Microbiol 1992;30:18371840.Google Scholar
18.Bender, BS, Bennett, R, Laughon, BE, et al.Is Clostridium difficile endemic in chronic-care facilities? Lancet 1986;2:1113.CrossRefGoogle ScholarPubMed
19.Fekety, R, Kim, KH, Brown, D, Batts, DH, Cudmore, M, Silva, J Jr. Epidemiology of antibiotic-associated colitis: isolation of Clostridium difficile from the hospital environment. Am J Med 1981;70:906908.CrossRefGoogle ScholarPubMed
20.Katz, GW, Gitlin, SD, Schaberg, DR, et al.Acquisition of Clostridium difficile from the hospital environment. Am J Epidemiol 1988;127:128194.Google Scholar
21.Garner, JS, Jarvis, WR, Emori, TG, Horan, TC, Hughes, JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128140.CrossRefGoogle ScholarPubMed
22.Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1995;44(RR-12):113.Google Scholar
23.McGowan, JE Jr, Finland, M. Usage of antibiotics in the general hospital: effect of requiring justification. J Infect Dis 1974;130:165168.CrossRefGoogle ScholarPubMed
24.John, JF Jr, Fishman, NO. Programmatic role of the infectious diseases physician in controlling antimicrobial costs in the hospital. Clin Infect Dis 1997;24:471485.CrossRefGoogle ScholarPubMed
25.Coleman, RW, Rodondi, LC, Kaubisch, S, Granzella, NB, O'Hanley, PD. Cost-effectiveness of prospective and continuous parenteral antibiotic control: experience at the Palo Alto Veteran's Affairs Medical Center from 1987 to 1989. Am J Med 1991;90:439444.CrossRefGoogle Scholar
26.Quale, J, Landman, D, Saurina, G, Atwood, E, DiTore, V, Patel, K. Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci. Clin Infect Dis 1996;23:10201025.CrossRefGoogle ScholarPubMed
27.Burke, J. Antibiotic resistance: squeezing the balloon? JAMA 1998;289:12701271.Google Scholar
28.Polk, R. Optimal use of modern antibiotics: emerging trends. Clin Infect Dis 1999;29:264274.CrossRefGoogle ScholarPubMed
29.Frank, M, Betteiger, B, Sorensen, S, et al.Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. Clinical Performance and Quality Healthcare 1997;5:180188.Google ScholarPubMed
30.White, AC, Atmar, RL, Wilson, J, Cate, TR, Stager, CE, Greenberg, SV. Effect of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities and clinical outcomes. Clin Infect Dis 1997;25:3039.CrossRefGoogle ScholarPubMed
31.Fraser, GL, Stogsdill, P, Dickens, JD Jr, Wennberg, DE, Smith, RP Jr, Prato, BS. Antibiotic optimization: an evaluation of patient safety and economic outcomes. Arch Intern Med 1997;157:16891694.CrossRefGoogle ScholarPubMed
32.Pestotnik, SL, Classen, DC, Evans, RS, Burke, JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996;124:884890.CrossRefGoogle ScholarPubMed
33.Evans, RS, Pestotnik, SL, Classen, DC, et al.A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998;338:232238.CrossRefGoogle ScholarPubMed
34.Johnson, S, Gerding, DN. Clostridium difficile. In: Mayhall, CG, ed. Hospital Epidemiology and Infection Control. Baltimore: Williams and Wilkins; 1996:399408.Google Scholar
35.Johnson, S, Gerding, DN, Olson, MM, et al.Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1989;88:137140.CrossRefGoogle Scholar
36.Brooks, SE, Veal, RO, Kramer, M, Dore, L, Schupf, N, Adachi, M. Reduction in the incidence of Clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following the replacement of electronic thermometers with single-use disposables. Infect Control Hosp Epidemiol 1992;13:98103.CrossRefGoogle Scholar
37.Pear, SM, Williamson, TH, Bettin, KM, Gerding, DN, Galgiani, JN. Decrease in nosocomial Clostridium difficile-associated diarrhea by restricting clindamycin use. Ann Intern Med 1994;120:272277.CrossRefGoogle ScholarPubMed
38.Brown, E, Talbot, GH, Axelrod, P, Provencher, M, Hoegg, C. Risk factors for Clostridium difficile toxin-associated diarrhea. Infect Control Hosp Epidemiol 1990;11:283290.CrossRefGoogle ScholarPubMed
39.Climo, MW, Israel, DS, Wong, ES, Williams, D, Coudron, P, Markowitz, SM. Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost. Ann Intern Med 1998;128:989995.CrossRefGoogle ScholarPubMed
40.Murphy, P, LeClair, J. Incidence of Clostridium difficile-associated disease following therapy with either ceftriaxone or ticarcillin-clavulanate. Presented at the 37th Interscience Conference on Antimicrobial Agents and Chemotherapeutics; September 18-22, 1996; New Orleans, LA. Abstract J40.Google Scholar
41.Rahal, JJ, Urban, C, Horn, D, et al.Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 1998;280:12331237.CrossRefGoogle ScholarPubMed
42.Rice, LB, Eckstein, EC, DeVente, J, Shales, DM. Ceftazidime-resistant Klebsiella pneumoniae isolates recovered at the Cleveland Department of Veterans Affairs Medical Center. Clin Infect Dis 1996;23:118124.CrossRefGoogle ScholarPubMed
43.Landman, D, Chockalingam, M, Quale, JM. Reduction in the incidence of methicillin-resistant Staphylococcus aureus and ceftazidime-resistant Klebsiella pneumoniae following changes in a hospital antibiotic formulary. Clin Infect Dis 1999;28:10621066.CrossRefGoogle Scholar
44.Paterson, DL, Yu, VL. Extended-spectrum beta lactamases: a call for improved detection and control. Clin Infect Dis 1999;29:14191422.CrossRefGoogle Scholar
45.Hayden, MK. Insights into the epidemiology and control of infection with vancomycin-resistant enterococci. Clin Infect Dis 2000;31:10581065.CrossRefGoogle ScholarPubMed
46.Donskey, CJ, Chowdhry, TK, Hecker, MT, et al.Effect of antibiotic therapy on the density of vancomycin-resistant enterococci in the stool of colonized patients. N Engl J Med 2000;343:19251932.Google Scholar
47.Donskey, CJ, Hanrahan, JA, Hutton, RA, Rice, LB. Effective parenteral antibiotic administration on persistence of vancomycin-resistant Enterococcus faecium in the mouse gastrointestinal tract. J Infect Dis 1999;180:384390.CrossRefGoogle ScholarPubMed
48.Lautenbach, E, LaRosa, LA, Marr, AM, Nachamkin, I, Bilker, WB, Fishman, NO. Changes in the prevalence of vancomycin-resistant enterococci in response to antimicrobial formulary interventions: impact of progressive restrictions on use of vancomycin and third-generation cephalosporins. Clin Infect Dis 2003;36:440446.CrossRefGoogle ScholarPubMed
49.Rice, LB. A silver bullet for colonization and infection with methicillin resistant Staphylococcus aureus still eludes us. Clin Infect Dis 1999;28:10671070.CrossRefGoogle Scholar
50.Wenzel, RP, Wong, MT. Managing antibiotic use: impact of infection control. Clin Infect Dis 1999;28:11261127.CrossRefGoogle ScholarPubMed
51.Farr, BM, Jarvis, WR. Would active surveillance cultures help control healthcare-related methicillin-resistant Staphylococcus aureus infections? Infect Control Hosp Epidemiol 2002;23:6568.CrossRefGoogle ScholarPubMed
52.Jones, RN, Marchall, SA, Pfaller, MA, et al.Nosocomial enterococcal blood stream infections in the SCOPE Program: antimicrobial resistance, species occurrence, molecular testing results, and laboratory testing accuracy. Diagn Microbiol Infect Dis 1997;29:95102.CrossRefGoogle ScholarPubMed
53.Low, DE, Keller, N, Barth, A, Jones, R. Clinical prevalence, antimicrobial susceptibility and geographic resistance patterns of enterococci: results from the SENTRY antimicrobial resistance surveillance program 1997-1999. Clin Infect Dis 2001;32(suppl 2):S133S145.CrossRefGoogle ScholarPubMed