Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship

Abstract

Objective: Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center.

Design: Quasi-experimental study.

Methods: We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS).

Results: In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (-9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (-4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively).

Conclusions: Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.

FIGURE 1

Timeline of antimicrobial stewardship program (ASP) strategies for broad-spectrum antimicrobials at the Hospital of the University of Pennsylvania.

FIGURE 2

Trends in consumption of broad-spectrum anti-gram-negative agents (days of therapy per 1,000 patient-days) by month for the 4-year study period.

FIGURE 3

Trends in consumption for all systemic antimicrobials, nonaudited antimicrobials, vancomycin, and antifungal agents (days of therapy per 1,000 patient-days) by month for the 4-year study period.

FIGURE 4

Trends in length of stay for total hospitalization and in length of stay after receipt of antimicrobials by month for the 4-year study period.