Contribution of antimicrobial stewardship programs to reduction of antimicrobial therapy costs in community hospital with 429 Beds --before-after comparative two-year trial in Japan

Abstract

Objectives: Do antimicrobial stewardship programs (ASPs) contribute to reduction of antimicrobial therapy costs in Japanese community hospitals? To answer this health economic question, a before-after comparative two-year trial in a community hospital in the country was designed.

Methods: The study was conducted at National Hospital Organization Tochigi Medical Center, a community hospital with 429 beds. We compared six-month period before-ASP (January 2010 to June 2010) and 24-month period after ASP (July 2010 to June 2012) in primary and secondary outcome measures. Three medical doctors, three pharmacists and two microbiology technologists participate in the ASPs. The team then provided recommendations based on the supplemental elements to primary physicians who prescribed injectable antimicrobials. Prospective audit with intervention and feedback was applied in the core strategy while dose optimization, de-escalation and recommendations for alternate agents and blood cultures were applied in the supplemental elements. The primary outcome was measured by the antimicrobial therapy costs (USD per 1,000 patient-days), while the secondary outcomes included the amount of antimicrobials used (defined daily doses per 1,000 patient-days), sensitivity rates (%) of Pseudomonas aeruginosa (P. aeruginosa) to Meropenem (MEPM), Ciprofloxacin (CPFX) and Amikacin (AMK), length of stay (days) and detection rates (per 1,000 patient-day) of methicillin-resistant Staphylococcus aureus (MRSA) and extended spectrum beta-lactamase-producing organisms (ESBLs) through blood cultures.

Results: In the study, recommendations were made for 465 cases out of 1,427 cases subject to the core strategy, and recommendations for 251 cases (54.0%) were accepted. After ASP, the antimicrobial therapy costs decreased by 25.8% (P = 0.005) from those before ASP. Among the secondary outcomes, significant changes were observed in the amount of aminoglycosides used, which decreased by 80.0% (P < 0.001) and the detection rate of MRSA, which decreased by 48.3% (P < 0.001).

Conclusions: The study suggested the possibility that ASPs contributed to the reduction of the antimicrobial therapy costs in a community hospital with 429 beds.

Keywords: Antimicrobial stewardship; Community hospital; Cost; Pharmacist; Team medicine.

Figure 1

Antimicrobial stewardship programs flowchart. ^*Hospitalized patients: High care, internal medicine, surgery, orthopedics, cerebral surgery, ophthalmology, obstetrics and gynecology, otolaryngology and oral surgery units. ^†Antimicrobial use: used Glycopeptides or Carbapenems used 3,4-Generation Cephalosporins or Quinolones for 14 days or more. ^‡Pathogenic microorganisms: Positive blood cultures, Methicillin-resistant Staphylococcus aureus, Extended spectrum beta-lactamase-producing organisms, Acinetobacter baumannii, Pseudomonas aeruginosa resistant to at least one among Carbapenems, Quinolones or Aminoglycosides ^§Team: a team comprised of medical doctors, pharmacists and microbiology technologists. The team then provided recommendations based on the supplemental elements to primary physicians who prescribed injectable antimicrobials. Other: recommendations for alternate agents and blood cultres.

Figure 2

Recommendation processs flowchart. ^†Antimicrobial use: used Glycopeptides or Carbapenems used 3,4-Generation Cephalosporins or Quinolones for 14 days or more ^‡Pathogenic microorganisms: Positive blood cultures, Methicillin-resistant Staphylococcus aureus Extended spectrum beta-lactamase-producing organisms, Acinetobacter baumannii Pseudomonas aeruginosa resistant to at least one among Carbapenems, Quinolones or Aminoglycosides.

Figure 3

Antimicrobial cost. ASPs: antimicrobial stewardship programs. P values are used for comparisons of After with Before by Mann–Whitney U-test.