Reducing Antimicrobial Use in an Academic Pediatric Institution: Evaluation of the Effectiveness of a Prospective Audit With Real-Time Feedback

Abstract

Introduction: Antimicrobial use is decreasing across freestanding children's hospitals, predominantly in institutions with antimicrobial stewardship programs (ASPs) in place. A highly effective ASP should effect a greater decrease in use than predicted by existing trends. Antimicrobial stewardship programs depend on clinician adherence to program recommendations, but little is known about factors associated with adherence.

Methods: Parenteral antimicrobial-use data for our institution and 43 additional freestanding children's hospitals were obtained and normalized for patient census. Segmental linear regression was used to compare rates of change of parenteral antimicrobial use before and after ASP implementation. Time-series models were developed to predict use in the absence of intervention. The odds of adherence to ASP recommendations were determined based on provider characteristics and recommendation type.

Results: In the 38 months before ASP implementation, parenteral antimicrobial use was decreasing at our hospital by 3.7%/year, similar to the 3.4%/year found across children's hospitals. The rate of change after implementation of the ASP at our hospital was 11.1%/year, compared to 5.6%/year for other hospitals over the same period. Of 643 interventions, teams adhered with recommendations in 495 cases (77.0%). According to adjusted analysis, primary service was not associated with adherence (P = .356). There was an association between adherence and the role of the clinician receiving a recommendation (P = .009) and the recommendation type (P = .009).

Conclusions: Understanding factors associated with adherence to ASP recommendations can help those who administer such programs to strategize interventions for maximizing efficacy. Our findings reveal the value of a formal ASP in reducing use when controlling for secular trends.

Keywords: antimicrobial stewardship; antimicrobial utilization; cost-effectiveness.

Figure 1.

Parenteral antimicrobial (A) and antibiotic (B) use at Monroe Carell Jr. Children's Hospital at Vanderbilt. The line marked “Predicted Utilization” represents predicted use based on autoregressive integrated moving average models; the light and dark shaded areas represent 80% and 95% confidence intervals, respectively, for the prediction adjusted for periodicity, seasonal trends, and the overall decreasing trend. The line marked “Actual Utilization” represents actual (observed) use. The y-axis is log-transformed. Abbreviation: DOT/1000, days of therapy per 1000 patient-days.

Figure 2.

Piecewise linear regression of parenteral antimicrobial (A) and antibiotic (B) use at Monroe Carell Jr. Children's Hospital at Vanderbilt in units of days of therapy per 1000 patient-days (DOT/1000), with a knot (vertical dashed line) placed at the time of ASP implementation. Abbreviation: ASP, antimicrobial stewardship program.

Figure 3.

Distribution of the percent change of parenteral antimicrobial (A) and antibiotic (B) use in all assessed PHIS hospitals before and after the date of ASP implementation at Monroe Carell Jr. Children's Hospital at Vanderbilt (MCJCHV). Solid circles, MCJCHV; bold lines, medians; boxes, 25th and 75th percentiles (vertical lines include the full range); open circles, outliers falling greater than 1.5 times the interquartile range above the 75th percentile or below the 25th percentile. Abbreviations: ASP, antimicrobial stewardship program; PHIS, Pediatric Health Information System.