An Infectious Diseases (ID) Physician Led Antimicrobial Stewardship Program (ASP) at a Small Community Hospital Improves Susceptibility Patterns and is Cost-Saving after the First Year

Background: One method of addressing the increasing burden of antimicrobial resistance is through an ASP but many community hospitals do not have an established ASP or ID consultant.  Almost half of U. S. hospitals are community based, with 100 beds or fewer.  However, little is known about the cost or benefit of an ASP in these facilities.

Methods: An ASP was established in March 2010 through direct salary support at a 70 bed rural hospital with a 6 bed ICU, where hospitalists are the primary admitting service. A board certified ID physician performed weekly post-prescription audits for all inpatients receiving anti-infectives. Face-to-face feedback to physicians followed. Educational sessions, order set design, and formulary management services were also provided. The physician was chair of the Infection Control Committee and available by pager to medical staff during the week; formal consults were not performed. Inpatient antimicrobial costs from January 2010 to December 2012 were obtained from pharmacy records. Annual antibiograms were used to assess changes in antimicrobial susceptibility (>30 non-duplicate isolates/year). 

Results: 1217 documented interventions were performed (mean 34/month) over 36 months. Recommendations to discontinue antibiotics, eliminate duplicate therapy, or narrow spectrum were most common.  Anti-infective costs per patient-day decreased from $16.06 in 2010 to $10.82 in 2012. Anti-infective expenditures decreased by 32% and 42% in years 2 and 3 respectively, for a total savings of $161,251.   Significant improvement in antimicrobial susceptibilities were observed for the following from 2010 to 2012 (drug % change):  Pseudomonas aeruginosa (levofloxacin 18%, piperacillin/tazobactam 16%, cefepime 14%), Proteus mirabilis (TMP/SMX 18%, ceftriaxone 14%), and Klebsiella pneumoniae (TMP/SMX 10%, gentamicin 7%) (p≤0.01 for all).

Conclusion: Following the first year, the establishment of an ID physician-led ASP was cost saving at this community hospital. Despite a small number of isolates, significant improvement in antibiotic resistance patterns for several organisms was seen. These results demonstrate a role for an ASP at community hospitals that are not large enough to support ID consultation alone.