Reducing Co-administration of Proton Pump Inhibitors and Antimicrobials Through an Antimicrobial Stewardship Program at a Large Urban Community Hospital

Background:

Hospital-acquired C. difficile infection (HACDI) leads to significant patient morbidity, mortality, and increased health care costs. Strategies such as antimicrobial stewardship programs (ASP) have significantly reduced these risks; however, antimicrobials continue to be a necessity in many hospitalized patients.  Co-administration of proton pump inhibitors (PPIs) and antimicrobials is associated with an increased risk of HACDI. Withholding chronically indicated PPIs during antimicrobial use may be a valuable strategy to reduce the risk of HACDI and has not been formally evaluated to date. We hypothesize that reducing co-administration of PPIs and high risk antimicrobials via an ASP initiated prospective audit and feedback program is a more effective strategy compared to a real-time automated computer physician order entry (CPOE) alert.

Methods:

A historical cohort study was completed. A CPOE antibiotic-PPI alert, followed by an ASP initiated prospective audit and feedback were phased in at 6 month intervals between April 2011 and September 2012.  Evaluation included baseline rates of antibiotic-PPI days on therapy (DOT), PPI DOT, HACDI, rates of transfusion and GI consultations which were then compared to post implementation of the CPOE alert phase and introduction of an ASP initiated prospective audit and feedback phase.

Results:

Table 1: Results of CPOE Alert and ASP Interventions

	Baseline Phase	Alert Phase  (p-value)*	ASP Phase  (p-value)*
Antibiotic-PPI DOT/100 PD	6.223	3.472 (0.010)	2.379 (0.001)
PPI DOT/100 PD	34.642	29.609 (0 .018)	26.356 (<0.001)
HACDI/ 1000 PD	0.7575	0.7395 (0.969)	0.6231 (0.795)
GI Consultation rate	61%	54% (0.053)	53% (0.030)
Blood Transfusion Rate	26%	27% (0.861)	27% (0.782)

*p-value compared to baseline

Conclusion:

ASP programs are designed to optimize antimicrobial use.  Antibiotic-PPI DOT was reduced by 55.8% utilizing a CPOE alert and was further reduced by 38.2% by the ASP. Limiting collateral damage from antimicrobial exposure though prevention of co-administration of PPIs and antimicrobials is not a traditional activity of the ASP yet could be incorporated into prospective audit and feedback practices. This low cost and simple initiative has the potential to improve patient safety by reducing rates of nosocomially acquired C. difficile.