Improving Antimicrobial Use Starts with Our Trainees

Background: Medical residents are responsible for most antibiotic orders in our hospital, and Antimicrobial Stewardship Program (ASP) outreach efforts should focus on this group. In this study, we aimed to 1) improve house staff antibiotic prescribing with an intensive educational intervention, and 2) to determine if improvements are sustained.

Methods: The Montefiore Medical Center in the Bronx, NY has one of the country's largest medical training programs. The Montefiore ASP conducted a pre- and post-intervention audit of house staff prescribing over a 2-year period (11/2012 to 9/2014). The intervention consisted of case-based lectures on appropriate prescribing, and a pocket antibiotic guide adapted from IDSA guidelines and tailored to local microbiology. Chart audit was conducted by a senior medical resident to assess "appropriateness" of selected regimens based on indication, dose, and duration using a standardized tool and independently audited by an ID attending. Statistical analysis was performed in MS Excel. Acceptability survey was given to a sampling of residents.

Results: Antibiotics were indicated at a similar rate pre- intervention, and in both post-intervention periods. Antibiotic appropriateness was initially 60%, which improved to 70% (P=0.049) at one month and 80% at 20 months (results in table below). Likewise, 20 month audit for appropriate dose and duration were favorable. Acceptability survey showed that 100% found the intervention to be a helpful adjunct to their training.

	Antibiotics Indicated	Appropriate Regimen for Syndrome	P- value	Appropriate Dose	Appropriate Duration
Pre-intervention	87% (n = 187)	60% (n = 187)	--	--	--
Post-intervention (1 month)	85% (n = 173)	70% (n = 163)	0.049	--	--
Post-intervention (20 months)	80% (n = 50)	80% (n = 50)	0.008	90%	88%

Conclusion: Global improvements in antibiotic prescribing are best achieved through recurring educational outreach using prescribing resources tailored to the local environment. Our antibiotic guide and case based lecture core curriculum continue to complement routine ASP activities and have a positive effect on prescribing more than two years later.