Background: Inappropriate antimicrobial prescribing leads to development of antimicrobial resistance and suboptimal clinical outcomes. Antimicrobial prescribing is determined by several behavioral factors, which are not often taken into account in antimicrobial stewardship programs.
Objective: To determine whether an antimicrobial stewardship approach based on prescriber participation and autonomy is effective in improving appropriateness of hospital antimicrobial prescribing.
Methods: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective stepped-wedge participatory action study performed between 2011 and 2015 (baseline period: 16 months, intervention period: 12 months).
Setting: Seven clinical departments (two medical, three surgical, and two pediatric) in two hospitals in the Netherlands.
Participants: Physicians prescribing clinical systemic antimicrobial drugs for any indication.
Intervention: After a root-cause analysis of inappropriate prescribing, prescribers were invited to choose and design interventions to improve their prescribing (Figure 1). The approach incorporated several features designed to profit from behavioral science insights.
Main Outcomes: Appropriateness of antimicrobial prescriptions using a validated approach measured 6 times per year. Antimicrobial consumption was extracted from pharmacy records.
Results: We assessed 1 121 patient cases with 700 antimicrobial prescriptions during the baseline period, and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. Averaged over 12 months after intervention start, antimicrobial appropriateness increased from 64.1% to 77.4% (+13.3%, odds ratio 1.98, 95% confidence interval (CI) 1.16 to 3.37), without a significant change in slope (Figure 2). We found a non-significant minimal decrease in antimicrobial consumption (2.0 to 2.0 days of therapy per admission, level -0.2%, 95% CI -20.1 to +24.8, slope -0.7%, 95% CI -2.7 tot +1.3).
Conclusion: A leading role of hospital prescribers in choosing and developing interventions to change prescribing behavior within their discipline resulted in a significant increase in antimicrobial appropriateness sustained for at least 12 months.
E. Peters, None
M. Kramer, None