686. Broad Spectrum Antibiotic Use at Choice, Change, and Completion throughout VA: Patterns of Initiation and De-escalation
Session: Poster Abstract Session: Stewardship: Data and Program Planning
Thursday, October 5, 2017
Room: Poster Hall CD
  • ID Week 2017 ASP metrics poster v3.pdf (404.1 kB)
  • Background:  Antimicrobial stewardship programs seek to reduce initiation of unwarranted therapy, promote de-escalation and prevent excessive duration.  The CDC Antibiotic Use option provides ward-level reports of antibiotic use and risk-adjusted Standardized Antibiotic Administration Ratios for pre-specified antibiotics groups that allow for inter-facility comparison, but do not provide the indication for use or temporal patterns that allow de-escalation assessments. 

    Methods: We characterized antibiotic use on days 0-2 (Choice), 3-4 (Change) and 5-6 (Completion) of therapy (CCC) for pneumonia (LRTI), skin-soft tissue infections (SSTI) and urinary tract infection (UTI).  We then explored the relationship between total MRSA or multi-drug resistant GNR (MDRO) antibiotic use and use over CCC intervals for LRTI and SSTI for patients in acute non-ICU settings in 33 high-complexity VA facilities.  Data were from 2016 and extracted from the VA Corporate Data Warehouse.

    Results:  The mean rates of anti-MRSA and anti-MDRO therapy were 108 and 123 Days of Therapy (DOT)/1000 days present, respectively.  The table shows the fraction (mean, range) of patients with SSTI or LRTI receiving anti-MRSA or anti-MDRO therapy at the CCC intervals and the change in use (i.e., de-escalation) over the treatment course.

    Fraction of Patients on Therapy

    Difference from Choice to










    34% (22-47%)

    26% (9-45%)

    24% (8-45%)

    8% (-10-26%)

    11% (1-26%)



    65% (39-81%)

    56% (37-83%)

    47% (26-79%)

    9% (1-21%)

    18% (-7-43%)



    46% (20-64%)

    39% (14-62%)

    37% (10-66%)

    7% (-1-18%

    8% (-4-27%)



    47% (21-67%)

    42% (13-69%)

    36% (9-57%)

    6% (-5-16%)

     11% (0-25%)

    Among the facilities there was a 0.55-0.86 correlation between overall use of MRSA or anti-pseudomonal antibiotics and the fraction of patients on therapy at each of the CCC metrics for LRTI or SSTIs. 

    Conclusion:  Syndrome-specific CCC metrics show substantial variations in the rates of de-escalation of antimicrobial use over treatment courses.  Insights provided by these metrics will allow facilities to identify specific areas for improvement by targeting syndrome-specific initial choices of therapy or antibiotic de-escalation. 

    Matthew Goetz, MD1,2,3, Christopher J. Graber, MD, MPH, FIDSA4,5, Makoto Jones, MD, MS6, Karl Madaras-Kelly, PharmD, M.P.H.7, Matthew Samore, MD, FSHEA8, Peter Glassman, MBBS, MSc2,9 and The Veterans Affairs Antimicrobial Use Learning Collaborative, (1)Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, (2)David Geffen School of Medicine at UCLA, Los Angeles, CA, (3)Infectious Diseases, VA Greater Los Angeles Healthcare System, Los Angeles, CA, (4)Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA, (5)David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, (6)Internal Medicine, VA Salt Lake City Health Care System, Salt Lake City, UT, (7)Clinical Pharmacy, College of Pharmacy, Idaho State University and VA Medical Center, Boise, ID, (8)University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, UT, (9)VA Greater Los Angeles Health Care System, Los Angeles, CA, Los Angeles, CA


    M. Goetz, None

    C. J. Graber, None

    M. Jones, None

    K. Madaras-Kelly, None

    M. Samore, None

    P. Glassman, None

    Findings in the abstracts are embargoed until 12:01 a.m. PDT, Wednesday Oct. 4th with the exception of research findings presented at the IDWeek press conferences.