Recommended strategies for antimicrobial stewardship (AMS) include prospective audit with feedback (PAF) and preauthorization (PA). Depending on hospital culture, initiation of PA can be difficult. The impact of various single AMS strategies on antibiotic consumption have been described, though the impact of several strategies over time have not been reported.
At an academic institution, the impact of various AMS strategies on daptomycin utilization were evaluated over time. A progression of 4 different approaches were used for restriction:
· Period 1 (P1): 9/2012- 6/2013 PAF
· Period 2 (P2): 7/2013-1/2016 8-d automatic stop
· Period 3 (P3): 2/2016-12/2017 3-d automatic stop, PA for >3d use required
· Period 4 (P4): 1/2018-5/2018 PA
Transition to each strategy was supported by a policy change, approved through the Pharmacy and Therapeutics Committee and Hospital Medical Board. During P1-3, reserved medication orders were reviewed daily by AMS with recommended interventions when appropriate and providers were notified of pre-set stop dates (P2-3). During P4, ordering providers were required to call AMS prior to initiation. Daptomycin utilization rates (DOT/1000 PD) and mean unique patients receiving daptomycin were collected for each period.
As restriction strategies enhanced, mean rate of daptomycin use (DOT/1,000 PD) progressively declined with a significant decrease during each period transition (Fig. 1); P1->P2 (11.6 vs 8.3; p<0.01), P2->P3 (8.3 vs 6.6; p=0.017), and P3->P4 (6.6 vs 3.2; p<0.01). Mean number of unique patients on daptomycin decreased with implementation of new AMS strategies; P1->P2 (30.1 vs 27.6; p=0.18), P2->P3 (27.6 vs 23.8; p<0.01) and P3->P4 (23.8 vs 13.3; p<0.01). Of note, linezolid balloon effect only occurred following transition from P3->P4 (6.1 vs 10.5 DOT/1000 PD; p <0.01).
This single center descriptive analysis of AMS restriction strategies reveals progressive decrease in daptomycin use with stepwise implementation. This significant decrease was most profound with ultimate transition to PA. AMS programs unable to initially implement highly restrictive policies can consider using a stepwise approach to ease practitioners into the new model and still have a meaningful impact on antimicrobial utilization.
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