Mandatory indications for antimicrobial agents are recommended by a number of organizations to act as a force function, requiring prescribers to provide a reason for prescribing at the time of order entry. We evaluated the impact of introducing a mandatory indication field into electronic order entry for selected antibiotics on utilization of antibiotics at a large community hospital in the context of an established antimicrobial stewardship program.
A descriptive analysis of the mandatory indication fields for the study antibiotics (intravenous and enteral clindamycin, ciprofloxacin, metronidazole, moxifloxacin and vancomycin) for adult patients 18 years and above for one-year (December 1, 2015- November 30, 2016) post-implementation was conducted. An independent t-test was used to measure the primary outcome of change in drug utilization of study and control antibiotics before (6 months pre) and after (12 months post) the initiation of mandatory indications. Drug utilization was calculated as Days of Therapy (DOT)/1000 patient-days for both the study and control antibiotics individually and as a group. Oral amoxicillin/clavulanate and intravenous piperacillin/tazobactam orders which have no mandatory indications were used to examine any associated shifts in antibiotic utilization.
A total of 8399 orders were evaluated in the one-year post-implementation period, of which 4572 were for study antibiotics. The preset mandatory indications were selected 30-55% of the time. For the primary outcome, there was a statistically significant decrease in DOT/1000 patient-days for study antibiotics as a group pre- and post-intervention (mean 100 versus 82 p=0.024) as but not individually. However, there was a statistically significant increase in DOT/1000 patient-days for the control antibiotics (mean 78 vs 91, p=0.01), driven by the increase in piperacillin/tazobactam utilization.
This study showed moderate use of preset mandatory indications which suggests that the preset list of indications can be optimized. Furthermore, mandatory indications were shown to be associated with a reduction in study antibiotics utilization but may lead to shifts in usage to other non-study antibiotics.
A. J. Chan,
B. Langford, None
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