Methods: A multidisciplinary group was formed to design and implement the ASP. The group included Antimicrobial Stewardship Pharmacists, an Infectious Disease Physician, and a Doctor of Nursing Practice Candidate. The study was conducted in a community hospital in the Northwestern United States. Components of the ASP included clinical decision support, a viral prescription built into the electronic health record, and education for providers, nurses, and patients. The study took place over a period of two years, allowing for seasonally comparative group pre- and post-ASP implementation data sets. Descriptive statistics were used to characterize the pre- and post-implementation cohorts. Categorical variables were compared between cohorts using Pearson’s chi-square test or the Fisher exact test. In all tests, a P-value of < 0.05 was considered statistically significant.
Results: In the pre- and post-intervention study, 5,504 and 4,510 patients were included, respectively. The institution witnessed a decrease in 994 patient presentations (18% reduction) in the post-implementation phase for the typically viral complaints of sinusitis, bronchitis, pharyngitis, and non-specific upper respiratory infection. Overall, antibiotic prescribing rates for these conditions decreased significantly. The proportion of patients who received an antimicrobial prescription decreased from 67.0% to 54.2% (12.8% decrease; P = 0.001).
The average duration of antibiotic therapy was shortened by 1.01 days from pre- to post-implementation. The average pre-implementation duration was 9.98 days which was cut to 8.97 days (P = 0.001) in the post-implementation phase. This equated to over 2,469 fewer days of antibiotics prescribed to patients.
In terms of selection of antimicrobials, providers wrote for less broad-spectrum and more targeted therapies on the whole after the implementation of the ASP. Macrolides were the most commonly prescribed non-first line antibiotic in the pre-implementation data (P = 0.001). In the post-implementation phase, antibiotics such as doxycycline and the penicillins replaced many of the macrolide scripts (P = <0.0001). These changes were congruent with the treatment algorithms provided.
The viral prescription was utilized 101 times in the post-implementation phase, indicating that 2.24% of the patients who presented to the clinics received it in lieu of an antibiotic. The cases of community acquired C. Diff decreased in the post-implementation phase, from 55 to 44. However, this is not statistically significant due to the decreased cohort size in the post-implementation.
Discussion: In this Northwestern Community Hospital system, the ASP led to a substantial and sustained improvement in the prescribing antimicrobials. Antibiotic prescribing was improved in every month after the implementation of the ASP. Education and resources for providers was shown to be effective. The overall decrease of 12.8% (P = 0.001) in prescriptions indicated a higher level of scrutiny prior to ordering a drug. It is likely to be a combination of the interventions imposed in the ASP that improved prescribing patterns.
Contrary to prevailing thought, ASPs are not meant to only deter the use of antimicrobials. Instead they are intended to optimize the use of antibiotics and prescribe them judiciously when indicated. This study suggests that because of the ASP, antibiotics were optimized. When an antibiotic was suitable, clinicians chose more appropriate classes and precise durations of therapy. Prescribing patterns followed the treatment algorithms in terms of increased scrutiny to prescribe, precise class of medication selection, evidence-based durations of therapy, and adjunctive treatments. Clinicians made a concerted effort to optimize the use of antibiotics as a result of the ASP.
The community outreach and education was shown to be effective. As a result of the community education, 18% (P = 0.0001) fewer patients presented to the clinics for predominately viral illnesses. This is critically important as it decreases some of the pressure to prescribe that providers experience. Patients appreciating that antibiotics do not decrease viral symptoms is crucially significant to the functionality of an ASP. Moreover, providers also dispensed 101 Viral Prescriptions, indicating that the tool is an effective means to avoid prescribing antimicrobials.
Implications for Practice: The profound need to protect antibiotics necessitates changes in the healthcare field. Antimicrobial Stewardship Programs optimize the appropriate and safe use of antibiotics, enhance clinical outcomes, decrease unintended consequences, and support providers in clinical practice. As demonstrated in this study, multidisciplinary stewardship teams offer expanded expertise and provide merit to the programs. Nurse Practitioners have the unique skillset to design and lead these taskforces in a meaningful way.
Much more research is needed on the topic of stewardship. Particularly in the outpatient arena, the lack of publications and validated interventions have hindered institutions from implementing such programs. The dearth of research highlights the challenges that researchers and clinicians face. The catastrophic threats that antimicrobial-resistant pathogens pose necessitate profound changes in healthcare at every level and cannot be deferred any longer.
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